VOLUNTARYISM

AND

HEALTH
'' 
''AND HEALTH

THE ROLE OF
THE NATIONAL
VOLUNTARY

HEALTH AGENCY

NATIONAL HEALTH COUNCIL
1790 Broadway New York 19, N.Y.
Copyright 1962
''PUBLIC HEALTH LIB.

“This hankering to be an individual is probably greater today
than ever before. Huge factories, assembly lines, mysterious mech-
anisms, standardization—these underline the smallness of the indi-
vidual, because they are so fatally impersonal. . . . It is the unique
strength of democratic methods that they can provide a way of
stimulating and releasing the individual resourcefulness and in-
ventiveness, the pride of workmanship, the creative genius of human
beings whatever their station or function. A world of science and
great machines is still a world of men; our modern task is more dif-
ficult, but the opportunity for democratic methods is greater even
than in the days of the ax and the hand loom.”

—David Lilienthal*

*Words to Live By, Edited by William Nichols. Simon and Schuster, New York.
''Aaah
CONTENTS L bray

Page
POreword «63s cewass taweus sean es see e ws PRO Re EO i-il
What Is Voluntaryism? ....... 0.0... 0.0 c cee ee eee 1-3
Birth and Growth of the
Voluntary Health Agencies ...............0 000 eee 4-6
The National Approach ss <::.eeeessscews cinwees tia 7-14
INtGEPlaY’ ce ees sewee mise mene seme TE ee ew 15-18
Challenges and Issues ......... 0.0.00 c cece eee eee 19-23
Voluntaryism in the Future............ 0.0.0.0 eee eee 23

 
''''FOREWORD

In 1960 the Board of Directors of the National Health Council
approved the development of a statement on the role of the national
voluntary health agency in the complex pattern of health services
today. The need for such an appraisal was clear from growing evi-
dence of public confusion, a confusion abetted by the tendency
of many critics to identify crucial issues in the field of voluntary
health ‘and welfare services with the national agencies. In acting to
authorize the statement, the Board noted that it is with respect to
the national voluntary health agencies that there is “greatest need
for new thinking and wider understanding.” Implicit in the decision
to sponsor the statement was recognition that this is a critical time
for voluntaryism in America. Not only is there danger that in the
very complexity and professionalization of health services, the deep
and personal tradition of voluntaryism will be obscured. The time
is also one of real issues and problems which the voluntary agencies
must face if they are to fulfill their promise of continued service.
The National Health Council believed that only by confining the
focus of this statement to the national agencies could valid and sig-
nificant generalizations be made which would contribute to a mean-
ingful discussion.

National voluntary health agencies were defined for the purpose
of this statement as agencies with these distinguishing characteris-
tics: they are composed of individuals both lay and professional or
of associations of both lay and professional individuals, voluntarily
and democratically organized on a national basis, the primary or
major purpose of which is health-related in that they are organized

 
''ii

to combat a particular disease, disability, or group of diseases and
disabilities, or to improve or protect the health of a particular group
of people—they are supported primarily by voluntary contributions
from the public at large rather than from governmental sources or
endowments—they engage in programs of research, education, and
service to individuals and communities in their particular sphere of
interest.

The national voluntary health agencies and their state and local
affiliates share their interests in health problems with a great many
other private organizations, including philanthropic foundations,
civic, fraternal, medical, religious, and labor groups, and other com-
munity associations. Private foundations are generous in their sup-
port of voluntary effort, principally through grants for specific pro-
grams that fall within their particular purposes so far as health is
concerned. Civic, fraternal, and other groups are in general staunch
supporters of the national agencies, contribute generously to their
work, and supply large numbers of dedicated volunteers. The scope
of this statement precluded discussion of their valuable work.

“Voluntaryism and Health” was prepared by an Ad Hoc Com-
mittee of the National Health Council under the chairmanship of
Dean W. Roberts, M.D. The members of the Committee were:
Ruth B. Freeman, Ed.D.; Mr. Melvin A. Glasser; John W. Knutson,
D.D.S.; Leonard W. Mayo, S.Sc.D.; Mr. James T. Nicholson;
Muriel B. Wilbur, Ph.D.; James E. Perkins, M.D.; and James H.
Sterner, M.D. Miss Daisy Byler assisted the committee as writer.

Cuorgg Sm ph—

President
National Health Council
''“The concept of neighbor, ‘good neighbor, is
part of the American heritage. We are a nation
of neighbors and we live in a world of neigh-
bors. And the way we give effective testimony
to this principle is by freely sharing our skills
and resources with others needing them.”

—Dwight D. Eisenhower

WHAT IS VOLUNTARYISM?

Americans are noted for asking questions, just
as they are for getting things done, freedom of
inquiry being one of the corollaries of freedom
of initiative. Today some of the questions are
pertinent ones about health services. In es-
sence, these questions involve the various ways
in which our society has moved toward reali-
zation of the potentials for better health for
greater numbers of people. As medical and
scientific advances have opened up new pos-
sibilities for conquering disease and disability,
Americans have responded by utilizing tradi-
tional processes of voluntary organization to
achieve the promised benefits for themselves
and for others. These processes have resulted
in unprecedented growth in numbers of vol-
untary health agencies and great expansion of
government health programs. The great vari-
ety of approaches to health—the health of the
individual, the family, and the community—
has given rise to such questions as: How did
so many different agencies come about? What
do they all do? Where does the individual fit
in the complex picture? Where do we go from
here?

These questions and others like them occur
in a changing environment that affects the
attitude of the questioner, the nature of the
question, and the nature of the answer. Amer-
icans live in a fast-moving world. Questions
new to the individual and new to society
emerge as some of the old ones are answered.
The scene shifts rapidly. With the heavy popu-
lation influx from rural areas, cities are ex-

panding into the surrounding countryside,
often absorbing the small town into a huge
urban and suburban area. Comfortable small
neighborhoods disappear in acres of high-rise
apartment buildings, arid parking lots, and
neon-lit shopping centers. The curve and
sweep of expressways dominate more and
more of the landscape, eloquently symbolizing
speed and change.

It is a world, too, in which modern com-
munications bring the farthest corner of the
globe as near as the television screen. The
small, the familiar, and the near in our lives
are daily being replaced by the large, the im-
personal, and the far-flung. Industrial develop-
ments, economic growth, and scientific and
technological progress have taken us far and
fast. They have changed the pattern of our
lives and relationships with others, the kinds
of jobs we hold, and the places where we live.
The very rapidity of developments lends ur-
gency to the need for a concurrent process of
assessment and questioning.

One aspect of the process is the search for
information, a reflection of the insatiable de-
sire of Americans to know more about more
things. Educators, journalists, physicians, sci-
entists, economists, and sociologists day after
day pour millions of words onto paper to
meet the demand. These words are published
in newspapers, magazines, and books; they
are converted into television and radio shows,
delivered as lectures, and produced as docu-
mentary films, for the reading, listening, and

1
''viewing audience. Other questions, like the
one which is being dealt with here, have to do
with the “why” and “how” of the ways in
which we seek to accomplish our objectives.
This kind of question goes deeper and involves
painstaking examination of where we have
been, where we are now, and where we ought
to be going.

Such an assessment of the national volun-
tary health agencies, undertaken as it must be
in the mid-stream of change, will do well to
reach back to their roots in an attempt to cap-
ture both the spirit of philanthropy and mean-
ing of “voluntaryism,” a quality that has per-
meated American behavior and institutions
since the beginnings of this democracy.

. The basic definition of “voluntaryism” as a

“system of supporting or dong anything by
voluntary action,” is further illuminated by the

eaning of “voluntary” in its sense of “free.”
Freedom of the individual, freedom of associ-
ation, and freedom of enterprise are at th
roots of voluntaryism in a democratic society,
The effects of these freedoms in terms of or-
ganized effort to meet problems were evident
early in our history.

As long ago as 1830, the often-quoted
Alexis de Tocqueville marveled at the use
which citizens of the then relatively new de-
mocracy were making of associations in civil
life. In Democracy in America he said, “I have
often admired the extreme skill with which
inhabitants of the United States succeed in
proposing a common object for the exertions
of a great many men and in inducing them
voluntarily to pursue it. . . . Thus the most
democratic society on the face of the earth is
that in which men have, in our time, carried
to the highest perfection the art of pursuing
in common the object of their common desires
and have applied this new science to the great-
est number of purposes.”

The emphasis on voluntaryism in our af-
fairs has continued unabated and is mani-
fested in thousands of associations for almost
every conceivable purpose—in business and
industry, in the professions, in the arts, in
education, and in health and welfare. In the
wealth and variety of such organizations and
associations there are some which provide mu-

2

tual benefits for members; others benefit in-
dividuals or groups outside the association
through helping to meet needs or to solve
problems which the individual alone cannot
handle. The growing complexity of society has
both multiplied these problems and needs and
changed their character. At the same time it
has increased the importance of the indi-
vidual’s sharing by voluntary action in reach-
ing solutions and achieving objectives for him-
self and for other individuals, and on behalf
of causes whether they be local or national in
scope, where need has been demonstrated and
where he has personal interest, experience, or
knowledge. Such activity is vital to maintain-
ing our ability as a people to do things for
ourselves and to exercise a creative influence
on the kinds of services which are provided
for us by government.

One of the deepest meanings of voluntary-

“ism is perhaps best expressed in terms of its _

significance to the individual. Voluntary ef-
fort in this country has been meaningfully
identified with humanitarian, religious, and
charitable traits of the American character,
and many human needs have been met through
the interaction of these forces. While the basic
qualities have remained constant, the ways in
which they can be demonstrated have changed
greatly, and it has become more difficult for an
individual to find ways of helping others.

The world is quite different from the days
when a neighbor’s concern for his neighbor
was likely to be expressed through direct per-
sonal relationships or through the actions of
a small group of people on behalf of others.
Fifty or sixty years ago when a family was in
difficulty the neighbors pitched in to help with
food, money, or their own labor and service.
Illness, hard times, and disaster were shared.
Families and communities were close and in-
timately aware when help was needed by one
of their members.

Such opportunities to respond to the needs
of others are infinitely fewer today. Family
ties are weakened as people move frequently
and far away from relatives and home com-
munities, Crowded urban living imposes new
stresses and strains which tend to cause people
to avoid rather than to seek out those in trou-
''ble, to be isolated rather than drawn together
as they are in close-knit small communities) A
city apartment dweller may not even know
who lives above him in the same building,
much less have any occasion to offer help in
time of distress. Suburban living tends to bring
together families and groups similar in age and
economic and social status. Needs of other
kinds of people are consequently both remote
and different.

Not only does the life of an individual, par-
ticularly one who lives in a large city—where
more and more of the American people do
live—offer less in the way of personal contact
with others who may be in need, he can easily
be overwhelmed by statistics on numbers of
people with various kinds of problems and
feel there is nothing he can do about it. More-
over, when he does come in contact with
needs, they will tend to be far less simple than
they used to be. Hunger and acute poverty,
while they unfortunately still exist, are not
everyday problems that the individual is called
upon to meet. When help is needed, it may
well be for specialized health care, family
counseling, or some other service the indi-
vidual himself can neither render nor secure.

Still, the individual persists in his desire to
be helpful to less fortunate persons and to
make some contribution to society. Fulfillment
of such desires can be of even greater im-
portance to the individual whose daily job is
routine and gives him little or no human satis-
faction. The numbers of such individuals con-
tinue to grow as our society becomes more
and more dominated by the machine and as
greater numbers of people are involved in the
production, distribution, and sales of material
goods{ Service to others through participation

E in voluntary philanthropic organizations is an |

antidote for materialism and impersonality
and a major outlet for the aspiration to do
good in the world»

The national voluntary health agencies of-
fer a wealth of opportunities for such service
whether the principal interest of the volun-
teer is in his own community, in his state, or
in the nation as a whole. They unite the health
professions with lay volunteers in attacking

health problems whose solutions require not
only local community effort but a broad of-
fensive on the research and educational fronts
as well, in order to advance knowledge of the
causes and prevention of disease and disability
and to develop new techniques and dissemi-
nate information about them so that they can
be utilized in more effective community serv-
ices.

The growth of these agencies has been rapid
and diversified and has resulted in organized
activities which reach into the lives of virtually

_every family. They make it possible for any

citizen to recognize a health need of his com-
munity or of the country and to join with his
neighbors to do something about it. His com-
mitment to the cause may be large or small
and may develop in significance over the years.
He may serve on boards of directors or com-
mittees where his participation is in studying
problems, recommending action, or determin-
ing policy. He may contribute labor or ma-
terials for the construction or equipping of re-
habilitation centers, clinics, or hospitals. He
may contribute his time or professional skills
in directly serving people. Whatever role he
may choose to play, the citizen volunteer is
presented with the opportunity for meaningful
service to the degree he is challenged by the
causes in which he is most greatly interested.
CThe national voluntary health movement is
a natural outgrowth of the tradition and ex-,-
perience of philanthropy organized on a vol-
untary basis:)The growth in numbers of agen-
cies and in their prominence reflects a rising
tide of interest and concern on the part of the
American people about health, a justifiable
concern in view of the fact that during the past
fifteen to twenty years with employment at
high levels illness and disability have been the
major causé of indigency in this country. The
desire for better health has been augmented by
confidence in the ability of science to solve
problems, and has been rendered susceptible
of translation into action by many factors,
among them our greatly increased material
resources, the larger amount of leisure time
which we have at our disposal, and the phe-
nomenal development of communications.
''“Man is born to act. To act is to affirm the
worth of an end, and to affirm the worth of an
end is to create an ideal.”

—Justice Oliver Wendell Holmes

BIRTH AND GROWTH OF THE
VOLUNTARY HEALTH AGENCIES

The possibilities for broad application through
coordinated national, state, and local efforts
of the growing body of knowledge about
health problems and what could be done about
them became dramatically evident by the be-
ginning of the twentieth century. Men were
stimulated to act to change the old order
quickly. The result was the emergence of the
’ national voluntary health agency supported by
philanthropy, an instrument for educating, for
conducting research, and for creating com-
munity services in order to bring health bene-
fits more rapidly to larger numbers of people.

‘Except for the American National Red

ss, which was established in 1881 and
whose career has been a symbol of voluntary
philanthropic effort, there were before the
turn of the century no agencies with programs
directed toward enlisting public interest and
support in alleviating health problems on a
national scale? However, the conditions for
their development were all present when the
curtain went up on the first act of the drama
with the launching of the National Tubercu-
losis Association in 1904.

The spirit of voluntaryism itself was one of
the conditions. The heritage of humanitarian-
ism was another, as was the propensity to or-
ganize. The great crusades for social justice
that took place during the Progressive Era in
American politics in the late nineteenth and
early twentieth centuries were a powerful in-
fluence.

 

The beginning realization at the close of
the 19th century of the potentialities of sci-
entific research in the health field had opened
new vistas of what might be done and had
changed attitudes toward health. People were
coming to be less fatalistic about premature
death from disease and to believe that man
might take an active part in preventing and
controlling many of the ancient enemies of
health.

he belief that if means can be found to
tell enough people about a problem and what
can be done about it, something will be dones,
—part of a general optimism which charac-
terizes our national approach in most matters
—had an important bearing on the attitude
of founders of the earliest national voluntary
agencies. Edward L. Trudeau said in his first
presidential address to the National Tuber-
culosis Association: “The first and greatest
need is education; education of the people,
and through them education of the state. It is
evident that if every man and woman in the
United States were familiar with the main facts
relating to the manner in which tuberculosis
is communicated and the simple measures nec-
essary for their protection . . . the people
would soon demand and easily obtain effective
legislation for its prevention and control.”
Subsequent progress in the control of tuber-
culosis has borne out the accuracy of this pre-
diction. In 1900 the death rate for that disease
was 194.4 per 100,000; in 1958 it was 7.0.*

*U.S. Bureau of the Census, Statistical Abstract of the United States: 1959, (Eightieth edition.) Washington, D. C.,

1959, p. 66.

4
''-~ With the flourishing of the free enterprise
system in the nineteenth century and the ac-
cumulation of large private fortunes, the tra-
dition of use of part of private wealth for the
public good also became soundly rooted and
was part of the favorable environment which
nourished the growth of the twentieth century
national voluntary health agencies. The habit
of giving for charitable purposes was ingrained
and with the spread of wealth it was no longer
the privileged few, but the many, who gave for
charitable purposes.

i ptothies force at work which had a bearing
on the development of these agencies was rep-
resented by the many associations of profes-
sional workers, such as the American Medical
Association, the American Public Health As-
sociation and others, some of which were
formed before 1850) While these associations
were at the outset primarily concerned with
matters of ethics, professional education and
standards, and other similar interests, they
were a further demonstration of emerging con-
cern with health matters.

These were some of the conditions, atti-
tudes, and developments which provided the
background for the organization of the first
national voluntary health agency shortly after
the beginning of the twentieth century. In the
succeeding six decades there have been mo-
mentous changes, including change in political
climate which has brought greatly increased
government programs and activity. Through
these changes, through two world wars, and a
major depression, the national health agencies
have continued to grow in number, and in size
and strength, as they have drawn support and
participation from steadily growing numbers
of people.

During the twenty years after the launching
of the National Tuberculosis Association in
1904, the development of national voluntary
health agencies was steady, with the formation
of the National Society for the Prevention of
Blindness, the American Social Health Asso-
ciation, the National Association for Mental
Health, the American Cancer Society, the
American Heart Association, the American

 

Hearing Society, and the National Society for
Crippled Children and Adults, all before the
end of the first quarter of the century. The
National Foundation (then for Infantile Paral-
ysis) was established in 1938, the only star
of magnitude among the agencies to emerge
in the “dark thirties.”

The forties and fifties saw a renewed up-
surge of activity, with the organization of
twenty or more national disease-oriented
agencies, many of which have achieved promi-
nence and a substantial measure of public
support. The National Multiple Sclerosis So-
ciety, the Arthritis and Rheumatism Founda-
tion, United Cerebral Palsy and Muscular
Dystrophy Associations, are among these.

The Gentle Legions* discusses in varying
detail twenty-seven national voluntary health
agencies which were most active at the be-
ginning of the sixties. Of these, eight have
been established since 1950. The National
Information Bureau provides a partial list
which includes more than seventy-five. These
vary in size and scope, but their very existence
is witness to the persistence and vitality of
the effective qualities which led to the devel-
opment of the first such agency.

No account, however brief, of the national
voluntary health movement can overlook the
presence in the background of almost every
one of the large agencies of some one person
of conviction and pioneering spirit. The in-
domitable Clara Barton of the American
National Red Cross, whose story has lasted
in the public memory, was the forerunner of
many other dogged individuals whose ideas
for doing something about a problem resulted
in the creation of a national organization.
Others have remained alive only in the annals
of their own organizations. Lawrence Flick
in the tuberculosis movement, Clifford Beers
in mental hygiene, Edgar Allen in the crippled
children’s society; all were such pioneers.

Leadership in the attack has come from
the medical profession and from the public
at large, the profession bringing technical
knowledge but often calling on others expe-
rienced in social and educational processes.

*Richard Carter, The Gentle Legions, Doubleday & Company, Inc., Garden City, New York. 1961.
''Initiative in one agency might come from the
profession; in another the drive might begin
with others with conviction as to the pressing
need for action.

(Several of the newer national voluntary
agencies have had their genesis in the efforts
of parents of children with specific diseases
with which the public and frequently the medi-
cal profession had hitherto had little concern’
Seeking solutions for their children and for
other parents, they have insisted on action
even though success seemed unlikely. They
have followed the tradition of organizing to
enlist the support of others with the same
problem and of that portion of the public
whose sympathy and support could be enlisted
for the cause.

The range among the agencies in purpose,
organization, and program is diverse, being
largely dependent on evolutionary processes
as voluntary effort has been focused by inter-
ested leaders in developing the action which
seemed most appropriate. All dedicated their
efforts in varying proportions to education,
research, and direct services benefiting the in-
dividuals who have the problems with which
the respective agencies are concerned. Most
have affiliated units on regional, state, or local
levels. (In fact, the majority of the national
agencieS-were preceded in their fields by local
or state groups which demonstrated the need
and_pointed to its existence on a national
scale.YA notable exception is the National
Foundation, which grew entirely from the top
down. Some of the more recent and smaller
foundations and agencies were established first
at the national level, as well.

State and local affiliates enjoy varying de-
grees of autonomy.)For the most part, the
older organizations have the more complex
structures, with greater freedom on the part
of local affiliates to develop program and or-
ganization. Standards of organization and
operation with which affiliates must comply
in order to retain status as a member are es-
tablished by the national body, in which local
representatives participate. Normally, the per-
centage of contributed funds which the local

and state share with the national agency is
stipulated in some type of contractual agree-
ment. Agencies that concentrate on national
activities in research and education utilize a
larger proportion of contributed funds for
those purposes. When emphasis is on direct
service to patients or community health educa-
tion, the bulk of funds raised in the state or
community is retained at these levels.) Among
the agencies, percentages for the national pro-
gram range from a low of 6 per cent to a high
of 75 per cent.

Generally speaking, the voice of affiliates
in policy-making in the national agencies is
through representation by volunteer members
of state or local boards of directors on the
national boards of directors, or by regional
representation. Hence, the making of policies
which apply to the organization as a whole is
a democratic process in which local opinion
is reflected through the presence on national
boards of members who are active in state
and local programs. Few, if any, agencies con-
sider adopting new rulings without due con-
sultation with affiliates and concern for the
effect on them. The problem of most of the
agencies in this connection is the same as
that of any group which represents a wide
range of sometimes conflicting interests and
whose policies, even though adopted by the
majority, cannot be equally acceptable to all.

The great strength of the national volun-
tary health agencies, as of other voluntary
effort, lies in the volunteers who are suffi-
ciently persuaded of their value to work for
them—on boards of directors, as professional
advisors, on committees, in fund raising, and
in service programs. By developing policies
and guiding the agencies and otherwise serv-
ing their purposes, they carry on, albeit in a
somewhat different fashion, in the spirit of
voluntary service and desire to do good which
motivated the agency pioneers. Such volun-
teers number in the millions. The people who
support the work of the agencies through
financial contributions alone number in the
tens of millions. Each of these, too, has a
stake in their programs.
''THE NATIONAL APPROACH

The national voluntary health agencies have
much tradition and history in common and
share certain basic characteristics of organiza-
tion and operation. All are non-profit, chari-
table corporations, subject to the laws of the
states in which they are incorporated or con-
duct activities. They are governed by volun-
tary boards of trustees which are elected by
responsible membership bodies. Their prin-
cipal support comes from voluntary contri-
butions made by the public in response to

organized fund-raising campaigns. While there
is substantial difference in size and type of
staff, each of the agencies maintains a national
headquarters which provides assistance and
guidance for affiliated state, local, or regional
agencies. Their privileged status as tax-exempt
organizations is determined by the regula-
tions of the Internal Revenue Service. In the
area of program, however, a wide variation of
specific aims and approaches appears.

PROGRAM

\Such factors as the nature of the disease or
condition with which the agency is concerned,
the most immediate needs, and the extent of
funds available directly influence the program
which the national agency and its affiliates
may undertake at any given point in time/ A
realistic appraisal of ability to secume tal
particular goals and consideration of prevail-
ing public and professional attitudes also help
to determine what any agency does with the
resources at its disposal. National policy, de-
termined in the light of such considerations,
may therefore give emphasis to research, to
education, or to community service programs.
The extent to which national policy is fol-
lowed by affiliates is related to the authority
which rests with the national body in the par-
ticular agency, as well as to community factors
of size, resources, and the services of other
agencies.

For example, the National Foundation for

Infantile Paralysis found it possible compara-
tively early in its history to place heavy
emphasis on both scientific research and direct
assistance to polio victims. Because of its
immediate success in raising funds the Foun-
dation was in a very short time able to engage
in a broad offensive against polio, with pro-
grams of basic and specific research, patient
aid, public and professional education, and
emergency epidemic aid. With the devel-
opment of a vaccine, the Foundation has
dropped its exclusive concern with polio and
has moved into other areas of need.

Most other agencies had to be more selec-
tive in the role they undertook. The heart
and cancer organizations could not begin to
consider direct assistance to patients in their
early days because of lack of resources, the
huge numbers of cases involved, and the more
urgently pressing needs for education and
research.
''The primary objective of the American
Cancer Society when it was created was to
bring about change in public and professional
attitudes toward cancer in a society that con-
sidered all cancer incurable and the word
itself indelicate. Its programs were heavily
weighted in the area of education, to stimulate
public awareness in order to force increased
activity in the cancer field and to alert people
to the imperative need for early detection. It
directed the attention of medical groups and
public health departments to the need for
improved facilities for diagnosis, treatment,
and follow-up, promoted the establishment of
' cancer hospitals and clinics, and worked for
increased government expenditures in cancer
research. Its own research program began to
take shape only after the obstacle of hopeless-
ness had been largely overcome.

Ignorance and a fatalistic viewpoint also
figured largely in the development of the
American Heart Association program. Prog-
ress in research, lay and professional educa-
tion, community services, and the promotion
of preventive and corrective techniques all
came after lay enthusiasm was injected into
the effort. Because of the nature of its program
the Heart Association still functions under
predominantly medical direction. Volunteer
participation in fund raising, publicity, and
local service programs, however, has had
much to do with increased public awareness
of needs.

The National Tuberculosis Association saw
the great unmet need not in a mysterious or
dreaded disease of unknown origin, but in a
specifically identified organism that was being
transmitted broadly through ignorance and
neglect of public and personal hygiene. Con-
tagion was the problem and public education
was the immediate step toward solution. Case-
finding and the promotion of facilities for ade-
quate isolation and treatment were companion
objectives.

Because of the breadth of its program and
its status as a quasi-governmental agency, the
American National Red Cross does not lend
itself to comparison with the other national
voluntary agencies. It was born out of the
need for assistance in times of war, famine,

8

and disaster, was subsequently chartered by
Congress, and is charged with extensive hu-
manitarian duties. Its other activities such as
blood banks, water safety instruction, life-
saving, first aid, home nursing, and so forth
are all programs of more recent date. Many
of the other national agencies work coop-
eratively with Red Cross in such programs.

The National Society for Crippled Children
and Adults gave its first attention to seeking
public recognition of the needs and potentiali-
ties of the crippled and to bringing about
legislation to provide basic medical and edu-
cational services. More recently it has focused
on the development and operation of rehabili-
tation facilities and services.

The National Association for Mental Health
gave first and continuing attention to assuring
humane and professional treatment to the
mentally ill in institutions. Newer knowledge
has resulted in an equal emphasis on the
development of diagnostic, treatment and re-
habilitation services in the community.

Organizations in the fields of cerebral palsy,
mental retardation, and epilepsy have grown
out of the void that confronted parents and
families of patients with those diseases or
conditions when they sought information and
service. Initially, programs of such agencies
have leaned heavily toward counseling, re-
habilitation, social acceptance, schooling, and
vocational guidance. Agencies in the field of
multiple sclerosis and muscular dystrophy,
two progressive and uniformly fatal diseases
of unknown origin and treatment, have appro-
priately placed their greatest emphasis on
research.

In the fields of the blind and deaf and
hard-of-hearing, well established agencies
have had successful careers directed largely
toward prevention and detection of these con-
ditions and to training individuals for a normal
place in society.

The specific programs by which the national
voluntary health agencies seek to attain their
objectives may be considered under the broad
categories of public education, professional
education, research, and community services,
including patient aid.
''PUBLIC EDUCATION programs employ
techniques ranging from personal contact to
network television in an effort to call atten-
tion to needs, stimulate public interest in
problems, and encourage individual action,
voluntary participation, and financial support.

One of the earliest programs was the Health
Crusade of the National Tuberculosis Asso-
ciation which utilized all the trappings of the
crusade period and drew school children
progressively into various phases of a per-
sonal hygiene program. It effectively popular-
ized principles of personal and family cleanli-
ness and was the forerunner of child health
programs in schools. Somewhat later, the
“Women’s Field Army” of the Cancer Society,
working largely through the Federation of
Women’s Clubs, brought a “Message of Hope”
into millions of homes with the purpose of
“routing ignorance and mystery” surrounding
cancer,

The agencies believe that their fund-raising
campaigns in themselves serve an educational
purpose, particularly those which involve a
volunteer in a personal call at the home where
she leaves various kinds of informational
material relating to prevention, protection,
care and treatment, research and services. The
Christmas Seal Drive, the March of Dimes,
the Cancer Crusade, the Easter Seal drive,
Heart Fund, the Mental Health Bell Ringer
Campaign, and other fund-raising appeals
have elements of education and exert an im-
pact on the public mind.

A more direct approach to education of the
public is through the dissemination of infor-
mational publications. All of the agencies
produce and distribute this kind of material,
including pamphlets, reprints, and special re-
ports and studies. Millions of copies of such
publications have found their way into homes,
offices, factories, and schoolrooms of America.

Pamphlets such as “Seven Danger Signals
of Cancer,” “Some Things You Should Know
About Mental and Emotional Illness,” “A
Message To Parents” (regarding polio pre-
cautions), and “What You Need to Know
About TB” contribute to the development of
general knowledge of health and the factors
involved in its attainment. Practical advice for

parents on carrying out home follow-up
therapy for a physically handicapped child
and on how to meet other special problems in
his upbringing, sources for additional help,
and accident prevention are illustrative of the
content of other educational materials pub-
lished by the national agencies.

Education of the public is accomplished
through other activities characteristic of all
the agencies. From the local volunteer who
speaks or shows a film before a civic club,
to the exhibit at the county health fair, to the
national annual convention with prominent
speakers and demonstrations, these activities
utilize personal contact to transmit knowledge,
to stimulate interest in the development of
health services, and to reach the individual
who may have a health problem of his own
or in his family.

Through mass communications media—
newspapers, magazines, radio, and television
—the agencies have found the channel to
their largest public. People have a consuming
interest in matters relating to their own health
and that of the community, and consequently
health information is popular with audiences.
Even so, the media have been generous in
their support of worthy programs and have
shown a willingness to use much of the mate-
rial regularly provided by the agencies them-
selves, as well as much they turn up on their
own. This support has earned them the warm
gratitude of the agencies. Every phase of
agency activity is covered in press releases,
feature stories, statements by national and
local officials, photographs, and interviews.
Radio and television networks and local sta-
tions use public service time to show educa-
tional films or to carry live or recorded stories
and announcements. The support—or some-
times the disapproval—of newspaper editors
is one of the most potent factors in shaping
public knowledge of the agencies’ activities.

A live appearance, film, or even a feature
story on what a healthy young lad with con-
genital absence of all four limbs can do when
he has the right prostheses and is trained in
their use, does a great deal to inform the
public on what rehabilitation means. A live
telecast of a heart operation on a youngster

9
''with a heart ailment makes millions of viewers
more aware that such work can be and is
being done. Similar kinds of activities consti-
tute an important part of the work of all of the
agencies.

Experts differ as to the extent to which this
total effort is health education, in a strict
sense, and how much is informational. The
line is hard to draw, and even the purely pro-
motional has an element of education. In the
final analysis, the indisputable heightening of
public awareness of health needs and prob-
lems, the techniques for meeting them, and
hopes for progress in the future testify to the
success with which the national voluntary
agencies are carrying out their objectives in
public education.

(PROFESSIONAL EDUCATION programs

epresent the efforts of the agencies to attack
one of the most troublesome problems in the
health field today, affecting public and private
agencies alike—the lack of sufficient numbers
of professional workers to staff services at all
levels of operation. Health services in general
not only need more staff now than they can
find in the present highly competitive market,
they face a future when the demands will be
even greater. More health personnel must be
trained and new recruits must be attracted to
the pool of health manpower if these needs are
to be met. Upgrading of present personnel
and the training of volunteers to take on some
parts of the professional workers’ task are
other ways of augmenting the resources of
personnel.

Agency programs seek to accomplish those
objectives. Their programs may also affect
the health professions by changing attitudes
toward the possibilities for effective treatment
of disease or injury, by facilitating the per-
formance of professional tasks through dis-
semination of information on new techniques
and equipment, and by bringing to the trained
professional worker the best available knowl-
edge in his field through publication of techni-
cal books and journals. In many instances,
greater demand for services has stimulated
professional action in areas long stagnant from
public apathy and ignorance, encouraging and

10

stimulating professional workers to increase
their attention to those areas. Mental retarda-
tion, epilepsy, and cerebral palsy are cases in
point.

Widespread utilization of lay volunteers in
organizational, administrative, and service
aide capacities has demonstrated that the skills
and talents of the professional worker in health
programs can be released for more exclusive
attention to technical phases of his work. Not
the least contribution in freeing the profes-
sional worker is the opening up of new sources
of financial support for programs previously
impeded by lack of funds.

Many activities are directed toward helping
the professional worker keep abreast of new
developments that affect his work. Books,
articles, teaching texts, manuals, and films form
the bulk of the printed and audio-visual mate-
rial. Several of the national offices publish
professional journals and provide library
services.

Financing of refresher and special courses
and sponsorship of conferences and symposia
are other ways in which the agencies reach
physicians, therapists, nurses, laboratory tech-
nicians, social workers, and others. In general,
the agencies strive by these techniques and
others, such as research reports, meetings of
advisory boards and committees, and provi-
sion of opportunity for exchange of ideas, to
keep open the lines of communication and to
foster the development of the “team” concept
among all elements of the total health force.

The serious effects of critical shortages of
professional personnel have led national agen-
cies and their affiliates to devote substantial
resources to recruitment and training pro-
grams. In this activity, as in other aspects of
their professional education programs, they
usually work closely with medical and pro-
fessional associations. Through the Commis-
sion on Health Careers under the auspices of
the National Health Council, the agencies have
cooperated in an intensive program to interest
young people in careers in health. They have
independently financed substantial scholarship
and fellowship programs.

The work of the national agencies in this
connection was commended in the 1956
''report on “Mobilization and Health Man-
power.” National voluntary health organiza-
tion support of recruitment and educational
activities for paramedical personnel, the report
said, “shows that such support is obtaining
results, for those professions which have had
the greatest financial support of recruitment,
scholarships and training have the best out-
look from a manpower standpoint.”

RESEARCH—In 1950, according to a re-
port compiled by the National Health Edu-
cation Committee, seventeen national agencies
designated for medical research $9,143,822,
or 11.5 per cent of their total funds. In 1959,
the same agencies allocated for medical re-
search $34,311,159, or 19 per cent of total
funds. While modest in relationship to the
tremendous amounts of money which are
available for federal government research
programs, these dollars and the interests of
the agencies are considered by authorities to
be invaluable in maintaining a sound balance
in research through the elements of initiative,
creativity, and exploration which they bring
to the overall national research effort. Many
of the agencies were in the forefront in stimu-
lating the development of the National Insti-
tutes of Health and have supported their
growth. Representatives of the agencies assist
in the formulation of government research
policy through participation in advisory and
study committees.

These kinds of contributions were cited edi-
torially in the April 14, 1961 issue of “Science,”
a publication of the American Association for
the Advancement of Science, as follows:

“They have pioneered in educating the pub-
lic in the prevention and treatment of disease;
in creating greater public understanding of
the importance and promise of research; in
ameliorating or conquering disease; and in
developing effective methods for allocating
research grants and fellowships.” The edi-
torial focused on the importance of diversity
in research support, in view of massive govern-
ment financing, and pointed out that such di-
versity is “essential to flexibility and creativity
in research.”

*Richard Carter, op. cit., p. 143.

Another point of view in this regard was
that expressed by Dr. John R. Heller, presi-
dent of the Memorial-Sloan-Kettering In-
stitute, and formerly director of the National
Cancer Institute, who emphasized the im-
portance of strong voluntarily supported re-
search programs when he said: “As to re-
search, it’s full of imponderables and should
not be controlled by a single group, no matter
how expert the group may seem. The exist-
ence of the Cancer Society as a powerful, al-
ternate source of research support is down-
right reassuring to scientists.”’*

The most dramatic of the achievements of
the national health agencies in the field of
research was the successful development of a
vaccine against polio under a program heavily
financed by the National Foundation, which
pointed up the potentialities for major break-
throughs when substantial effort is directed
toward a single objective. It was estimated
that the free pooling of research effort which
was made possible by voluntary agency lead-
ership meant a saving of five years in the
development of an effective vaccine.

The American Heart Association has led
the field in the prevention of most recur-
rences and many first attacks of rheumatic
fever, through programs of professional and
lay education leading to widespread use of
confirmed prophylactic measures.

An early pioneer in voluntary agency sup-
port of research was the National Association
for Mental Health which, since 1934, has
administered over $1,500,000 for research in
schizophrenia, supplied by the Scottish Rite.
The NAMH Research Foundation now ad-
ministers these and other funds to support
biological and social research related to men-
tal health.

Other important results are being derived
from the investment of the national voluntary
health agencies in research. The long, slow
process of accumulation of basic knowledge—
a fundamental process that must be supported
to pave the way for final achievement of
successful prevention or cure of disease—is
being financed by many agencies. Work in
genetics, cellular biology, pulmonary physiol-

11
''ogy, embryology, and in the growth process
in bone are areas of basic research in which
the agencies are engaged and which hold
promise for applicability to fields beyond any
one disease-centered concern.

The pattern of research support by govern-
ment and other private agencies has been in-
fluenced by techniques developed by the
agencies, such as the establishment by the
American Heart Association and subsequently
by the American Cancer Society of research
professorships through which a promising in-
vestigator is guaranteed financial support for
lifelong independent research.

Voluntary agency support has been a key
factor in isolating the cause of paralytic polio;
in the development of improved diagnostic
procedures in cancer, polio, heart ailments,
tuberculosis, and neuromuscular diseases; in
discovering the role of improper administra-
tion of oxygen to premature babies in blind-
ness; in research into drugs and other treat-
ment for the mentally ill, cancer and heart dis-
ease, arthritis and rheumatism, etc.; research
into advanced surgical techniques; and in the
development of improved prosthetic appli-
ances, the “iron lung” and other devices.

The agencies which devote any substantial
amount of their resources to research produce
carefully developed reports on the content
and expectations of projects which they are
supporting. Such reports usually appear in two
forms—one for the scientific audience and
one for the lay reader’s information. They
make public their procedures for selecting
projects and investigators, and a list of the
individuals who advise them in the process
would include most of the top men in the
country. The investigators supported by grants
from voluntary agencies and the institutions
where they work are among the most dis-
tinguished in the United States.

COMMUNITY SERVICE-+The impact of
the national voluntary health~ agency is felt
most immediately at the community level,
where the local affiliate provides services
which directly assist the individual and his
family»Reference has been made to the broad
range in type of organization among the

12

agencies. This variety affects the extent and
type of local service programs. They are also
affected by national policy and by the relative
proportion of funds which remain in the com-
munity, as compared with the funds which are
allocated for research and education at the
national level. Conversely, local needs and
actions when channeled to the national group
may affect national policy and procedures.
Activities which agencies carry out on the
community level cover a range as broad as
the health needs of the community itself. The
people who receive their services are all ages
from the infant to the elderly and of all races
and creeds. They usually receive assistance or
care without cost, although some may pay a
portion of it if they are able to do so and if the
desired services are not available elsewhere.
Specific programs run the gamut from provi-
sion of sickroom supplies to the operation of
comprehensive rehabilitation centers; from
diet control classes to broad health education.
National agency affiliates may promote the
general health of the community through san-
itation measures; they may help individuals
pay for hospital and medical care; they may
augment the community’s health resources by
establishing or supporting clinics and diagnos-
tic facilities, convalescent centers, and re-
habilitation and treatment centers; health serv-
ices may be extended through mobile units to
reach special patients and those in remote
areas; physical, occupational, and speech
therapy may be provided in special centers,
in schools, and in homes. Case-finding and
psychological services, camps, craft programs,
and other recreational services; vocational and
employment services, needed supplements to
the public school system, such as nursery
schools, schools or classes for exceptional
children; and miscellaneous services such as
provision of special equipment, transportation,
and home visitor programs are other promi-
nent aspects of local affiliate services. Many
also devote resources to counseling parents
and patients. They play an important role as

participants in the overall community ap- |.

proach to health problems by developing and
increasing health facilities, conducting surveys

of community resources and needs, stimulat- |
''ing local organizations, legislators, and public
health departments to greater activity, and
working with other professional and private
organizations in the health field.

National agency relationships to community
‘service programs of affiliates vary as their or-
ganizational structure and the nature of service
activities themselves vary. The parent organ-
ization may play a variety of roles, including
conducting studies and surveys to determine
needed programs, guiding with respect to
agency policy, providing expert advisors to
assist in planning and operating services, as-
sisting in recruitment and training of profes-

sional staff, and augmenting the skills of staff
and volunteers through conferences, seminars,
and institutes, and printed and audio-visual
materials. National agency policy frequently
encourages local affiliates, when appropriate,
to utilize the services provided by other volun-
tary agencies rather than to embark upon
separate programs. For example, many of the
diagnostic agencies such as cerebral palsy,
arthritis and rheumatism, multiple sclerosis,
and others may arrange to purchase therapy,
counseling, or other services from rehabilita-
tion centers operated by local societies for
crippled children and adults.

INFLUENCE ON PUBLIC POLICY

When the nature of needs have been such as to
warrant legislative action for their accomplish-
ment, national voluntary health agencies and
their affiliates have historically been vocal in
pointing out those needs to local, state, and
federal legislative bodies, and have supported
desirable legislation One of the unique con-
tributions of the voluntary health movement
has been its demonstration of needs, fre-|
quently through the financing of a service until
it was accepted as a public responsibility) Edu- |
cational and promotional activities of national
voluntary health agencies have played an in-
disputably important role in legislative devel-
opments in the field of health in this century.

By providing leadership in identifying needs,
by supplying information to support the exist-

ence of needs and to document the specific
steps which can be taken to meet them, and
by demonstrating good programs; the national
voluntary agencies have greatly influenced
both the development of specific legislation
and other aspects of public policy.)They have
provided the mechanism through which the
community can bear witness to the needs of
its people, and the backing to give force to the
community’s voice. The effect of such volun-
tary citizen interest can be seen in the policies
of local school systems, in the administrative
structures and procedures of state-health, edu-
cation, and welfare departments, in budgets
for institutions and services, and in many other
parts of the system of local, state, and national
governmental health services.

FINANCING AND ACCOUNTABILITY

The American public, through giving gener-
ously, is probably better acquainted with the
fund-raising campaigns of the national volun-
tary health agencies than with any other
aspect of their programs. However, striking
similarity among the agencies in the techniques
which they employ in raising money, the
growing number of such appeals, and the pres-
sures exerted by United Funds at the local
level have raised many questions. Neverthe-
less, even this increased focus of attention
is an expression of the importance the public

attaches to health problems and their desire to
help sick people. Either by letter, or by house-
to-house solicitation the agencies reach mil-
lions of potential givers annually. Television,
radio, newspaper, magazine, and other pub-
licity dramatizes individual agency appeals.
The public’s support in response to requests
for money has been generous and continues
to grow.

Fund-raising activities of the national volun-
tary health agencies are subject to scrutiny
under the laws and regulations of a growing

13
''number of states and municipalities, as are the
activities of other groups soliciting funds for
charitable or educational purposes. Construc-
tive scrutiny is in the public interest, and
bona fide agencies accept and support reason-
able measures for review of their activities.
Among other approving agencies, the Na-
tional Information Bureau, with offices in New
York, is a well-established service which pro-

vides a listing of agencies which meet stand-
ards set by the Bureau.

Standards developed by the National Social
Welfare Assembly include the generally ac-
cepted criteria by which the practices and
operations of bona fide organizations can be
judged. These standards have been adopted by
the boards of directors of many national agen-
cies,

JOINT EFFORTS

Representatives of the national voluntary
health agencies, both board and professional
staffs, devote considerable attention to ways
and means of dealing not only with common
agency problems, but also with mutual inter-
ests in the field of health. The National Health
_ Council is an effective instrument for such
‘Cooperation. Most of the agencies contribute
financial support to the Council and their
board members and staff give time and effort
to joint projects undertaken under its auspices.
The Health Careers Commission, a pooling of
resources in a program to recruit and train
professional health personnel, is an example of
such activity.

Under the Council the agencies have also
established committees on local health depart-
ments to further the development of com-
munity health planning groups, on health
education to help clarify and improve such
programs, and on research.

Another committee of the National Health
Council has developed uniform accounting
procedures for the national agencies. Need for
such procedures, which would facilitate the
presentation by each agency of financial data
which could be compared with those of others,
has been frequently cited by accrediting agen-
cies and by representatives of the general
public.

14

Agencies have jointly sponsored training
programs for professional and administrative
personnel, such as those at the University of
California, Columbia University, and Wayne
University. Through joint meetings and studies
they have shared experience in organization
and staffing problems. Special study groups of
agency representatives have worked on such
problems as timing of fund-raising campaigns
and conflicts of interest or program between
local affiliates, as well as on cooperative proj-
ects in support of mutual interests.

At the beginning of the sixties there ap-
pears also to be growing awareness on the part
of the agencies of the need for sober considera-
tion of ways in which a more unified impact on
basic health problems with which they are
now individually concerned might be achieved.
No agency is willing to rest upon its laurels
and the boards of trustees of national volun-
tary health agencies cannot and should not
relax in their effectiveness nor the exercise of
their responsibility on behalf of the causes for
which the agencies were established. But there
is increasing recognition on their part of the
need to achieve their objectives in full aware-
ness of the variety of organizations in the com-
munity and within the framework of con-
sciousness of the responsibilities and services
of others.
''INTERPLAY

The role which the national voluntary health
agencies play is affected by forces and changes
in society as a whole and within the health
movement itself. The various parts of the vast
system of public and private health services
must fit together to make an effective whole
despite the fact that the parts are constantly
changing shape and size and are shifting in
their relationships with each other, making a
static picture impossible.

Changes affecting the overall pattern of
health services and the relationships of agen-
cies in the field have abounded in twentieth
century America. One of the most influential
factors is the growth of material resources and
the effect on the amount of money that can
be put into health services. The nation’s econ-
omy continues to expand. Gross national
product in 1960 is estimated at $500 billion,
and by 1970 if the annual rate of growth re-
mains the same it will be in the neighborhood
of $750 billion. Our standard of living, the
envy of the world, is going up, with an average
family income of just over $7,000 in 1960.
We have the means to support expanding gov-
ernment services through taxes and at the
same time to buy a great deal more private
health care and to contribute in ever-increas-
ing amounts for philanthropic purposes.

The growth in sheer numbers of people—
the population increased 19.5 million from
1940 to 1950, and 29 million from 1950 to
1960, almost 50 million people in twenty

 

“This time, like all other times, is a very good
one, if we but know what to do with it.”

—Ralph Waldo Emerson

years*—has an obvious effect on the numbers
of services required.
At the same time, the age groupings of the
population are shifting and increased num-
bers of elderly people are imposing new de-
mands on health services. With successful con-
trol of the great bulk of communicable dis-
eases among the young, and with life-saving
advances in surgery and other treatments,
chronic illness and disability in both youn
and old are emerging as the dominant problem’
of the future, involving more and different
kinds of facilities, services, and personnel.
Health services must reach people wherever
they are and the high rate of mobility of our
population complicates this task. About 19 >
per cent of the people, thirty-three million in
number, changed their place of residence in
1959, millions because the bread-winner
changed his job. Five and a half million
moved to another state.** The trend of move-
ment continues to be from rural areas to the
cities, and suburbia continues to attract large
numbers of families. Metropolitan areas out-
side central cities have been growing at a
rapid rate. Sprawling, congested cities with
their satellite suburban areas pose a challenge
to dynamic planning for health services in the
future. No less important is the challenge of
bringing to rural areas and small communities
health services as competent and as high in
quality as those available in urban centers with
their concentration of facilities for expert care.

*Bureau of Census. Current Population Reports. Series P-25, No. 223, Jan. 26, 1961.
**“Modern Mobility and Its Effects on People,”—a speech delivered by Ewan Claque before the National Travelers

Aid Association, April 6, 1960.

15
''Ours is a society where all areas of activity
are increasingly dependent upon the expert.
Specialization is the rule of the day in the
health field, as well. This has its effect on the
kinds of services which people come to feel
a need for and to seek, as well as on the
numbers of professional personnel needed and
on the training which is required of them.(Qurs
is an era, too, when scientific research has
advanced more rapidly than social research
and we are lagging in knowledge of how to
organize, administer, and finance the health
services people need and want)

Sweeping changes have also taken place in
the philosophy and practice of health services
in recent decades. The essence of charity with
its human warmth and concern for poverty
and suffering has been given substance and has
been enriched as goals broadened from the
immediate ones of alleviating distress, or of
saving lives and preventing illness and disa-
bility, to include efforts which involve the in-
dividual, his family, and his community in
the achievement of maximum rehabilitation
and satisfaction and competence in interrela-
tionships.

As the nation sought to keep pace with
growth and change in character of the popula-
tion, expansion of the economy, research and
technological developments, and the enriched
philosophy of scope and content of health
services, private and public programs have
been tremendously expanded.

Total expenditures for all private and public
health and medical care were 3.6 billion in
1929 and 26.5 billion in 1960, including pri-
vately purchased care, philanthropy, and
government. Americans were spending overall
more than seven times as much for health
and medical care in 1960 as they were 31
years before.*

Government expenditures for health and
medical care in 1929 were 513 million. By
1960, 31 years later, they were 6.2 billion. In
1929 philanthropy supported expenditures for
health and medical care of 80 million. This
total was more than eight times as great in
1960 when philanthropy provided 700 mil-

 

lion. In 1929 philanthropy supported 2.2 per
cent of the total cost for health and medical
care. By 1960 such support was 2.6 per cent
of the total.

Combined government expenditures and
those supported through philanthropy for
health and medical care (excluding privately
purchased care) in 1949 were six times as
high as 20 years earlier in 1929, and increased
86.1 per cent in the succeeding 11 years.
Philanthropic giving’s share of the combined
figure was 13.5 per cent in 1929, 10.7 per
cent in 1949, and 10.1 per cent in 1960.

Considering the magnitude of the endeavor
and the spread of years involved, these figures
seem to demonstrate a considerable stability
in the basic balance between private and pub-
lic support of health services in the United

States. (T hey suggest, however, that unless the

trend is reversed, philanthropic effort will sup-
ply an ever-diminishing share of America’s
health effort in comparison with government
programs?

Expansion of government services has
brought about a shift in the traditional roles
of public and private agencies. Up to twenty-
five years ago government health services had
been restricted in scope and application and
poorly financed. Experimentation and demon-
stration and provision of direct services were
conceived to be the domain and strong point
of voluntary agencies. However, since the en-
actment of the Social Security Act in 1935
the federal government has not only broad-
ened its responsibility for protecting individ-
uals against the major economic and social
hazards, but has become increasingly involved
in specialized, demonstration, and even ex-
perimental programs. While there remains the
fundamental distinction between the freedom
of the voluntary agency and the statutory re-
quirements which are imposed on government
programs, there are today many areas in which
they may be in a position to render essentially
the same type of service for the same kinds of
people.

Voluntary and government health agencies
are increasingly interdependent. Voluntary

*Expenditures for Health and Medical Care 1928-29 —1959-60, U.S. Department of Health, Education, and Welfare,
Social Security Administration, Division of Program Research. Research and Statistics Note No. 9, August 29, 1961.

16
''effort substantially supported the expansion of
government health services and today recog-
nizes and accepts their important and appro-
priate role. Government in turn through re-
search or demonstration grants and purchase
of care from privately owned facilities sup-
ports the voluntary way. These circumstances
place extreme importance on the necessity for
full exchange of information, cooperation, and
collaboration among voluntary and govern-
mental agencies.

At the center of this changing and complex
picture of health care stand the physician and
the individual private patient. They are backed
up by the great government programs for the
overall health of the public, supplemented by
both voluntary and public programs that pro-
vide the kinds of services which either are not
otherwise available or which are beyond the
ability of the individual either to find or to
afford for himself.

Maximum benefits in terms of the health
of the people can be derived only if there is
full interplay among the following elements:
informed self-help, governmental services that
protect the individual from the health hazards
of life beyond his individual control, and
voluntary associations that cope with problems
that are not a proper concern of government
or which have such a low priority for govern-
ment action that only voluntary action will
get the necessary help to those who need it.
The problem is to achieve a balance among
the three so that there will be recognition and
confidence in the ability of people to act in-
telligently in their own behalf, and so that gov-
ernmental action will not lead to inanition
and deterioration of individual competence or
sense of responsibility.

The national voluntary health agencies have
fostered and sustained the roles which volun-
taryism represents in the interplay among
agencies in the health field. These roles may
be described as:

1. a humanizing role, in that voluntary
health agency services involve general
citizens who are sufficiently moved by
needs of people to work and give to
help meet those needs. Thus, elements
of personal relationships are instilled in

a way not usually possible in official
agencies.

a balancing role with respect to profes-
sional and volunteer efforts, by provid-
ing opportunity for volunteers to take
an active part in service programs. The
rapid professionalization of the service
careers in the United States has de-
veloped a corps of dedicated, well-pre-
pared, sensitized workers. At the same
time the needs of people are seen in
much broader perspective than was true
a generation ago, and greater numbers
of professional personnel are required
to serve those needs. It is not within
the realm of present reality to expect to
have a force of such workers large
enough to provide all needed services,
and much must be done by people
themselves—for themselves, their fam-
ilies, their neighbors. Much will also
need to be done by those who are
neighbors by proxy, who work as volun-
teers to help meet the health needs of
the community. The voluntary health
agency is developed on the joint and
coordinated efforts of the professional
worker and the volunteer and in most
instances has considerable skill in the
delicate and complex task of coordinat-
ing their efforts.

a sustaining role. A voluntary health
agency’s purposes and efforts are so in-
terwoven with the people of a com-
munity that they provoke and sustain
public support of necessary health ac-
tion with respect not only to their own
programs but also to the health con-
cerns of government and of other volun-
tary agencies.

a stimulating and initiating role. Be-
cause they are free to organize to meet
needs as they are seen locally and na-
tionally, voluntary agencies may experi-
ment with new programs of yet un-
proven value, and conduct investigation
or demonstration to develop the meth-
odology or to prove the value of par-
ticular programs. While not unique to
voluntary agencies, this is an area in

17
''which their flexibility and freedom gives
them great potential. In this respect vol-
untary funds might be called “venture
capital” in the health services field.

5. an expressive role. The voluntary agency
provides for anyone an opportunity to
say to his community or to some seg-
ment or individual within the commun-
ity “I care”; to find a suitable channel
through which his concern for others
can be expressed in tangible action. It
offers an opportunity to improve one’s
capacity to help, by increasing knowl-
edge or skill, or by organizing efforts so
that people who need help and those
who can give it are brought together.
Thus the voluntary agency, whatever its
size, combats the depersonalizing influ-
ence of bigness and of over-profession-
alization for the donor as well as for
the recipient of services.

These roles are carried out by national,
state, or local voluntary health agencies. The

18

particular functions and contributions of the
national agency lie in its ability and responsi-
bility for attack on health problems through
the accumulation of knowledge and experience
to develop research, to develop programs of
education of the public and professional per-
sonnel, and to encourage and guide commun-
ity programs of research, education, and
service.

The development in a community of a pat-
tern of health services that will take account of
the particular contribution to be made by
voluntary agencies, government, and people
themselves and will be attuned to the realities
of community facilities and habits, demands
imagination. It is facilitated by national plan-
ning to set the general framework of purpose
and program, by regional or state planning to
establish administrative structure, and by
local program planning at the level where the
work will ultimately get done. The voluntary
agency has a key role to play in the process of
welding together the effort of private and pub-
lic agencies into a unified, effective whole)
''CHALLENGES AND

In rapidity of development and variety, the
_ course of the national voluntary health agen-
cies has paralleled that of most other aspects
of life in twentieth century America. Growth
and diversification have characterized progress
in our economy and in our society in recent
decades. The effects of these conditions are
prime factors in creating the major challenges
and issues with which the national voluntary
health agencies are faced today. They have
earned great volunteer interest and financial
support. As mature agencies they must be
responsive to criticisms and question both
those they themselves are aware of and also
those brought to their attention through pub-
lic concern.

The question is frequently asked as to
whether there are not too many national agen-
cies, and whether there are not duplication and
waste of effort in the many programs which
seem directed toward meeting rather similar
needs. The establishment of new agencies,
particularly those concerned with a single dis-
ease, has greatly increased the number of
appeals for public support of programs of re-
search, education, and services which appear
to correspond closely to other programs al-
ready in existence. This question has several
different aspects. Some overlapping of interest
and activity does exist among the agencies,
resulting from the zeal and desire of citizen
groups to do something about a problem, or
specific aspects of a problem, promptly and
aggressively. In the final analysis by giving or
withholding support the community decides if

-

ISSUES

the services of a given agency will be con-
tinued. However, the agencies need to make
a serious effort to identify the areas where
undesirable overlapping exists and to seek op-
portunities to enhance cooperation, to elimi-
nate duplication without restricting their ca-
pacity to explore for valid new enterprises,
and to merge the efforts of groups when this
is consistent with their mutual interests and
the interests of those whom they were organ-
ized to serve.

On the other hand, there are few commun-
ities in the country where the needs are so
adequately met that there is no place for added
citizen interest. There are likewise few, if
any, problems of health or disability about
which there is nothing more to be learned, as
to prevention, treatment, or cure. Therefore
there will always be areas of need, and hope-
fully always individuals who want to associate
with others to do something about them. Their
basic right and freedom to do so is inherent
in our democratic society.

Overlapping of interest and diversity of
approach have yielded great benefits to man-
kind in many areas of endeavor. Competition .
itself is an excellent antidote for complacency.
All can be desirable if it means that different
groups are working constructively on needed
programs even though they involve the same
or closely related problems. Medical and sci-
entific advances constantly open up new ave-
nues for research and hold out hope that it
may in time become possible to prevent, treat,
or cure even those diseases and conditions

19
''about which nothing can now be done. With
all the possibilities, there is room for several
approaches to a many-faceted problem which
may at a given point in time be pursued by
different agencies.

There is need for more study and considera-
tion before it is determined whether or not a
new national organization is needed and be-
fore an attempt is made to organize one. Be-
fore such an organization attempt judicious
consideration should be given to the following
questions:

1. Is the problem one that is national in

scope?

2. Is it a problem that is likely to be af-
fected by community action as differ-
entiated from governmental action?

3. Is the action required sufficiently inten-
sive and widespread to justify national
action?

4. After careful review of existing pro-
grams, can it be determined that the
proposed action could not be achieved
as well by an existing agency?

5. Is the cause one that will be able to ac-
quire the necessary professional direc-
tion?

6. Can the proposed new organization
achieve a structure that will provide
controls to assure efficient and effective
operation, including a board of direc-
tors, standards for local affiliation, staff,
etc.?

7. Is the need a long-term one, or might
the objectives be better accomplished
by some other mechanism than a na-
tional voluntary health agency, such as
short-term commissions which have
functioned well in certain areas, for ex-
ample the Commission on Chronic III-
ness?

Mergers of existing agencies may be ef-
fected when their purposes are so closely
related that a combined program can be ex-
pected to yield greater benefits. Mergers have
occurred in the past and continue to take
place from time to time. In the field of heart,
cancer, mental health, and social hygiene, for
example, such amalgamations have been suc-
cessfully accomplished. Others have failed, but

20

there has been sufficient effort of this kind to
encourage the hope that it can be successful
in other instances.

Alertness on the part of the agencies for
opportunities to consolidate their interests,

areness of changing needs, and, above all,
a willingness to keep the “cause” itself and not
the “agency” in the center of attention are
qualities which should be cultivated and which
if they are maintained will help prevent un-
desirable duplication, Volunteer boards of
trustees have a great’ responsibility in this
regard and if progress is to be made they must
exercise that responsibility.

Mergers are not easily accomplished, and
when they cannot be achieved, self-appraisal
and evaluation of what an agency is doing in
the light of services of others frequently will
lead to greater coordination of effort and im-
proved quality of services, with resultant re-
duction in duplication.

Multiplicity of agencies, and consequently
of fund-raising appeals, is at the heart of the
much publicized controversy between the pro-
ponents of United Funds and other forms of
federated fund raising and the national inde-
pendent fund-raising organizations. United
Funds, dedicated to the consolidation of cam-
paigns in the asserted interests of efficiency,
lower costs, and reduced annoyance and con-
fusion for the giving public, have in many
areas of the country sought to bring affiliates
of the so-called “independents” under the
once-for-all umbrella. Many of the national
agencies, convinced that continuation of in-
dependence and success in pursuing their goals
are inextricably tied to freedom of direct ap-
peal to the public on their own behalf, have
established policies which prohibit affiliates
from joining United Funds. Other national
agencies have policies with varying degrees of
permissiveness. Both types of policies have
led, in many instances, to acute differences of
opinion as to which way is the right one for
a given community.

There appear to be merits on both sides of
the frequently stated case. It is self-evident
that the public is asked to support a myriad
of causes but that such support is voluntary.
It is also indisputable that the public gives
''freely, even though on octasion there is evi-
dence of restiveness with respect to an ever-
growing number of appeals. The right of a
community to determine how it will support
its voluntary health services and the equal
right of a bona fide philanthropic organiza-
tion to determine how its funds should be
raised and spent are twin factors of equal
validity and importance.

The issue is not one which will be resolved
easily. Pressure or coercion on the one side,
or blind adherence to policy on the other will
contribute nothing to the growth and develop-
ment of health services, and is inconsistent
with the character of voluntary philanthropy.
Statesmanship and good will on the part of the
volunteers, many of whom work both for
United Funds and for the independent agen-
cies, are necessary to the development of a
pattern of co-existence. The danger in the
controversy is that the good interest behind
the philanthropy will be obscured or dissipated
in the excessive attention and controversy
over the mechanics of fund raising. It is this
danger to which those who are concerned
should be most on guard. Total level of phi-
lanthropy in this country is high but the pro-
portion of support from this source in the
health field has somewhat decreased. Philan-
thropy needs encouragement and the public
must not loss sight of the importance of these
national voluntary health agencies through
controversy. Criticism of multiple solicitation
could easily be an excuse for those who wish
to justify decreased support for these impor-
tant programs.

Overall, the community’s concern for health
should provide scope for the expression of
volunteer interest which is committed to cer-
tain causes, whether they be heart, cancer,
crippled children, or others, while at the same
time it assures enough leadership and alert-
ness to see and act on other needs.

Regardless of differences of opinion and
approach on fund raising, joint community
planning and cooperation among agencies in
the development of services are essential and
should not involve the question of participa-
tion in federated fund-raising drives. The na-
tional agencies have a major responsibility to

conduct themselves in full recognition that the
right of voluntary association does not confer
the right to disregard the essentiality of joint
planning for services, nor to program without
regard for the mechanics of such planning.
Among themselves and together with other
private and public organizations, the volun-
tary health agencies must engage in a con-
tinuing process of clarification of goals and
adjustment of interrelationships and respon-
sibilities in the light of current needs and,
specific situations, keeping their major focus
on helping people and not on perpetuating
agencies.

Continuing community health councils or
other health planning bodies should be so de-
veloped as to make possible full democratic
representation and organizational and finan-
cial participation by all agencies serving the
health needs of the community. This is un-
fortunately not always the case, and there
have been instances where agencies not affili-
ated with Community Chests or United Funds
were discouraged or even prevented from par-
ticipation in community planning groups. The
National Health Council in 1959 issued a set
of important guides for participation in com-
munity health planning for national health
agencies and local affiliates. Three major
points having a bearing on the concerns ex-
pressed by national agencies and some of their
affiliates in this connection were emphasized:

1. Community planning bodies for health
improvement should be fully represent-
ative of all forces which can contribute
to effective health planning.

2. Community planning bodies for health
improvement should be adequately fi-
nanced through the support of par-
ticipating organizations, although no
organization should be barred from par-
ticipation if unable to contribute finan-
cially to the support of the community
planning body.

3. Community planning bodies for health
improvement must be free from control
by any one member agency or special
interest.

Careful adherence to these principles will

greatly facilitate the full participation of volun-

21
''tary health agencies, including the local affili-
ates of national organizations, institutions, and
hospitals; official agencies; professional socie-
ties and associations; business, labor, and civic
organizations; consumer groups; and citizens
at large. Only with such participation can the
most effective planning for the improvement
of community health services be accomplished.

Planning on a scale larger than the local
community involves the full application of all
facets of interplay between voluntary agency
and government programs, and recognition of
their increasing interdependence. Wisdom dic-
tates that‘there be no effort to make arbitrary
assignment of some areas of activity to volun-
tary and others to government programs, but
rather that they be mutually complementary
and supportive. Voluntary agencies will need
to retain and exercise their freedom to cru-
sade and stimulate. Government support of
voluntary services in the form of grants or pur-
chase of service can be important to their
growth, but care should be exercised that sup-
port of this type does not undermine the es-
sential independence of voluntary effort.

The national voluntary health agencies are
continually challenged to demonstrate their
flexibility and receptivity to change. This chal-
lenge can be met if they are willing to examine
and reassess their objectives and structure and
to adjust in the light of changing health needs,
a mobile and growing population, and new
programs, both private and governmental. Be-
cause of the very nature of the agencies in
their dedication to a certain cause, with com-
mitment of interested volunteers, there is the
ever present hazard that they will become fixed
in patterns of operations and services. At-
tachment to time-honored ways of doing
things should never be allowed to long resist
needed changes.

A further issue before the national volun-
tary agencies is the implementation of uni-
form accounting and reporting procedures
which will make their respective reports com-
parable as well as understandable and inform-
ative to the public. There is no dispute over
the desirability of such uniform procedures,
nor over the responsibility of the agencies in
this regard.

22

Accountability, however, is measured by
more than financial reports. Exercise of the
responsibility implicit in the freedom to or-
ganize and to solicit funds also involves the
conduct of services of high quality, staffed by
qualified personnel, directed by boards of
trustees of stature and community standing,
and guided by appropriate professional ad-
visors. Agencies should examine whether their
annual reports and other informational ma-
terials effectively interpret what they are ac-
tually doing and how they are doing it. Mem-
bers of the public, on the other hand, also
have a right and responsibility to inquire into
agency services and operations.

The subject of scrutiny and regulation by
municipal and state governmental authorities
needs to be thoughtfully approached, bearing
in mind the legitimate right of the public to
have full information, and also with recogni-
tion of the hazards of imposing systems which
will be unduly burdensome and expensive.
Submission of data and registration by the
state or national agency on behalf of affiliates
would seem to provide adequate protection
with savings in terms of efficiency and funds.
Along these lines, there is a need for model
state legislation which would serve as a guide
and be conducive to a more orderly approach
to the matter.

Among the more urgent problems of the
national agencies is that of maintaining suffi-
cient numbers of qualified staff. Greater efforts
need to be devoted to recruiting and training
top-level staff leadership in organization and
administration, in addition to the professional
personnel which will be required in ever-
increasing numbers to man service programs.

Not only adequate financing, but the con-
tinued growth of the national agencies, will
depend on their success in creating a larger
and more deeply committed body of volun-
teers. More people need to be brought more
intimately into contact with service programs,
and intelligent and informed interest in specific
problems needs to be cultivated. The agencies
need to evaluate the use they are making of
volunteers and develop means for involving
them more deeply in relationships with the
people who are served.
''To the meeting of these issues the national
voluntary health agencies bring a wealth of
experience and a background of remarkable

achievement. These will be greatly needed in
the years ahead if America is to realize the
promise of ever better health for all its people.

VOLUNTARYISM IN THE FUTURE

The national voluntary health movement in
this country has flowered out of the funda-
mental and precious heritage of philanthropy
and voluntaryism. For our society as we con-
ceive of it now and as we envision its future,
freely given support for those in need is the
breath of life. Its manifestation through the
national voluntary health agency has been of
deep and significant import to the health of the
nation. Programs of these agencies have done
much to educate the public on health and dis-
ability and on the positive things which can be
done to improve the one and diminish the ef-
fect of the other. They have stimulated and
supported great legislative and research pro-
grams, while pioneering in the establishment
of projects which have vividly demonstrated
the possibilities for better and more productive
lives for millions of people. Their own re-
search has produced imposing results and
promises further contributions to basic knowl-
edge of man’s ills. Thousands of communities
across the nation have new and improved
health services, rehabilitation centers, and ed-

ucational services as a result of their activities.

Particularly in this country national volun-
tary health agencies as we know them function |
as a dynamic and leading force in promoting |
the health of the public. They are as American |
as our form of democracy and we are as well |
known by them in many parts of the world as |
we are by other attributes of freedom. Preser- |
vation of these freedoms and of our way of
life must be by conscious acts on the part of
the American people. If voluntaryism and
philanthropy are to be kept alive in all areas
of endeavor, it will mean service and partici-
pation by more and more people who work at
it: people who inform themselves and help to
solve problems.

The future success of the national voluntary
health agencies is wholly dependent on the de-
gree to which we are willing to support and
improve. our free institutions. Current chal-
lenges and issues can be met if they are |
clearly perceived and tackled with good will |
and with faith in the essential rightness of the |
system.

23
''''ev deys

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About The National Health Council

The National Health Council, established in 1921 and
consisting, in 1962, of seventy-five national organizations con-
cerned with health preservation and improvement, is a con-
ference ground for all elements of the health movement. Its
functions include:

1. Helping member agencies work more effectively to-
gether in the common interest.

2. Helping identify, call attention to, and promote solu-
tions of, national health problems.

3. Promoting better state and local health services,
whether governmental or voluntary.

 

 
''OFFICERS

  
  
 

National
Health

1790 BROADWAY e@ NEW YORK 19, N. Y.

.. President-Elect

7 Vice Presidents

stant Treasurer

cutive Director

ACTIVE MEMBERS

 

 

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