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The care of the chronically ill; a survey of the existing facilities and needs of Vancouver McFarland, William Donald 1948

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Of-1 THE CARE OF THE CHRONICALLY ILL A Survey of the Ex i s t i n g F a c i l i t i e s and Needs of Vancouver. hy ULLIAM DONALD McFARLAND Thesis Submitted i n P a r t i a l Fulfilment of the Requirements f o r the Degree of MASTER OF SOCIAL WORK i n the Department of Social Work 1 9 4 - 8 K^Tj The University of B r i t i s h Columbia Abstract This study surveys the resources, f a c i l i t i e s f o r care and medical treatment provided f o r the chronically i l l of . Vancouver. The h i s t o r i c a l development of the problem has been b r i e f l y covered, also, the probable future situations which w i l l a r i s e . As the care of the chronically i l l has become one of the major public welfare problems i n the post-war period, the economic circumstances and implications of chronic i l l n e s s have been emphasized. Each of the i n s t i t u t i o n s described was v i s i t e d and over two hundred chronically i l l patients personally i n t e r -viewed. More than four hundred f i l e s and records were read i n various s o c i a l agencies; information was also secured from interviews with administrators, directors and owners of the various services described. The survey reveals many problems and inadequacies. Hospital, c l i n i c a l and custodial f a c i l i t i e s f o r the most part are seriously inadequate and not always properly u t i l i z e d . A confused administrative structure and an unsatisfactory d i v i s i o n of r e s p o n s i b i l i t y are further obstacles t o more ef f e c t i v e co-ordination. Recommendations for the improvement of existing situations and the creation of new services are made. The importance of the s o c i a l caseworker i n the establishment of an e f f e c t i v e treatment program for the chronically i l l i s stressed. Table of Contents Chapter I . The Nature of Chronic I l l n e s s The u n i v e r s a l i t y of the.problem; P a r t i c u l a r aspects of chronic diseases; What i s chronic i l l n e s s ? The chronically i l l i n Vancouver; The purpose of the study. Chapter I I . The Acute General Hospitals and the Chronically 111 The ce n t r a l i z a t i o n of the problem i n the Vancouver General Hospital; The Outpatients' Department of the Vancouver General Hospital; St. Paul's Hospital, St. Vincent's Hospital. Chapter I I I . "B" Class I n s t i t u t i o n s f o r the Care of the Chronically  111 i n Vancouver. Glen Hospital; Grandview Hospital; Heather Street Annex; St. Joseph's Oriental Hospital (Chronic Section); . The Holy Family Hospital; The Private Nursing Homes and Small Private Hospitals; The Marpole Infirmary and i t s subsidiaries - Mount St. Mary and A l l c o . Chapter IV. S o c i a l Assistance and the Chronically 111 The assumption of the r e s p o n s i b i l i t y of providing boarding-home and nursing-home care by the C i t y S o c i a l Service Department; Control over Glen and Grandview Hospitals. Chapter V. The Chronically 111 as Individuals Ten case studies i l l u s t r a t i n g a number of the socio-medical problems faced by the chronically i l l ; P a r t i c u l a r emphasis i s l a i d on the economic problem of chronic disease. Chapter VI. The Essentials of a Community Program The effect of divided r e s p o n s i b i l i t y ; The required f a c i l i t i e s f o r effective care. The need f o r a chronic h o s p i t a l . Care for those not i n need of chronic h o s p i t a l accommodation; The need for a scale of s o c i a l allowances based on need; An improved administrative structure. Chapter V I I . The Social Worker and the Chronically 111 Casework services available f o r the chronically i l l ; New casework services at St. Paul's Hospital; The need for a trained social worker at the Marpole Infirmary and i t s subsidiaries; Casework services f o r patients i n a Chronic Hospital; The s o c i a l worker and the mobilization of community resources. Appendices A - Services f o r the Chronically 111. not properly included i n the main study. B - S t a t i s t i c a l Tables Dealing With Occupants i n Glen,. Grandview and Heather Street Annex Hospitals, Marpole Infirmary. C - Bibliography. Tables i n Text Page Table A Reasons f o r Patients Being i n Vancouver General Hospital f o r ninety days or over. 28 Table B Length of Hospitalization period of long-term occupants of acute beds. 29 Table C Age Dis t r i b u t i o n of these Patients 29 Table D Date of F i r s t Application f o r treatment at O.P.D. for f i f t y patients studied. 35 Table E Age Distribution of the f i f t y patients. 35 Table F Medical Diagnosis of the f i f t y patients. 36 Table G F i n a n c i a l Circumstances of the f i f t y patients 37 Table H Nursing Homes - Private Hospitals, Feb. 194-9 57 Table I Age Distribution of Patients i n the Marpole Infirmary. 64. Table Period of Hospitalization of Chronic Patients Marpole Infirmary, Vancouver, Feb. 1, 194-9 168 Table Type of Patients i n Marpole Infirmary, Feb. 1, 1949. 169 Table if Age Distribution of Patients i n Glen, Grandview and Heather Street Annex, Nov. 1, 194-8 170 Table M Types of Patients, Glen, Grandview, Heather Street Annex, Nov. 1, 194-8 171 / Tables i n the Appendix. Acknowledgement s I would l i k e to convey my sincere appreciation to the many s o c i a l agencies and i n d i v i d u a l workers who have been so helpful i n accumulating the information necessary to complete t h i s study. In pa r t i c u l a r , I would l i k e to express my appreciation of the assistance given to me by Miss Olive Cotsworth, R.N., Director of the Vancouver General Hospital S o c i a l Service Department, Miss Mary Maclnnis, also of that Department; Mr. J . I . Chambers, Administrator of the City S o c i a l Service Department and Miss Mae McKenna, nurse-iii-charge of the Medical Section of the City Social Service Department; Mrs. Mary Law, Superintendant of Infirmaries; and the many i n d i v i d u a l workers i n the City S o c i a l Service Department and the Vancouver General " Hospital S o c i a l Service Department who so generously gave a great deal of time i n providing and checking my information. My sincere thanks also to Dr. L. C. Marsh of the Department of Soc i a l Work University of B r i t i s h Columbia f o r the valuable help that he provided. THE CARE OF THE CHRONICALLY ILL A Survey of Ex i s t i n g F a c i l i t i e s and Needs of Vancouver. Chapter I The Nature of Chronic I l l n e s s The provis ion of f a c i l i t i e s and funds for the care and treatment of thousands of chron ica l ly i l l and incapacitated people has become the most pressing publ ic welfare issue of the post-war per iod . S o c i a l assistance payments fo r the maintenance and care of the chronica l ly i l l have doubled and even t reb led wi th in the past ten years . In Canada, s o c i a l assistance i s avai lable only t o the unemployable, and, of the' population included i n t h i s category, the ch ron ica l ly i l l represent an unprecedented and exceptionally high proport ion. For every person known t o the publ ic welfare au thor i t i es there are two others, e i the r i n p r iva te hospi ta ls or i n t h e i r homes, who are f i n a n c i a l l y independent and able to carry on without requir ing publ ic ass is tance. Thousands of ch ron ica l ly i l l . persons are known only t o the pr iva te physicians who give them per iodic check-ups and prescribe t h e i r medicines. Considering the high cost of prolonged medical and hosp i t a l care i t i s remarkable that the proportion i n receipt of publ ic assistance i s not greater . Chronic i l l n e s s knows no economic boundaries; the r i c h man i n the comfortable mansion i s jus t as l i k e l y to be a v i c t i m of a chronic cardiac condit ion as the o ld age pensioner i n a cheap house-keeping room along the waterfront. The man i n the street i nva r i ab ly thinks of a chronic i n v a l i d as a person of advanced age suffering from an incurable disease. I t amazes most people to l ea rn that over h a l f the patients i n i n s t i t u t i o n s - 2 -f o r the ch ron ica l ly i l l are under the age of fo r ty j a l so , that a person can be chron ica l ly i l l for fo r ty years and not miss a day's work. Dr . E rns t . P . Boas, d i r ec to r of the famous Montefiore Hospi ta l f o r Chronic Diseases i n New York and an outstanding authority on chronic diseases, gives these s t a r t l i n g f igures : "Eight per cent of persons wi th chronic i l l n e s s e s are chi ldren under the age of f i f t e en ; eight per cent, i nd iv idua l s between the ages of f i f t een and twenty-f ive; one t h i r d are young adults from twenty-five t o for ty- four years of age; one t h i r d are i n the age group between f o r t y -f ive and s ix ty- four and sixteen per cent are s i x t y -f ive years of age or o lde r . The problem i s one of the productive years of l i f e . F u l l seventy per cent of the cases occur i n persons under f i f t y - f i v e years of age."( l ) To most l a y people the terms. "chronic" and "incurable" have become synonymous. The word "chronic" usua l ly conjures up a p ic ture of a bed-ridden o ld man or woman who has not many more days t o l i v e . This stereotyped idea has unfortunately affected government th ink ing so that the procuring of any s izable appropriation from government funds for more adequate i n s t i t u t i o n a l care of the ch ron ica l ly i l l i s at present an i m p o s s i b i l i t y . Mary C. Ja r re t t another outstanding American authori ty on chronic diseases, believes that the indifference and lack of understanding of the publ ic i s the greatest s ing le obstacle i n the way of implementing an adequate diagnost ic and treatment program f o r chronic diseases. She says: "The term ' ch ron ic ' has become so i d e n t i f i e d i n common usage with extreme bodi ly i n f i r m i t y that even those whose profession i s the care of the s i ck are apt t o forget that i t i s merely a way of expressing. (1) Boas, Ernst P . , M.D. The Care of the Chronica l ly 111. Reprinted from the Proceedings of the Nat ional Conference of S o c i a l Work -New York , Columbia Un ive r s i ty Press, 1939, Page 2. - 3 -t h e d i f f e r e n c e between a n a c u t e d i s e a s e , w h i c h comes s u d d e n l y and i n t h e c o u r s e o f a c o m p a r a t i v e l y s h o r t t i m e w i l l r e s u l t i n d e a t h o r c o m p l e t e r e c o v e r y , and a p r o l o n g e d d i s e a s e p r o c e s s , w h i c h u s u a l l y h a s a g r a d u a l b e g i n n i n g a n d l e a v e s t r a c e s o f permanent i n j u r y t o t h e body even when a p r a c t i c a l r e c o v e r y has b e e n made. P a r t l y b e c a u s e i n t h e d i s e a s e s , c l a s s e d as c h r o n i c , t h e r e i s r a r e l y a c o m p l e t e r e s t o r a t i o n o f f u n c t i o n i n t h e body c e l l s a f f e c t e d , and p a r t l y b e c a u s e b e c a u s e m e d i c i n e h a s begun t o g a i n knowledge o f t h e n a t u r e and t r e a t m e n t o f t h e s e f o r m s o f d i s e a s e c o m p a r a t i v e l y r e c e n t l y , t h e y have been r e g a r d e d a s i n c u r a b l e ; so t h a t ' c h r o n i c ' a n d ' i n c u r a b l e ' have come t o mean t h e same t h i n g t o most p e r s o n s . " ( i ) A n o t h e r common m i s c o n c e p t i o n i s t h a t c h r o n i c d i s e a s e s a f f e c t o n l y t h e p o o r e r c l a s s e s o f s o c i e t y . T r u e , t h e p u b l i c w e l f a r e a u t h o r i t i e s know o n l y t h e c h r o n i c c a s e s i n t h e l o w e r income g r o u p s b u t t h e r e a r e t h o u s a n d s o f p e o p l e who l i v e w i t h t h e i r c h r o n i c d i s e a s e s w i t h o u t becoming a c h a r g e on t h e p u b l i c . P e o p l e who were i n d i g e n t s b e f o r e t h e y became c h r o n i c a l l y i l l a r e i n a d e f i n i t e m i n o r i t y . A d m i t t e d l y t h e m a j o r i t y o f t h e p a t i e n t s o c c u p y i n g beds i n c h r o n i c i n s t i t u t i o n s a r e p e o p l e w i t h o u t a n y income o r r e s o u r c e s ; b u t i t i s i m p o r t a n t t o remember t h a t i n a l m o s t n i n e t y p e r c e n t o f t h e s e c a s e s t h e c o s t o f p r o l o n g e d m e d i c a l a n d n u r s i n g c a r e , w h i c h c a n r e a c h f a n t a s t i c f i g u r e s a t t i m e s , h a s u s e d u p t h e s a v i n g s and r e s o u r c e s o f t h e s e p e o p l e u n t i l t h e y h a v e b e e n f o r c e d a s a l a s t r e s o r t t o become p u b l i c c h a r g e s . T h e r e i s , on t h e o t h e r h a n d , c o n s i d e r a b l e e v i d e n c e t h a t l o w income f a m i l i e s a r e more l i k e l y t o c o n t r a c t c e r t a i n c h r o n i c d i s e a s e s s u c h a s r h e u m a t i c f e v e r a n d t u b e r c u l o s i s ; b u t i t c a n be s a i d w i t h o u t h e s i t a t i o n t h a t when c h r o n i c i l l n e s s s t r i k e s a f a m i l y , w h e t h e r i t be r i c h o r p o o r , t h e i m p a c t i s e q u a l l y d e v a s t a t i n g w h a t e v e r ( l ) J a r r e t t , M a r y C . C h r o n i c I l l n e s s i n New Y o r k C i t y . V o l . 1 . T h e P r o b l e m s o f C h r o n i c I l l n e s s ; W e l f a r e C o u n c i l o f New Y o r k C i t y , New Y o r k , C o l u m b i a U n i v e r s i t y P r e s s 1 9 3 3 , Page 2 . - u -the income l e v e l . The importance of environment upon chronic i l l n e s s i s s t i l l important. I t has sometimes been sa id that "poverty breeds chronic disease". Poor housing, l ack of proper san i t a t ion , l ack of proper food and warm c lo th ing and often l a ck of medical care accentuate the problem of chronic i l l n e s s amongst the lower income groups. Dr . Boas says tha t : "There i s hardly a fami ly , one member of which i s not s t r icken by some such i l l n e s s as heart disease, rheumatism, cancer or diabetes. He who has had personal experience wi th an i nd iv idua l disabled by a chronic i l l n e s s knows the cost that i t en t a i l s i n phys i ca l and mental suffering and knows fur ther how the presence of a chronic i n v a l i d conditions the l i f e of a whole fami ly . The presence of an i n v a l i d whose phys ica l and mental suffer ing, whose needs, des i res , whims and fancies are always i n the foreground, determines the work, the recreation and the development of the l i v e s of the other members of the f ami ly . Even i n a w e l l - t o -do home a chronic i n v a l i d i s a burden on the whole . household, among the poor these d i f f i c u l t i e s are /,-. accentuated and often lead to in to le rab le s i tua t ions ."* ' I t i s safe to say that the major causative fac tor behind the dependency of thousands of otherwise self-support ing fami l i e s upon publ ic assistance i s some form of chronic disease. A Massachussets survey found that the incidence of chronic i l l n e s s was f i f t y per cent higher among the poor than among those i n the higher income groups. Among fami l ies receiving some form of publ ic assistance, 6 2 . 3 per cent had members ( 2 ) suffering ffom chronic disease. In a survey of chronic disease i n Cleveland, Mary C. Jarre t t a r r ived at t h i s conclusion: "The frequency of chronic i l l n e s s has been found i n various surveys t o increase wi th the ( l ) Boas> Ernst P . , M.D. The Unseen Plague. Chronic Disease. New York, J . J . August i n Inc . 1 9 4 - 0 , Page 14- . ( 2 ) I b i d . . Page 3 0 . - 5 -decrease of income. The incidence of chronic d i s a b i l i t y i s much more serious amongst the low income groups. Richard Conant, another American author i ty on chronic disease, claimed that chronic i l l n e s s was the greatest s ingle cause of poverty i n the United States, being responsible, by a conservative estimate, for twenty (2) per cent of i t . Pa r t i cu l a r Aspects of Chronic Diseases The number of deaths from contagious and infec t ious diseases has decreased i n recent decades but the deaths from chronic diseases have increased. Great s t r ides have been made i n the past century i n lowering the rates of infant morta l i ty and deaths from communicable disease. Deaths from tuberculosis have decl ined great ly and deaths from pneumonia have become comparatively ra re . As a resu l t of improved diagnostic and publ ic health f a c i l i t i e s , cancer and hear diseases have supplanted infec t ious diseases as the leading causes of death. In 1900 the f i ve leading causes of death i n the United States were l i s t e d as ( l ) tuberculos is , (2) pneumonia, (3) e n t e r i t i s , typhoid fever and other i n t e s t i n a l diseases, (4) heart disease, (5) cerebral haemorrhage and thrombosis. By 194-5, pneumonia, e n t e r i t i s and typhoid fever were at the bottom of the mor ta l i ty l i s t s . Tuberculosis i s no longer the major cause of death. Heart diseases are now far out i n the lead i n the number of deaths wi th cancer second on the l i s t . Cerebral haemorrhage and thrombosis have moved up to t h i r d place wi th f a t a l accidents (1) J a r r e t t , Mary G . , Care of the Chronica l ly 111 of Cleveland and Cuyahaga County. Cleveland, The Benjamin Rose In s t i t u t e 1944, Page 3. (2) Conant, Richard K . , Chronic Disease and the Pub l i c Welfare. The Commonwealth. Quarterly B u l l e t i n of the Mass. Dept. of Pub l ic Health, Vol.16, No. 4, Qct-Nov-Dec 1929, Page 112. - 6 -occupying the four th pos i t ion ( l a rge ly because of the great increase i n (1) automobile t r a f f i c ) . Nephr i t i s now holds f i f t h place . In 1947 the f i v e leading causes of death i n Canada were ( l ) diseases of the heart, (2) cancer and other malignant tumors, (3) v io l en t deaths, (4) neph r i t i s , (2) (5) diseases pecul ia r t o the f i r s t year of l i f e . Unfortunately morta l i ty s t a t i s t i c s do not give any i n d i c a t i o n of morbidi ty . A person wi th a cardiac disorder may l i v e one day or he may l i v e t h i r t y years af ter the onset of h i s i l l n e s s . Deaths from a r t h r i t i s are recorded low i n the mor ta l i ty t ab l e s , but an except ional ly high number of beds i n i n s t i t u t i o n s car ing for chronic i nva l id s are f i l l e d wi th a r t h r i t i c s because of the long term, c r i p p l i n g nature of t h i s pa r t i cu l a r disease. Seventy years ago chronic diseases caused only one-fif teenth of the deaths i n the United States; today they are responsible fo r as many as one-half . Chronic diseases have become not only a major cause of death but a l so a major cause of i l l n e s s and i n v a l i d i t y . As has been pointed out before, years of sickness may precede death from a chronic i l l n e s s but l ay people looking at morta l i ty tables f a i l t o take t h i s i n t o considerat ion. Dr . Boas speaks very strongly about t h i s point : "Although the pest i lences have been brought under con t ro l , the great volume of chronic diseases form a plague of .as great proportion as any to which mankind has been subject . I t i s a hidden and ins id ious plague, lacking the dramatic and fearsome q u a l i t i e s of a major epidemic. I t i s t h i s that makes i t a l l the more deadly for i t s wide range i s hardly recognized; society has not yet learned of the t o l l that chronic (1) Medical Science and the Longer L i f e , Science. V o l . 107, No. 2778 March 26, 194-8. Published by the American Associa t ion for the Advancement of Science; Business Press Incorporated, Lancaster, Pennsylvania 194-8. (2) Canada, Department of Trade and Commerce, Dominion Bureau of S t a t i s t i c s , The Canada Year Book 194.7. Ottawa, K ing ' s P r i n t e r , Page 167. - 7 -disease takes i n i l l n e s s , death and cause of des t i tu t ion and of family l i f e there i s no r e a l i z a t i o n that they are ever present and inescapable, that they occur at a l l ages, and that i f we are spared them i n our youth, they w i l l almost inev i t ab ly overtake us i n our older years? In 1935 i t was estimated that one per cent of the population of (2) the United States were chronic i n v a l i d s . Canada now has an estimated population of twelve m i l l i o n people. On the basis of t h i s f igure there are 120,000 people suffering from one. of the chronic diseases i n t h i s country. This f igure may seem to be except ional ly high but surveys car r ied out i n various c i t i e s i n the United States apparently confirm i t . The Massachusetts Department of Health found, i n a house-to-house survey covering most of the s tate , that one i n every one hundred and nine persons was completely disabled by chronic i l l n e s s , - inc luding tuberculosis and mental diseases. The Counci l of S o c i a l Agencies i n Boston estimated that the ch ron ica l ly i l l i n that c i t y , excluding tuberculosis and mental diseases, numbered one i n every one hundred and f i v e persons i n the c i t y . A Phi ladelphia survey estimated that i n i n d u s t r i a l c i t i e s , one out of every two hundred ind iv idua l s were disabled by some form of chronic i l l n e s s . The uni ted States Pub l i c Health Survey, conducted on a na t ion-wide basis and involv ing m i l l i o n s of people i n 1935, estimated that 23,000,000 persons i n the United States had some chronic disease or permanent impairment; of these 23,000,000 persons, 1,500,000 were permanent i n v a l i d s . ^ Despite a l l the f igures to the contrary about the number of (1) Boas, Ernst P . , M. D . , The Unseen Plague. Chronic Disease. J . J . August i n Inc . 194-0, Page 14* (2) I b i d . . Page 7. (3) I b i d . . Pages 7 - 8 . - 8 -ch ron ica l ly i l l people i n the lower age groups, the fact s t i l l remains that the majority of the patients i n beds i n chronic i n s t i t u t i o n s i n both Canada and the United States are over seventy years of age. In the Montreal survey of chronic diseases conducted under the auspices of the Metropoli tan L i f e Insurance Company, i t was found that almost h a l f of (1) the patients i n chronic i n s t i t u t i o n s were over the age of s i x t y . Another in te res t ing fact discovered was that the age group of greatest concentration among the aged i s ten years l a t e r fo r females than for males, (2) which re f l ec t s the greater longevi ty of females. The majority of these pat ients were suffer ing from degenerative diseases which were the d i rec t r e su l t of the great s t r ides made by the medical profession i n prolonging the human l i f e t o twice what i t used to be. E f fo r t s i n t h i s d i r e c t i o n are being pressed s t i l l further , and, as the number of the aged increase, so w i l l the numbers of chronica l ly i l l older persons. In the United States i t was estimated i n 194-0 that seven per cent of the population was over the age of s i x t y - f i v e . By 1970 i t i s estimated that ten per cent (3) of that country's population w i l l be over the age of s i x t y - f i v e . In 1900 the l i f e expectation of a male American at b i r t h was 48.23 years, that of a female being 5 1 . 08 years . By 1942 i t had been extended to 6 3 . 6 5 years for males and 68.61 for"females. Thus, male expectation of l i f e has increased f i f t een years since the beginning of the century, (1) Specia l Committee of Montreal S o c i a l Workers (Mrs. M. A . Lanth ie r , Chairman), The Case of the Chronica l ly 111 i n Montreal . Metropoli tan L i f e Insurance Company, Canadian Head Office Ottawa. 1941, Page 5 . (2) I b i d . . Page 11 . (3) Durand, John D. The Trend Toward an Older Populat ion, The Annals of the American Academy of P o l i t i c a l and S o c i a l Science. V o l . 237, January 194-5, Page 14-2. - 9 -and the average length of l i f e has been increased by p r a c t i c a l l y one !anac (2) t h i r d i n fo r ty y e a r s . ^ The l i f e expectation of a C nadian male i n 1942 was 63.0 years at b i r t h and for a female 66.3 years. These f igures give some ind ica t ions why the problem of car ing for the chron ica l ly i l l i s becoming more ser ious. Medical science, coupled with' better publ ic heal th measures, better s o c i a l services and reduced maternal mor t a l i t y , has succeeded i n prolonging l i f e , now i t s task must be an effort to succeed equally as w e l l i n caring fo r those whose l i f e has been prolonged, only t o spend t h e i r l a t e r years i n helpless misery and suffer ing. Hospi ta ls fo r the chronica l ly i l l are crowded wi th people whose bodies have simply worn out. What i s Chronic T i l n e a p Up to t h i s point only the more general aspects of chronic diseases have been discussed. I t i s necessary, however, to decide what i n f i r m i t i e s are included under chronic i l l n e s s e s and jus t how a chronic i l l n e s s d i f f e r s from an acute i l l n e s s . Spec ia l ized de f in i t i ons of chronic i l l n e s s are as many and var ied as the number of diseases known to medical science. Most of the de f in i t i ons agree on two facts however. Chronic disease i s usua l ly the name' given to a disease of long and i n d e f i n i t e duration which can be a l l e v i a t e d but only i n rare instances, cured. In the Montreal survey a ch ron ica l ly i l l person was defined as one whose (1) Dubl in , Louis and L o l k a , A l f r e d ; Trends i n Longevity, Annals of the American Academy of P o l i t i c a l and S o c i a l Science V o l . 237, January 1945, Page 123. (2) Canada, Department of Trade and Commerce, Dominion Bureau of S t a t i s t i c s , The Canada Year Book 194-7 Ottawa, K i n g ' s P r i n t e r , Page 160. disability was of three months duration or more, and who was therefore i incapable of following the daily routine of an average normal individual and whose disability would continue for an indefinite period. ^  Doctor Boas does not attempt to define chronic disease, but instead sets out the boundaries within which he thinks a chronic disease f a l l s . He maintains that nchronicity is a concept, so that no classification of disease as acute or chronic can be absolute". It is his opinion also that "whereas chronic diseases are insidious in their onset and slowly progressive, acute diseases have a self limited course from which a person either recovers completely or dies. The course of chronic diseases extend over months or years; there may be arrest of the morbid process, but (2) there is never complete restoration to normal." In the National Health Survey of 1935 in the United States a chronic disease was defined as a disabling or non-disabling chronic pathological condition known to the informant, the symptoms of which had (3) been recognized for at least fehree months. Private physicians and hospitals are prone to regard a chronic disease as one that may be expected to require an extended period of medical supervision and/or U ) hospital, institutional, nursing or supervisory care. (1) The Care of the Chronically 111 in Montreal. Metropolitan Life Insurance Co., 1 9 4 1 , Page . 5 . (2) Boas, Ernst P., M.D., The Unseen Plague. Chronic Disease. J. J. Augustin Inc. 194-0, Page 19. (3) Perret, F. St. J., The Problem of Chronic Disease, Psychosomatic Medicine. Vol. 7, January 194-5, Page 22. (4.) Rogers, E. C, Chronic Disease, A Problem that Must be Faced. American Journal of Public Health. Vol. 36, April 1946, Page 34-5. - 11 -Under one or other of these d e f i n i t i o n s , p r a c t i c a l l y every complaint l i s t e d i n the medical d ic t ionary could be c a l l e d a chronic i l l n e s s . Long term orthopedic cases, such as an e lder ly person with a broken hip bone, are ce r t a in ly i n need of prolonged hosp i t a l or nursing home care and i n many cases patients i n t h i s category never completely recover. Some hospi ta l au tho r i t i e s , even i n Vancouver, d e f i n i t e l y regard long term orthopedic cases as chron ica l ly i l l people. Mental diseases and mental deficiency are chronic diseases i n every sense of the word, but they are such a spec i f i c section of the whole f i e l d that i t i s questionable whether mental i l l n e s s and such diseases as diabetes and cardiac disorders should be discussed under the same general heading. S imi la r questions a r i se i n regard t o tubercu los i s . Although the contagious -aspects of tuberculosis are w e l l known, there are many persons wi th a chronic tuberculosis condi t ion that i s qui te as c r i pp l i ng and as incurable as the severest case of a r t h r i t i s . I s cancer an acute condi t ion or a chronic condition? I t seems reasonable t o assume that cancer i s an acute condition u n t i l the tumor becomes malignant and inoperable, o r , i n other words, t e rmina l . Many doctors and hosp i t a l au thor i t ies have widely d i f f e r i ng viewpoints about the disease of cancer. Which should be assumed correct? Pos t -pol io cases and paraplegics are ce r t a in ly incurable although i n many cases t h e i r condit ion may be improved. They are suffering from the af ter-effects of a disease or accident, but they have no disease symptoms which could be aggravated. In Ipract ical ly every study of chronic disease mental diseases and tuberculosis have been omitted. They are classed as spec i a l categories fo r which they f e e l reasonably adequate diagnost ic and treatment - 12 -f a c i l i t i e s have already been, provided. The general pub l ic a lso does not regard these two i l l n e s s e s as chronic diseases. Dr . Boas l i s t s the f i v e most prevalent chronic diseases as ( l ) rheumatism, (2) heart disease, (3) a r t e r i o - s c l e r o s i s and high blood pressure, (4-) hay fever and asthma, (5) hernia; and as causes of d i s a b i l i t y ( l ) nervous and mental diseases, (2) rheumatism, (3) heart disease, (4.) tuberculosis and (5) a r t e r i o - s c l e r o s i s and high blood pressure. The leading chronic diseases i n t h e i r order as causes of death are: heart diseases, cancer, a r t e r i o - s c l e r o s i s (and high blood pressure), » e p h r i t i s . ( l ) The duration of these diseases p r i o r t o death i s d i f f i c u l t t o estimate i n that i t depends on the nature of the disease, the treatment provided, the degree of accuracy with which the o r i g i n a l diagnosis was made and the stage at which the disease was recognized. In a Massachusetts survey i t was found that patients wi th untreated cancer l i v e d on an average of two years, those wi th a heart disease from seven t o nine years , those wi th chronic rheumatism fourteen years or more and person suffer ing from rheumatic fever l i v e d an average of f i f t een years af ter the onset of the i l l n e s s A chronic disease may vary widely from place t o place i n tgrms of prevalence, d i sab l ing effects and mor ta l i ty . Rheumatism, the most prevalent chronic disease, i s second as a cause of d i s a b i l i t y and fourteenth as a cause of death. Tuberculosis , although only f i f t een th i n prevalence, i s a major cause of d i s a b i l i t y and death. Heart diseases rank high i n prevalence, d i s a b i l i t y and mor ta l i ty . Rheumatism c r ipp le s ( l ) Boas, Ernst P . , M.D. The Unseen Plague. Chronic Disease. J . J . Augustin Inc . 194-0, Pages 8-9. - 13 -far more than i t k i l l s . I t i s a much more serious cause of i n v a l i d i t y than cancer, which ranks high as a cause of death. Organic diseases .of the nervous system cause d i s a b i l i t y and inva l id i sm of very long dura t ion . Pat ients wi th degenerative diseases of the nervous system form a large (1) proportion of those i n custodia l homes for the chronic s i c k . The Chronica l ly 111 i n Vancouver I t was estimated i n 194-7 that t h i r t y - f o u r per cent of the t o t a l population of B . C. and 4-3*5 per cent of the population of B . C. (2) . r e s id ing i n organized t e r r i t o r y , l i v e d i n Vancouver. The C i ty of Vancouver now has an estimated population of 376,000. Assuming that one per cent of the population i s usf fer ing from chronic disease, there are 3,760 people i n t h i s c i t y who can be classed as chron ica l ly i l l . This estimate i s probably very low. Ret i red people from a l l over the Dominion and espec ia l ly from the three p r a i r i e provinces are coming t o B r i t i s h Columbia i n ever increasing numbers. The moderate climate of Vancouver a t t rac ts hundreds of residents from out ly ing d i s t r i c t s of the province who wish to escape the r igours of the i n t e r i o r winters . Many of these are s i ck people suffering from one or another of the chronic diseases. They come to Vancouver where there are better opportunities fo r medical a t tent ion and where cheaper l i v i n g accommodation i s ava i l ab l e . Proof of t h i s i s found i n the number of o ld age pensioners i n Vancouver compared with the number i n the whole province. There are now (1) I b i d . . Pages 10-13 (2) Goldenberg, H. C a r l : P rov inc ia l -Munic ipa l Relat ions i n B r i t i s h Columbia. Report of the Commissioner, V i c t o r i a , K ing ' s P r i n t e r , 194-7, Page X 24-. (3) Figure given by the Assessment D i v i s i o n at the Vancouver C i t y H a l l , March 1, 194-9 for Vancouver proper. - H -approximately 9,000 old age pensioners in Vancouver. Well over four hundred field service reports were examined by the worker to find what proportion of these were in need of medical care. Almost every report read thus: "Pensioner has been having a great deal of trouble getting around because of his arthritis"; "Pensioner finds i t difficult to manage in his upstairs room because of his heart condition"; "Pensioner has considerable difficulty in walking because of a circulatory disorder" and so on without end. Another striking indication that the numbers of chronically i l l persons in this city are increasing rapidly can be found in the 194-8 annual report of the Victorian Order of Nurses, Vancouver Branch. In 194-7 the V.O.N. paid 15,060 visits to 364- chronically i l l patients. In 1948 they paid 20,013 visits to 516 such patients. Not only did the number of cases increase but also the average number of (1) visits per patient. A very high proportion of these patients were in need of much more than two or three visits a week by a visiting nurse. Most of them were people who should have been in nursing homes or boarding homes. A considerable number of these people were patients who would, under normal circumstances, be receiving active treatment in an acute hospital; but because of the chronic nature of their condition and because of the scarcity of hospital beds they found i t impossible to gain admission. Further indications of the increasing numbers of chronically i l l people coming to Vancouver are the long l i s t of Vancouver residents awaiting admission to the Infirmary, the great demand for private (l) Annual Report for the Year 194.8. Victorian Order of Nurses, Vancouver Branch. - 15 -nursing home accommodation despite their exorbitant rates and the ever-increasing numbers of chronically i l l patients being referred to the Vancouver General Hospital Outpatients* Department by physicians too busy to care for them. In 1946 there were only 3,802 institutional beds for the chronically i l l in the whole of Canada, of which 1,64-3 were in ten institutions in Ontario. At that time British Columbia had 3 6 4 . beds in the Marpole Infirmary and its subsidiaries.^ This number of available (2) beds in these provincial institutions had been reduced to 330. In addition to these, there were 220 beds for Vancouver cases available in Glen, Grandview and Heather Street Annex Hospitals. Shaugnessy Hospital and its subsidiaries provided about 150 beds for the institutional care of the chronically i l l veteran. Mount St. Joseph's Oriental Hospital has accommodation for thirty-five chronically i l l orientals. Private nursing homes bring the total available beds up to a maximum of 800 beds. Less than two thirds of the beds being used are occupied by Vancouver residents. The vast majority of these beds provide custodial care only, and in most cases no attempt is made to provide even a minimum of treatment facilities or more than nursing care. There is nothing except the Marpole Infirmary that even remotely resembles a real chronic hospital. It has been previously estimated that there are about 3,760 chronically i l l people in Vancouver with about one third (l,250) in need of accommodation in special institutions. (1) Annual Report of Hospitals in Canada for the Year 1946. Institutional Statistics Branch, Dominion Bureau of Statistics, Ottawa, King's Printer, Page 102 (2) Only about fifty of these beds are occupied by Vancouver residents. 1 - 16 -Only about one person i n f i f t y i n Vancouver knows that Glen, Grandview and Heather Street Annex Hospi ta ls even e x i s t . The majority of the residents of Vancouver believe that the Marpole Infirmary i s an o l d people's home and they are completely unaware of what i s being done there for the ch ron ica l ly i l l . Obviously the hospi ta ls and the C i t y S o c i a l Service Department cannot hope t o improve standards i n ex i s t i ng i n s t i t u t i o n s or double t h e i r accommodation i f the general p u b l i c , who after a l l supply the funds, are completely unaware that there i s a problem or that there are conditions that need improving. A good publ ic information campaign i s grea t ly needed. I t i s h ighly important to r e a l i z e that the new scheme of compulsory hosp i t a l i z a t i on just coming i n t o effect i n B r i t i s h Columbia makes absolutely no provis ion for the ch ron ica l ly i l l ; and yet the whole success of the scheme res ts op the assumption that not a s ingle patient w i l l remain i n hosp i ta l a day longer than i s necessary. I f a ch ron ica l ly i l l patient i s forced to occupy an acute bed for l ack of other more sui table accommodation, the whole scheme i s impeded. Outside of the C i t y S o c i a l Service Department the Metropolitan Health Department and interested o f f i c i a l s i n the Vancouver C i ty H a l l , few people i n the c i t y have any conception of the staggering cost of providing publ ic assistance for ch ron ica l ly i l l persons, boarding home and nursing home care for the indigent and medical and nursing care for thousands of chronica l ly i l l i n Vancouver. Only the thousands of people i n Vancouver suffering from chronic disease have any r e a l i z a t i o n of Ijttsi how l i m i t e d are t h e i r f a c i l i t i e s fo r diagnoses, treatment and bed care. - 17 -The whole s i tua t ion i n Vancouver could be summed up i n one "The ex i s t ing f a c i l i t i e s fo r the care of the chronic s i ck present a very confused p ic tu re - patients at home that should be i n hosp i ta l s , pat ients i n homes for the aged, that are not prepared to minis ter to t h e i r wants, patients i n convalescent homes occupying beds needed for another purpose; a mad confusion of patients and i n s t i t u t i o n s - the patients scrambling t o f i n d refuge where they may, the i n s t i t u t i o n s admitting them grudgingly, and having admitted them, not providing the care that they need. I t i s a scene of great d isorder . Publ ic and pr ivate hosp i ta l s , homes for the aged, convalescent homes, v i s i t i n g nurse services , after-care agencies, medical s o c i a l work departments and family service agencies - every one of them accepts w i th reluctance the burden of the chronic s i c k , and t r i e s t o sh i f t r e s p o n s i b i l i t y t o another agency which i s no better The present study i s an attempt to evaluate the effectiveness and extent of the f a c i l i t i e s that already ex is t fo r the care of the chron ica l ly i l l population of Vancouver, and to suggest how these f a c i l i t i e s can be improved and strengthened. An attempt w i l l be made t o point out what basic pre-requis i tes fo r the proper care and treatment are l a c k i n g ; and an- examination of the administrat ive structure already set up t o deal with the problem of the chron ica l ly i l l w i l l be ca r r i ed out t o assess i t s effectiveness and shortcomings. Wel l over two hundred chron ica l ly i l l pat ients have been personally interviewed and twice that number of h o s p i t a l and s o c i a l service f i l e s read. Each ©f the i n s t i t u t i o n s described was v i s i t e d personally and several days spent i n paragraph paraphrasing a statement of Dr . Boas: The Purpose of This Study:. ( l ) Boas, Ernst P . , M.D. The Unseen Plague. Chronic Disease. J . J . Augustan I n c . , 194-0 Page 75. - 18 -each case In Glen and Grandview Hospi ta l s , Heather Street Annex, the Outpatients ' Department of the Vancouver General Hosp i t a l , and the Marpole Infirmary. Administrators or owners of the various i n s t i t u t i o n s and organizations were interviewed at length and various aspects of the whole problem were discussed wi th s o c i a l workers involved i n the hosp i t a l clearance or l o c a l assistance programs. This study i s p r imar i ly a study of the ch ron ica l ly i l l residents of Vancouver and the i n s t i t u t i o n s for t h e i r care and treatment wi th in the c i t y boundaries. Unfortunately chronic i l l n e s s does not always abide by c i t y l i m i t s ; i t was found that frequently i n s t i t u t i o n s outside of Vancou-ver and residents of other parts of the province had to be referred t o because of the u t i l i z a t i o n of the f a c i l i t i e s of Vancouver by the whole province"and the u t i l i z a t i o n of p r o v i n c i a l i n s t i t u t i o n s fo r Vancouver res idents . To c l a r i f y t h i s po in t , a Vancouver resident or a Vancouver, r e s p o n s i b i l i t y for the purposes of t h i s study, i s a person who has l i v e d i n Vancouver continuously fo r one year. For persons i n receipt of s o c i a l assistance the term "Vancouver r e s p o n s i b i l i t y " i s used t o describe a person who l i v e d i n Vancouver continuously for one year without being i n receipt of any form of publ ic assistance before applying for s o c i a l assistance. Burnaby, North Vancouver, West Vancouver and Richmond are not included i n t h i s study even though they make f u l l use of Vancouver's hosp i t a l and medical f a c i l i t i e s whenever t h e i r own are inadequate. North Vancouver i s the only adjacent munic ipa l i ty wi th a hosp i t a l of i t s own. Since the terms "chronica l ly i l l " and chronic i n v a l i d are so wide i n scope and app l i ca t ion , i t i s found necessary to l i m i t t h e i r - 19 -d e f i n i t i o n . For the purposes of t h i s study a ch ron ica l ly i l l person i s defined as one whose d i s a b i l i t y has been of ninety days duration or more, who has been incapable of fo l lowing the d a i l y routine of an average normal i n d i v i d u a l and whose incapacity w i l l probably continue for an inde f in i t e per iod. Except i n rare cases the patient i s suffering from a condi t ion that can be a l l e v i a t e d but not cured. Al so fo r the purposes of t h i s study, persons suffering from pulmonary tubercu los i s , psychotic disorders and congenital defects i n c l u d i n g , the deaf, dumb and b l i n d have not been included on the grounds that these are categories fo r whom spec ia l p rovis ion i s heeded and has been already made; they are i n any case not o r d i n a r i l y c a l s s i f i e d as chronic diseases. The term "chronic i n v a l i d " has been used t o describe a person who i s unemployable because of some chronic disease and i s not able t o care for himself . A "chronical-ri. • l y i l l " person may be a chronic i n v a l i d or he may be a f f l i c t e d by a chronic disease which does not make" him completely unemployable. This person, although phys ica l ly impaired i n some way, i s able t o provide for h i s phys ica l needs, though i n need of medical care. Cer ta in minor (1) def in i t ions and abreviat'ions have a lso been standardized. ( l ) The Vancouver General Hospi ta l i s referred t o as the General Hosp i t a l . The shortened form, "C i ty S o c i a l Service" has been used rather than the f u l l name of "The C i t y S o c i a l Service Department of the C i t y of Vancouver". The shorter t i t l e "Marpole Infirmary" has been used i n place of "The P r o v i n c i a l Infirmary at Marpole". A "staff" patient i s one who i s not able t o pay for h i s own care. The terms "nursing home" and "private hosp i t a l " have been used interchangeably because of t h e i r i d e n t i c a l function i n Vancouver. An "Acute" hosp i t a l i s one i n which generalized services inc luding maternity and surgery f a c i l i t i e s are a v i l a b l e . - 20 -Chronica l ly i l l patients and the i n s t i t u t i o n s car ing for them have been d iv ided in to four main groups. Group n A " pat ients are those requir ing medical care fo r diagnosis and treatment which, wi th few exceptions, i s obtainable only i n the acute hosp i ta l s . Group "B" includes patients requi r ing l i t t l e more than s k i l l e d nursing care such as provided i n the nursing homes and i n the Marpole Infirmary. Group "C" need only cus tod ia l care which i s ava i lab le i n various types of boarding homes throughout the c i t y . Group "D" refers t o those more fortunate cases who, though suffering from some chronic disease, are s t i l l able t o l i v e i n t h e i r own homes and to carry on with the a id of a pr ivate physician without nursing or cus todia l care . - 21 -Chapter I I The Chronica l ly 111 and the General Hospi ta ls In Vancouver, the ch ron ica l ly i l l pat ient requir ing ac t ive diagnostic and treatment services can f i n d them only i n the Vancouver General Hosp i t a l , S t . Pau l ' s Hosp i t a l and S t . Vincent ' s H o s p i t a l . Through no choice of t h e i r own, these hospi ta ls are forced to provide the only Class "A" care that i s avai lable fo r the chron ica l ly i l l i n Vancouver. Each of the hosp i t a l s , p a r t i c u l a r l y the Vancouver General H o s p i t a l , faces the problem of how t o maintain a constant turnover of beds when an appreciable number of these beds are occupied by chronica l i n v a l i d s for whom no a l te rna t ive accommodation can be found. The hospi ta ls are forced t o admit many chron ica l ly i l l persons when t h e i r condit ion becomes so emergent that they cannot continue i n t h e i r own homes or i n a nursing home. The problem i s i n t ens i f i ed at the Vancouver General Hosp i t a l where so many of the patients are s t a f f patients admitted through the Out-pa t i en t ' s Department. The acute general h o s p i t a l as at present consti tuted i s unsuited fo r the care of long-term pat ien ts . The average long term patient requires less cos t ly care than that provided i n the acute general h o s p i t a l . To continue to care fo r the long-term patient i n the acute hosp i t a l i s wasteful; i t provides care which i s more expensive than he (1) ac tua l ly needs, and which i s often unsuited t o h i s requirements. (1) The work of a jo in t committee; Planning f o r the Chronica l ly 111, Pub l i c Welfare V o l . 5, No. 10, October 1947, Page 221. - 22 -If a chronically i l l person is admitted to the hospital when his condition becomes acute, what is to be done with this patient after his acute condition subsides and his chronic complaint required active medical treatment for a long period afterwards? The Centralization of the Problem in the Vancouver General Hospital Almost since the Vancouver General Hospital's inception the chronically i l l have constituted a major administrative and financial problem. After forty-six years of operation the question of what to do with the chronically i l l is s t i l l being asked. With the implementation of the new compulsory hospital insurance scheme, the question of what to do with the chronically i l l occupying acute beds becomes even more in need of solution. Every bed in the hospital occupied unnecessarily by a chronic patient reduces the number available for the accommodation of the acutely i l l . Despite the efforts of the hospital administration and the hospital medical social workers, a significant number of beds, which should normally be at the disposal of acutely i l l patients, are occupied for long periods of time by patients who are in need of nothing more than convalescent hospital or nursing home care. The acute symptoms of their illnesses have subsided and they require only a minimum of medical and nursing care. Continuous efforts have been made by the hospital authorities to provide a maximum of medical care with a minimum utilization of the acute hospital facilities. Historically this has been accomplished by using annexes or leasing beds in private nursing homes to care of the chronically i l l . In 1917, a building known as the Military Annex was constructed on the present site of the Semi-Private Pavilion to house - 23, -war casua l t i es . Gradually as the number of wounded sold iers decreased, the beds were turned over to the care of chronic patients from the main h o s p i t a l . By 1928 the bui ld ing (then known as the 12th Avenue Annex) held 250 pat ients , both male and female, most of whom were chronic i n v a l i d s . Both paying and non-paying pat ients were accommodated there . By 1930 the l a s t of the veterans had been removed. In February 1917, a bankrupt ho te l i n Marpole, now known as the Marpole Infirmary, was taken over by the Vancouver General Hosp i t a l t o serve as an out le t for i t s chron ica l ly i l l . The p r o v i n c i a l government assumed cont ro l of the i n s t i t u t i o n i n Ju ly 1923* Again i n 1918, Heather Street Annex, a group of frame bui ldings opposite the h o s p i t a l on Twelfth Avenue, was opened to accommodate v ic t ims of the "Spanish Influenza" epidemic. Gradually these beds a lso came to be used for chronic i n v a l i d s . The same bu i ld ings , though recent ly moved one block away to make room for a new nurses' home, are s t i l l i n use. About 1931-32 the Vancouver General Hosp i t a l began plac ing pat ients requir ing long-term nursing care and those that were considered t o be chronica l ly i l l i n the pr ivate nursing homes of Glen, Grandview and Bayview. About the same time, a small number of pat ients were placed i n the Royal Derby Hosp i t a l and the Florence Nightingale Hosp i t a l . The numbers placed i n these two i n s t i t u t i o n s were small and placements i n them were discontinued af ter a few years . By 1937 the main hosp i ta l became so crowded wi th chronics and the hosp i t a l was i n such desperate f i n a n c i a l s t r a i t s that something had to be done to release some of the beds being occupied by chronica l ly i l l patients no longer i n need of acute hosp i t a l care. In that year the - 24, -p r o v i n c i a l government induced the hosp i t a l to set up an independent S o c i a l Service Department (under the d i rec torsh ip of Miss Ol ive Cotsworth, R.N.) to work out a system of hosp i t a l clearance and t o act as l i a i s o n of f ice between the hosp i t a l and the C i t y S o c i a l Service Department. Working i n close col labora t ion with the hosp i ta l s o c i a l service department, the Medical Section of the C i t y S o c i a l Service Department made arrangements for nursing home care to be provided for chronic and convalescent cases i n selected pr ivate hosp i t a l s . The scheme put in to operation i n 1937, continued u n t i l Ju ly 1942 at which time the C i t y S o c i a l Service Department withdrew from any pa r t i c ipa t i on i n the h o s p i t a l clearance program. The C i t y S o c i a l Service s t i l l continued to accept r e s p o n s i b i l i t y for pat ients i n Heather Street Annex. Mount S t . Mary had been opened the previous year and t h i s , along with the Marpole Inf irmary, was expected to provide suf f ic ien t accommodation fo r the chron ica l ly i l l cared fo r by the Vancouver General H o s p i t a l . At one time the Vancouver General Hospi ta l considered c los ing down Heather Street Annex. However, i n January 1943 the General Hosp i t a l agreed to keep open and t o - operate Heather Street Annex on the condit ion that the C i t y S o c i a l Service Department would pay the f u l l cost of operating the i n s t i t u t i o n . Under t h i s agreement a l l admissions t o Heather Street Annex were to be made through the C i t y S o c i a l Service Medical Section and not through the Hosp i t a l . Medical care for the patients was t o be provided by the Vancouver General Hosp i t a l . In January 1948, the C i t y S o c i a l Service Department changed i t s p o l i c y again and agreed t o accept f i n a n c i a l r e s p o n s i b i l i t y for a l l pat ients i n Glen and Grandview Hosp i t a l s . Medica l , d i e t e t i c and s o c i a l - 25 -service supervision i n these i n s t i t u t i o n s was provided by the General H o s p i t a l . Problems of Admission and Discharge Before making an examination of the current s i tua t ion i n the General Hospi ta l i t i s necessary t o discuss the question, of admission and discharge to the hosp i t a l that exis ted p r i o r t o the beginning of the compulsory hosp i t a l insurance scheme. In the f i n a l ana lys i s , the system i n use regulates the admission of the ch ron ica l ly i l l to the h o s p i t a l and t h e i r ult imate dispers ion t o t h e i r homes or t o continued care i n nursing homes or boarding homes. Each publ ic ward i n the hosp i t a l has a cer ta in number of s ta f f beds, admission and discharge to which are regulated by the resident interne of the ward. Approximately one t h i r d of the s t a f f pat ients are admitted through the Outpatients ' Department of the hosp i t a l , the other two th i rds being re fe r ra l s from pr ivate p r ac t i t i one r s . Doctors i n the Outpatients ' Department must consult wi th the resident interne of the ward before admitting any pat ient . Both s ta f f and paying pat ients are admitted d i r e c t l y i f t h e i r case i s one of extreme emergency; ce r ta in beds are kept cont inual ly ava i lab le for t h i s purpose. Paying cases admitted for medical and su rg ica l treatment are admitted by nurses i n the main hosp i ta l admitting o f f i c e . Seriousness of the i l l n e s s and p r i o r i t y i n date of the doctor 's app l ica t ion for a bed are determining factors i n admission. When there are beds ava i l ab le for the l e s s acute cases, the doctors and the nurses i n the admitting off ice discuss the case and decide whether i t i s necessary t o admit the pat ient . I f the doctor can prove the necessity of h o s p i t a l i z a t i o n , the patient w i l l be - 2 6 -admltted. Usual ly beds are booked about seven days i n advance for non-emergency cases. Several wards have beds which are cont ro l led by i n d i v i d u a l doctors, e . g . , an orthopedic spec i a l i s t may have four beds and a genito-urinary s p e c i a l i s t two, which are reserved for t h e i r cases. The admissions and discharges to these beds are decided by the i n d i v i d u a l doctors . This means i n effect , that a chronica l ly i l l person, whose i l l n e s s causes him considerable discomfort but whose condit ion i s not regarded as acute, has l i t t l e chance of being admitted to hosp i t a l ; l a t e r h i s condition may become so acute that nothing can be done fo r him. The resident interne discharges patients from the s ta f f beds under h i s cont ro l when he decides that the patient has recovered s u f f i c i e n t l y . I f the patient i s an in te res t ing or unusual case the chances are that he w i l l be kept i n hosp i t a l longer than, say, a s i c k old woman, suffering only from diabetes who has l i t t l e in teres t fo r the learning in te rne . A l l other patients have t h e i r discharge date decided upon by t h e i r own doctor. Usual ly a paying patient does not stay a day longer than necessary because of the expense. When a person requires a longer than ordinary period of hosp i t a l i z a t i on i t i s the duty of the accounting department to judge whether the pa t i en t ' s future a b i l i t y t o pay h i s hosp i t a l b i l l i s exceeded. When t h i s s i tua t ion occurs, the pa t ien t ' s doctor i s no t i f i ed that the patient w i l l be t ransferred t o the s t a f f l i s t . Some doctors discharge t h e i r pat ients rather than have t h i s happen. Many of the s ta f f cases and a few of the pr ivate cases are kept i n the hosp i t a l because the doctors refuse t o discharge them to . inadequate or unsuitable l i v i n g accommodation. I f they were discharged - 2% -they would only be re-admitted wi th in a short t ime. The S o c i a l Service Department arranges fo r the accommodation of these people i n nursing homes or boarding homes. Transfers to pr iva te boarding and nursing homes fo r paying patients as w e l l as fo r s ta f f pat ients are arranged by the s o c i a l Chronic Pat ients Occupying Acute Beds i n the Hosp i ta l The t o t a l ward capacity of the Vancouver General Hospi ta l excluding maternity, infec t ious disease and the three annexes i s 881 beds; of these 814 were occupied when a check was made (by the S o c i a l Service Department) on August 1, 194-8. When the ward l i s t s were again checked on (2) August 12, 186 of the o r i g i n a l 816 patients were s t i l l i n h o s p i t a l on that date. Checking again af ter t h i r t y days, 109 of these pat ients were s t i l l found t o be occupying "acute beds". In other words, eight per cent of the t o t a l number of beds i n the hosp i ta l at that time were occupied by persons who had been i n the hosp i t a l fo r at l eas t t h i r t y days. Of the o r i g i n a l 816 pat ients i n the hosp i t a l on August 1, 194-8, twenty or 2.4-per cent had been admitted to e i the r Glen or Grandview Hospi tals (Heather Street Annex was closed during t h i s per iod) . On November 1, 194-8 a further check of ward l i s t s was made by the S o c i a l Service s ta f f , and i t was then found that of the o r i g i n a l 816 pa t ien ts , f i f ty -one or 6.2 per cent were s t i l l occupying acute beds i n the (1) The above descr ip t ion of admissions and discharges to the Vancouver General Hospi ta l has been changed considerably by the inauguration of the new hosp i t a l insurance scheme. There i s now no such th ing as a "staff" or a "paying" pa t ien t . The demand for beds has become much more urgent and the chances for a ch ron ica l ly i l l person to be admitted are even more remote. (2) . Vancouver General Hospi ta l considers that the average length of stay of i t s patients i s eleven days. - 28 -h o s p i t a l . Four more admissions t o Glen or Grandview Hospi tals brought the t o t a l number of admissions t o these i n s t i t u t i o n s to twenty-four or i • approximately three per cent of the o r i g i n a l 816. Three of the remaining f i f t y one were eliminated because they were not considered to come wi th in the scope of t h i s s t u d y . ^ An examination of the medical condi t ion of the remaining for ty-e ight patients showed that the majority of the patients were there because of the need of prolonged hosp i t a l i za t ion rather than because they were chronic i n v a l i d s . Table A Reasons for Being i n Hosp i ta l Diagnosis Wo. of Pat ients Paraplegia and pos t -pol io 11 Fractures 8 Heart & Ci rcu la to ry Disorders 5 T . B . of Spine or Hip Bone 3 A r t h r i t i s 2 Burns 3 Dermati t is 2 Osteomyelit is 1 Diabetes 1 Gast ro- In tes t ina l Disorders 1 External Ulcers 2 Urinary Disorders 2 Others 7 T o t a l 48 Excluding the fracture cases and the pos t -pol io and paraplegic cases which must be t reated as spec i a l categories, there were twenty-nine cases l e f t from the o r i g i n a l 816 who were suffering from disorders of a chronic nature. ( l ) Of these three, one had T . B . of the chest, one had a congenital defect and the t h i r d was suffering from a psychotic disorder . - 29 -An examination of the length of stay of these twenty-nine pat ients i n the hosp i t a l showed wide var ia t ions i n the time spent i n h o s p i t a l . Table B Length of Hosp i t a l i za t i on Per iod Number of Pat ients 11 4 2 2 2 2 0 2 2 - More than 365 days __2 T o t a l 29 Approximately one h a l f of the twenty-nine pat ients were over the age of s i x t y . Table C Age D i s t r i b u t i o n of Pat ients No. of Pat ients Time (days) 90 - 120 121 - 150 151 - 180 181 - 210 211 - 240 241 - 270 271 - 300 301 - 330 331 - 365 0 - 1 0 4 1 1 - 2 0 1 21 - 30 7 3 1 - 4 0 1 4 1 - 5 0 2 5 1 - 6 0 2 6 1 - 7 0 5 7 1 - 8 0 7 T o t a l 29 - 30 -Of these twenty-nine people, ten were paying fo r t h e i r care, f i v e were paying as much as they or t h e i r fami l ies could afford, and fourteen were s ta f f cases unable t o contribute anything toward the cost of t h e i r h o s p i t a l i z a t i o n . The eleven paraplegic and pos t -pol io cases are considered as a separate category; nevertheless, for a l l p r a c t i c a l purposes they are chronic i n v a l i d s , unable t o work or care for themselves. They have been brought together at the Vancouver General Hospi ta l and have been kept there because of the t r a i n i n g f a c i l i t i e s and physio-therapy treatments avai lable only i n t h i s h o s p i t a l . F ive of the eleven were from towns out-side of Vancouver. Some of these paraplegics and pos t -pol io do not need acute hosp i t a l care but u n t i l recently no a l te rna t ive accommodation has been ava i l ab le for them. Almost a l l of the paraplegics and post -pol io cases had been i n the hosp i t a l for at l ea s t s i x months* One exceptional patient was admitted to the hosp i ta l on August 1, 194-5 and had received treatment continuously since then. I t appears that only a convalescent hosp i t a l and a chronic hosp i t a l operated i n conjunction wi th the Vancouver General Hospi ta l i s the only so lu t ion t o the problem. The General Hospi ta l w i l l continue t o have t h i r t y or for ty beds f i l l e d wi th chronic and convalescent pat ients unless a l t e rna t ive accommodation i s made ava i l ab l e . The three annexes cannot poss ib ly hope to cope with the number of patients that the hosp i t a l would l i k e to t ransfer t o them. The Outpatients ' Department of the Vancouver General Hospi ta l The present Outpatients ' Department can trace i t s o r i g i n back to the year 1906 when i t was formed as an adjunct of the old C i t y Dispensary. - 31 -I t was not u n t i l 1915 that the medical services car r ied on by t h i s department were completely taken over by the Vancouver General Hosp i ta l and a properly const i tuted Outpatients 1 Department was set up i n some o ld frame bui ldings near the h o s p i t a l . A wing of the Heather Street Annex was taken over by the Outpatients ' Department i n 1926. The work of the department was car r ied on at f i r s t by a voluntary Medical Direc tor and a s t a f f of attending doctors , nurses, s o c i a l service workers and c l e r i c a l workers. In 1938 a f u l l - t i m e Assistant Medical Di rec tor was a p p o i n t e d . ^ He was t o take complete charge of the more rout ine medical se rv ices . In 1939 the c l e r i c a l s t a f f was re-organized and a Chief Clerk appointed. In September 194-3 the Outpatients ' Department was transferred t o i t s present quarters i n the Semi-Private P a v i l i o n . In 1915t 4-50 cases were treated by the Outpatients ' Department; i n 194-7 the t o t a l number of pat ients was 5,74-9. E l i g i b i l i t y fo r free treatment i n the Outpatients ' Department i s based on income and residence. A s ingle person earning l ess than seventy do l l a r s a month i s e l i g i b l e for free treatment; for a married couple the maximum i s ninety d o l l a r s . An exemption of twenty d o l l a r s fo r each dependent thereafter i s al lowed. At frequent in t e rva l s the scale of e l i g i b i l i t y i s reviewed and allowances made for changes i n the cost of l i v i n g . New e l i g i b i l i t y ru les for t h i s year are being drawn up and the exemptions w i l l be considerably l i b e r a l i z e d . Family allowance i s not counted as income and borderl ine cases having heavy medical expenses are given every considerat ion. The C l i n i c accepts a l l Vancouver ( l ) The pos i t ion of Assistant Medical Di rec tor i s now vacant and there i s a group of doctors that work on a ro ta t ion system wi th senior internes pa r t i c ipa t i ng more ac t i ve ly i n the work of the Outpatients ' Department. - 32 -residents but a person from an outside munic ipa l i ty , e . g . , Burnaby, Richmond, New Westminster and Surrey, i s accepted for care providing he obtains a wri t ten order from that munic ipa l i ty . North Vancouver provides separate f a c i l i t i e s fo r i t s own res idents . The Medical Services Di rec tor of the Province of B . C . a lso refers patients to the c l i n i c . A patient may be referred t o the Outpatients ' Department by any private physic ian or he may personally apply at the c l i n i c . The pub l i c health nurses and C i t y S o c i a l Service workers are responsible fo r a large number of the r e f e r r a l s t o the Department. When a new patient i s admitted he i s given a complete phys i ca l examination and has routine tes ts performed by an in te rne . A prel iminary diagnosis of the pa t i en t ' s condit ion i s made. The patient i s then r e f e r r -ed t o one of the spec i a l c l i n i c s fo r treatment by a s p e c i a l i s t . In some cases the patient i s examined i n several different c l i n i c s before a de f in i t e diagnosis of h i s condit ion i s made. I t i s the po l i cy of the Outpatients ' Department to have every patient admitted or readmitted, interviewed by the s o c i a l worker. There i s one group of s i ck people i n the low income group that are not able t o a v a i l themselves of the services provided by the Out-pat ients 1 Department. These are the people l i v i n g on pensions or super-annuation payments who are too i l l t o come to the Outpatients ' Department fo r treatment and diagnosis. The i r income i s not low enough for them t o qua l i fy fo r s o c i a l assistance and i t s accompanying medical care . Their income i s e i ther a l i t t l e more than the e l i g i b i l i t y minimum or they are not o ld enough for Old Age Pension. The pr ivate medical p r a c t i t i o n e r , unless he has known the family over a period of years, i s u n w i l l i n g to - 33. -make frequent and non-paying v i s i t s , e spec ia l ly when he has a large p rac t i ce . Many fami l ies of moderate or low income e .g . , around one hundred do l l a r s a month, do not receive medical treatment u n t i l t h e i r condit ion i s too serious t o be a l l ev i a t ed or t h e i r condi t ion becomes so acute that they have t o be admitted t o the h o s p i t a l . An adequate system of Health Insurance i s the only method which would ensure that these people would receive proper medical care p r i o r t o the hosp i t a l i z a t i on stage. In an effort t o ascer ta in what treatment f a c i l i t i e s for the chron ica l ly i l l were provided by the Outpatients ' Department of the Vancouver General Hosp i t a l , the f i l e s and medical charts fo r f i f t y long-term patients were read and summarized. Each of these patients had been act ive cases i n 1938 and they were s t i l l ac t ive cases i n 194-8. The se lec t ion was purely at random, taking the f i r s t f i f t y of the approximately one hundred cases i n the f i l i n g cabinet. The period 1938-194-8 was chosen because i t provided a chance to examine the effects of chronic i l l n e s s upon these people during three en t i r e ly d i f fe ren t periods when wages, l i v i n g conditions and a v a i l a b i l i t y of medical care var ied g rea t ly . The post depression years and the f i r s t years of the war saw an increase i n the numbers of chronica l ly i l l people coming t o the Outpatients ' . Depart-ment for diagnosis and treatment. The pr iva te physician no longer needed the assured but low remuneration that he received during the depression for the medical care of indigents . Instead, as the numbers of h i s paying patients increased he began t o refer more and more of h i s non-paying cases t o the Outpatients ' Department. During the war, many of the spec i a l c l i n i c s and. treatment f a c i l i t i e s provided by the Outpatients ' Department were cu r t a i l ed or - % -discontinued due to a shortage of doctors. The war had another effect upon cer ta in groups of chron ica l ly i l l i n d i v i d u a l s . Due to an extreme shortage of labour, many persons previously considered unemployable were able t o secure employment and earn good wages, which precluded them from receiving free medical treatment from the Outpatients ' Department. There s t i l l remained a small but recognizable group of ch ron ica l ly i l l people who received very low incomes and required cont inual medical care. Thei r numbers again increased after the war. At the same t ime, more people than ever before were able t o pay t h e i r doctor ' s b i l l s , and as the pr ivate phys ic ian ' s pract ice increased he became more reluctant t o use h i s time t o t rea t the chronic and often non-paying pa t ien t . In consequence re fe r ra l s to the Outpatients ' Department have increased considerably since the end of the war. With a few exceptions, the f i f t y cases s i f t ed out i n the present study received continuous treatment during the whole ten year per iod. Only i n the younger age group was the income l e v e l ra ised s u f f i c i e n t l y t o make them i n e l i g i b l e for treatment at the Outpatients ' Department for part of the war years . The f i f t y cases examined were mostly i n the older age group. As i t happened, the f i f t y cases studied comprised t h i r t y males and twenty females. Some of the cases had been known to the Outpatients ' Department fo r several years p r i o r t o 1938 but others came t o the Department i n 1938 for the f i r s t t ime. Table D Time of F i r s t Appl ica t ion for Treatment at the 0. P . D. Year No. of Pat ients 1922 1 1931 1 1932 4 1933 3 1934 10 1935 0 1936 1 1937 1 1938 29 T o t a l 50 Of the f i f t y pa t ien ts , t h i r t y were over the age of s i x t y - f i v e . T-he one person under twenty years of age was a g i r l (aged 14) who had received cont inual medical care for a va r i e ty of childhood complaints since her b i r t h . Table E Age D i s t r i bu t i on of the 50 Pat ients Age Number Age Number Under 21 1 61-65 5 31-35 1 66-70 11 36-40 1 71-75 9 41-45 5 76-80 6 46-50 2 81-85 3 51-55 4 86-90 1 56^60 1 T o t a l 50 As a matter of in teres t i t can be noted that of the f i f t y persons studied, twenty-six were born i n the B r i t i s h I s l e s , f i f t een i n Canada, f i ve i n Scandinavia, two i n Russia , one i n Czechoslovakia and one i n the U . S . A . A l l of the f i f t y persons had been resident i n Canada for at l eas t - 36 -ten years p r i o r t o 1938 and only fourteen had l i v e d i n B r i t i s h Columbia l e s s than ten years . Only three of the f i f t y had l i v e d i n Vancouver less than three years. In other words, the group was a f a i r l y representative B . C . group. An analys is of the medical diagnosis of the f i f t y pat ients reveals that twenty-eight out of the f i f t y were suffering from heart d i s -orders, a r t h r i t i s or diabetes, and many had some combination of the three. Table F Diagnosis No. of Pat ients Cardiac Disorders 12 A r t h r i t i s 9 Diabetes 7 Epilepsy 3 Thyroid Disorders 3 Genito-Urinary Disorders 2 Stomach Ulcers 2 Anaemia * 2 Varicose Ulcers 2 Chronic O t i t i s Media 2 Psychoneurosis 2 Asthma 1 Dermatitis 1 Hemmorrhoids 1 Others 1 The majority of the f i f t y pat ients d id not receive continuous medical care i n the sense that they saw the doctor every time they came t o the c l i n i c . For instance, the person suffering from diabetes, although rece iv ing periodic check-ups, came r e g u l a r l y ' f o r h i s i n s u l i n but d id not see the doctor every time that he came t o the c l i n i c . Of the seven diabetf.i i c s , f i ve were suffering from other disorders such as a r t e r i o - s c l e r o s i s or cardiac condi t ions . The diabetes i n i t s e l f d i d not make the person un-employable, but the pa t ien t ' s age and the other diseases i n conjunction - 3? -with the diabetes, made chronic inva l id s out of them. S i m i l a r l y , eight of the twelve persons suffering from cardiac disorders had add i t iona l a f f l i c t i o n s such as a r t h r i t i s , u l ce r s , e t c . Seven of the a r t h r i t i c s had other complicating i l l n e s s e s . Of the f i f t y pa t ients , the condi t ion of twenty-eight had not Im-proved at a l l during the ten year i n t e r v a l and the diagnosis of t h e i r i l l -ness i n I94.8 was exactly the same as i t was i n 1938. I t must be noted however, that the majority of these patients, would have died i f they had not received the treatment and medicine that the Outpatients ' Department provided for them. Of the f i f t y pa t ien ts , twenty had required at l eas t one period of hosp i t a l i za t i on for t h e i r i l l n e s s ; several had required four and f i v e periods. Eight of the f i f t y had not required any h o s p i t a l i z a t i o n . The other twenty-two had had one or more periods of h o s p i t a l i z a t i o n for i l l -ness other than the one for which they were receiving constant' treatment i n the Outpatients ' Department. A l l of the cases examined were i n receipt of some form of publ ic a s s i s t a n c e ^ or were from extremely low income homes. Table G F i n a n c i a l Circumstances of the Pat ients Source of Income No. of Pat ients In rece ip t of s o c i a l assistance 15 In rece ip t of o ld age pension 14-D i s a b i l i t y or other pension 9 Earning an income of $70 or less 8 Supported en t i r e ly by r e l a t ives or other members of the family 4. To ta l 50 ( l ) Under the new scheme of medical care for assistance r ec ip ien t s , a l l s o c i a l assistance, o ld age pension and mothers - 38 -According t o t h i s evidence, w e l l over h a l f of the chronic cases are i n receipt of some form of assis tance. In f a c t , of the 5,74-9 patients that attended the Outpatients 1 Department i n 194-7, 3,648 or s ix ty- three per cent were i n receipt of some form of ass is tance. S t . Pau l ' s Hosp i ta l and the Chronica l ly 111 S t . P a u l ' s Hospi ta l opened i t s doors i n 1894 t o take i n twenty-four pat ients . The hosp i t a l , now with a bed capacity of 650, i s operated by the S i s te r s of Chari ty of Providence. Today i t i s the largest pr ivate general hosp i ta l i n B r i t i s h Columbia. The hosp i t a l has i t s own s t a f f of doctors and a l l pat ients are admitted to the hosp i t a l by t h e i r own doctor, whereas i n the Vancouver General Hosp i ta l s t a f f pat ients are admitted by the resident in ternes . The same doctors are responsible for the discharge of t h e i r own pat ients and the hosp i t a l administrat ion constantly checks the doctors and pat ients to see that no patient i s kept i n hosp i t a l any longer than i s necessary. A much needed improvement was inaugurated by the opening of a s o c i a l service department i n September, 1948. P r i o r t o t h i s , the removal and placement of chron ica l ly i l l pat ients i n a l ternate accommodation was the r e spons ib i l i t y of the f l oo r supervisors. A l l arrangements fo r p lace-ment are now being made by the s o c i a l worker but i t seems hard t o believe that case-work services for 650 pat ients can be provided by one lone s o c i a l worker. With the opening of t h i s department, severa l chronic patients who have occupied acute beds for many years were placed i n nursing homes allowance cases w i l l be cared for by private physicians and w i l l not go to ' the Outpatients ' Department except fo r spec ia l reasons. Th i s scheme came in to effect March 1, 1949 - 39 -and boarding homes. In January 194-9, the S i s t e r Superior of the h o s p i t a l stated that there were only about twelve beds i n the hosp i t a l s t i l l oc-cupied by chronic i n v a l i d s . Prominent amongst the twelve patients were f i ve very o ld women who have been i n the hosp i t a l some time but whom the s i s t e r s f e e l i t would be impossible to move because of t h e i r f r a i l t y . S t .Pau l ' s Hosp i t a l has only twenty-five " s t a f f teaching beds" compared to the several hundred of the Vancouver General Hospi ta l so that the problem of what t o do wi th large numbers of ch ron ica l ly i l l indigent patients i s not so pressing. The chron ica l ly i l l patients mentioned before are a l l on one f l o o r to make i t easier to provide nursing care for them. Since S t . Pau l ' s Hosp i ta l has no wards holding more than eight pa t ien ts , the i n d i v i d u a l patient gets more a t tent ion than does the patient i n the large publ ic wards at the Vancouver General H o s p i t a l . The average ward i s a c tua l l y a four bed ward. The nurses i n the hosp i ta l have become qui te attached to many of the long-time chronic patients and become very indignant when one i s moved out of the h o s p i t a l . These s t a f f patients receive the same t r e a t -ment and care as a paying pat ient . I f the demand for acute hosp i t a l accommodation continues i t w i l l become necessary for the hosp i t a l t o make arrangements for the removal of even the small number of chron ica l ly i l l patients occupying acute beds. Since the commencement of the hosp i t a l insurance scheme S t . Pau l ' s Hospi ta l has had to increase the turnover of beds i n the h o s p i t a l . At present the chronic patients occupying acute beds are receiving unnecessar-i l y expensive care and despite the h o s p i t a l ' s moral r e s p o n s i b i l i t y t o care for some of these people, these extra beds must be made ava i l ab l e . The - 46 -hosp i t a l has an excel lent s o c i a l service department i n operation and the in teres ts of the patients are ce r t a in ly being given f i r s t consideration i n that they are not being too pressed t o go to other accommodation. S t . Vincen t ' s Hospi ta l S t . Vincent '3 Hospi ta l was opened at i t s present loca t ion (adjacent t o Shaugnessy Hospital) i n Ju ly 1939. Operated by the S i s t e r s of Char i ty of the Immaculate Conception, i t i s the most recent addi t ion t o the acute hospi ta ls of Vancouver. I t has a capacity of 103 beds and 17 bassinets , and provides services under contract for most of the employees of the Canadian P a c i f i c Railway. Because of the type of patients who come to t h i s hosp i t a l , and i t s comparatively small bed capaci ty , the h o s p i t a l has no chronic i n v a l i d problem of any magnitude. At the time of the work-e r ' s v i s i t there were only two patients who could be c l a s s i f i e d as ch ron ica l ly i l l . Both of these patients were s t i l l urgently i n need of acute hosp i t a l care and only one was t o be referred t o the Inspector of Hospi ta ls Office for placement; the S i s t e r Superior stated that excel lent co-operation i s secured from the doctors i n having t h e i r patients d ischarg-ed as soon as they are no longer i n need of acute hosp i t a l care. The hosp i t a l maintains excel lent re la t ions wi th Inspector of Hospitals o f f i ce and the. Medical Section of the C i t y S o c i a l Service Department, and as a r e s u l t , the hosp i ta l has never had any d i f f i c u l t y i n having i t s chronic patients removed t o a nursing home or boarding home whenever that becomes necessary. A l l arrangements fo r placement are made by one of the s i s t e r s of the h o s p i t a l . - 41 -Chapter I I I Ins t i tu t ions for the Care of the  Chronica l ly 111 i n Vancouver Chronica l ly i l l patients requir ing s k i l l e d nursing care are cared for i n the pr ivate hospi ta ls and nursing-homes of Vancouver. Some are p r iva t e ly owned and operated while others are p u b l i c l y owned or pub l i c l y subsidized. For a c i t y the s ize of Vancouver there are su rp r i s ing ly few pr iva te hospi ta ls for the care of the chron ica l ly i l l and convalescent pa t ien t . Glen Hosp i ta l Glen Hosp i t a l had i t s beginning at 1134 East 12th Avenue where i n 1920 Miss Kate Smith, a graduate nurse, and her s i s t e r Mrs. Mary Westwood opened a pr ivate nursing-home. They started wi th four patients but were soon overwhelmed wi th applicants seeking care. Before long they moved t o a larger house at 2734 Glen Drive whence the present name of Glen Hosp i t a l i s der ived. Soon t h i s bu i ld ing too proved inadequate and the present bu i ld ing at the corner of Sal isbury and Napier streets i n the Grandview d i s t r i c t , the former home of an Aus t ra l i an m i l l i o n a i r e , was taken over i n 1924« With t h i s move the capacity of the nursing.-home was expanded to t h i r t y - e i g h t . The demand for nursing-home care became so acute that the house next door was taken over as an annex. In 1937 a new modern concrete annex- was added to the o r i g i n a l bui ld ing and f o r t y -eight add i t iona l beds were made ava i l ab l e , br inging the t o t a l capacity of - 42 -the i n s t i t u t i o n up to e igh ty - s ix . For many years only pr ivate patients with t h e i r own doctors attending them were admitted. In 1933 Glen Hospi ta l contracted t o take several s t a f f patients from the Vancouver General H o s p i t a l . The numbers of these were s teadi ly increased u n t i l on January 1, 194-8 the General Hospi ta l contracted for every bed i n the nursing-home. The agreement spec i f ied that a l l pr iva te patients i n the hosp i ta l at that time should remain, but no further pr ivate patients should be admitted af ter t h i s date. At present only f i v e of the e igh ty -s ix beds are s t i l l occupied by these pr ivate pat ients . The hosp i t a l i s now owned by the two sons of Mrs. Mary Westwood, one of whom i s the present manager. Glen Hosp i t a l , now the largest p r iva t e ly owned hosp i t a l i n B . C . i s l icensed t o care for " o l d -age, semi-medical and i n f i r m i t y " cases. The Vancouver General Hosp i t a l paid Glen Hosp i t a l $4-5 per month for each s t a f f case placed there i n 1933. Gradually t h i s amount was increased to $60, t o $72, to $80, then t o $90. Since December 1, 194-8 the General Hospi ta l has paid $105 per month per pa t i en t . The owners of the hosp i t a l have found i t feas ib le t o take these patients at lower rates than are asked by other pr iva te nursing--homes, because they are assured of keeping every bed f i l l e d . They can r e a l i z e a steady income without having t o face the problem, a l l too f a m i l i a r i n t h i s f i e l d , of the patient who enters as a paying pat ient , but af ter using up h i s resources, continues t o occupy a bed without payment u n t i l the owner can have him removed or make arrangements wi th the municipal au thor i t i es t o assume the r e s p o n s i b i l i t y for h i s care. A doctor from the Vancouver General Hosp i t a l sees each patient twice a week. An orthopedic s p e c i a l i s t a lso v i s i t s once a week. The - 4 3 -d i e t i t i a n from the Vancouver General Hosp i ta l v i s i t s once a week and the medical s o c i a l worker twice a week. The hosp i t a l has a s ta f f of t h i r t y - f i v e , inc luding s i x graduate nurses and eighteen nurses ' a ides. Glen Hospi ta l was one of the f i r s t hospi ta ls i n B . C . t o use nurses' a ides , and the present system of t r a i n i n g and employment of nurses ' aides throughout the province i s l a r g e l y based on the Glen Hosp i t a l system. Glen Hosp i t a l considers i t s e l f more of a convalescent hosp i t a l than a chronic h o s p i t a l . S t a t i s t i c s for the year 194-7 seem t o support t h i s c la im. I f possible the General Hospi ta l t r i e s to place i t s younger pat ients there and most of the long-term orthopedic cases are placed there , rather than i n Grandview Hosp i t a l . Patients under care 194-7 3 4 1 T o t a l number of patients admitted 2 5 1 Carried over from 1 9 4 6 8 6 Discharged 1 5 0 Deaths 1 0 6 T o t a l Number of Hospi ta l Days 3 1 ,027 Patients i n hosp i t a l December 3 1 , 1 9 4 7 8 5 Figures for 1 9 4 8 are not yet ava i l ab le except that the number of deaths for the year was s ix ty- two, about the average over a number of years. The hosp i ta l i t s e l f i s a l a rge , gaunt three-storey house wi th a concrete addi t ion tacked on the s ide; the administrat ive departments and the kitchens occupy the basement. The o ld o r i g i n a l part of the bui ld ing was never intended as a hosp i t a l and the service f a c i l i t i e s i n t h i s part are very inadequate. The wards, of various s izes accommodating from two t o twelve pat ients , are kept qui te clean and the l i n e n i s changed frequently. The food i s good but lacks va r i e ty ; several of the - 44 -patients, complained of not get t ing enough. In the course of h i s work wi th the C i ty S o c i a l Service Department, the worker spent considerable time i n Glen and Grandview Hospi tals and had an excel lent opportunity to observe the operation of the hospi ta ls and t o become fami l i a r wi th the patients.. Except i n a few cases, every patient was interviewed at frequent i n t e rva l s during the four month per iod . The chief complaint that can be made against Glen Hosp i t a l i s that i t suffers from a serious shortage of s t a f f . A l l of the patients complained of lack of attention' but a l l f e l t that what they d id receive was good. The greatest need i n Glen Hosp i t a l i s male o r d e r l i e s . The nurses are not strong enough to manipulate the male pat ients without help and even many of the female patients are too heavy to be moved. This lack of male order l ies prevents many of the patients from get t ing out of bed as often as they might, and cr ippled pat ients f i n d i t p r a c t i c a l l y impossible t o get a helping hand when they would l i k e to manage on t h e i r own. A v i s i t o r to the wards i s struck by the l ack of l i t t l e extras that one i s accustomed t o seeing i n other i n s t i t u t i o n s car ing for the s i c k . Very few of the patients have t h e i r own radios and there appears t o be p r a c t i c a l l y nothing wi th which pat ients can occupy themselves. No occupational, recrea t ional or physiotherapy f a c i l i t i e s are provided. Some of the pat ients would be too s i ck t o take advantage of such f a c i l i t i e s but most of them would be great ly benefi ted. I t has sometimes been said that the most unhappy people are those wi th nothing to do. This i s ce r t a in ly t rue i n t h i s h o s p i t a l . I t i s most depressing t o go from bed' to bed hearing each pa t ien ts 1 complaintsj they have nothing to do except t a l k to the patient i n the adjoining bed - i f that person i s able t o t a l k . - 4 - 5 -Many of the patients f e e l that t h i s place i s the end of the road and b i t t e r l y resent being l e f t i n such a place t o d i e . They f e e l that i t i s humil ia t ing and degrading to have to accept s o c i a l assistance and to have to answer the numerous questions of the s o c i a l worker. No attempt i s made to consider the i n d i v i d u a l needs, desires or in te res t s of the patient other than a cer ta in amount of routine nursing serv ice . The hosp i t a l , as a pr ivate enterprise , i s run as economically as possible so that the maximum p r o f i t i s r e a l i z e d . Extras cost money and decrease p r o f i t s . On the whole the c i t y gets what i t pays for at Glen Hosp i t a l ; Class"B" care for the chron ica l ly i l l i s provided. Standards of c lean-l i ne s s and of nursing care are f a i r l y good but might e a s i l y be improved. The pressing need i s a greater emphasis on treatment rather than merely the providing of a bed for the l i m i t e d purpose of c lea r ing these patients out of the General Hosp i t a l . The lack of recrea t ion , occupational therapy and suf f ic ien t s o c i a l service f a c i l i t i e s precludes any form of. treatment program and makes t h i s a cus tod ia l centre rather than a properly organized chronic or even convalescent h o s p i t a l . Grandview Hosp i ta l Less than a block away from Glen Hospi ta l i s Grandview Hosp i ta l s i tuated on the corner of Napier Street and V i c t o r i a D r i v e . I t a lso i s a large three-storey frame house converted i n t o a nursing-home. At t h i s point the s i m i l a r i t y between the two i n s t i t u t i o n s ends. Grandview H o s p i t a l , now the oldest pr ivate hosp i t a l i n Vancouver, was opened i n 1912 by a group of doctors fo r the care of medical , s u r g i c a l and maternity cases. In 1914- the present owner and h is w i fe , a graduate nurse, took over the sixteen bed h o s p i t a l . U n t i l the admission of -46 -maternity cases was discontinued in 1934, various types of patients were admitted. The present owner is very proud of the fact that 1,555 babies (1) were born in the hospital during this period. Several times the hospital was on the verge of bankruptcy. Finally in 1935, lack of patients and lack of money necessitated a change of policy in the hospital and four chronic staff cases were taken from the Vancouver General Hospital. Each year a l i t t l e has been added to the building, bringing the capacity up to the present number of sixty beds. The staff has been expanded from five to twenty-six. Because of poor working conditions there has been a great turnover in nurses and the hospital is now under-staffed to a dangerous degree. The building occupied by the hospital is very old and somewhat dilapidated. The lower floor is used for male patients and most of the second floor for female patients. Both male and female patients use the same bathroom. The old saying that "first impressions are always the worst" holds true here. The first impression on entering this building and which remains, is the stench of urine and excreta. The bed linen on the beds of the male patients is dirty and changed infrequently; and this condition is aggravated by the extreme shortage of staff. The patients receive a minimum of nursing care and i f they are (l) A very interesting description of Grandview Hospital by Dr. A. K. Haywood and his associates is found in the Report of the  Vancouver Hospital Survey Commission Upon the Hospital  Situation of Greater Vancouver (1930. "Grandview hospital is in a poor locality of the city and those using i t are of moderate means. At the time this building was visited i t was dirty,, oderous and very poorly equipped for the class of work attempted. It has accommodation for fifteen patients. There are no facilities for sterilization; the whole place seemed to be in very poor condition and the impression was gained that very questionable work might be done there without interference." - 47 -able to manage on t h e i r own, they become forgotten men. The food i s poor, and every patient interviewed complained about i t . The lack of male order-l i e s t o care fo r the male pat ients makes i t p r a c t i c a l l y impossible for the nurses t o do anything for many of the patients even i f they had t ime. The wards for women ups ta i rs are considerably better than the male wards downstairs. There are more and better nurses there and the . difference between the two f l oo r s i s s t r i k i n g . Sanitary and lavatory f a c i l i t i e s fo r the men downstairs are gravely inadequate. The stench of what f a c i l i t i e s there are and the nauseating odour of the unemptied urine bot t les standing for long periods on the tables beside the pa t i en t s ' beds i s enough t o give anyone a bad impression of the place. In one room i n pa r t i cu l a r downstairs, where there were several Or ien ta l pat ients and a Hindu pat ient , conditions were indescr ibably f i l t h y . Part of the blame fo r these conditions can be l a i d t o the shortage of s ta f f , but a large part of i t was due t o the fact that u n t i l recently the matron i n charge was not temperamentally sui ted to caring for t h i s type of patient and the resul t was a continuous c o n f l i c t between the matron, the pat ients and t h e i r f ami l i e s . Recently a new matron has been appointed and there has been considerable improvement i n every respect. Unfortunately f a c i l i t i e s for the s ta f f are almost as bad as f o r the patients and for t h i s reason i t i s very d i f f i c u l t t o keep a complete s t a f f . The patients are a l l d i s s a t i s f i e d and complain con t inua l ly . The reputation of the hosp i t a l has spread throughout the c i t y with the resu l t that s o c i a l workers f i n d i t a hopeless task t o persuade patients i n the General Hospi ta l to go to Grandview Hos p i t a l . Pa t ients are a f ra id that r 48 -they w i l l not receive the proper treatment there and t h e i r f t iends and r e l a t i v e s w i l l be u n w i l l i n g to v i s i t them i n such a place. The t o t a l bed capacity of s i x ty i s under contract t o the General H o s p i t a l . No pr ivate patients are accepted. Medica l , d i e t e t i c and s o c i a l services are provided by the General Hosp i t a l . The doctor and s o c i a l worker v i s i t the hosp i t a l twice a week and the d i e t i c i a n once a week. Grandview Hospi ta l receives the same per capi ta payment of $105 a month as Glen H o s p i t a l . Absolutely no extras or comforts, rec rea t iona l or occupational therapy f a c i l i t i e s are provided for the pat ients . As i n Glen Hosp i t a l many of the patients could not use these f a c i l i t i e s i f they were provided but there are very few patients who could not get some enjoyment out of a radio i n the ward. Grandview Hospi ta l i s a s t r i k i n g example of why an i n s t i t u t i o n caring for the chron ica l ly i l l should not be run as a profit-making private enterpr ise . The Vancouver General Hosp i t a l and the C i t y S o c i a l Service Medical Section have no a l ternat ive t o the placing of t h e i r pat ients i n t h i s h o s p i t a l . Insuf f ic ien t beds are avai lable fo r the chronica l ly i l l and they have to take what they can get . The needs of the patient are of secondary importance. The au thor i t i es responsible fo r the supervision of standards i n i n s t i t u t i o n s such as these must take the blame for a l low-ing such conditions t o e x i s t . Heather Street Annex Heather Street Annex was b u i l t in- 1918 to care for the v ic t ims of the Spanish Influenza epidemic of that year . The one-storey frame bu i ld ing , s t i l l i n use, was b u i l t and opened for the reception of pat ients - 49 -wi th in two weeks from the commencement of construct ion. For several years the bu i ld ing was used as a m i l i t a r y annex. Gradually the f o r t y - f i v e beds i n the bui ld ing were turned over to s t a f f chronic cases. For many years • at l ea s t twelve of the beds were used for V . D . pa t ien ts . U n t i l 1943 the Vancouver General Hosp i t a l Outpatients ' Department was housed i n one wing of the b u i l d i n g . When t h i s Department moved to i t s new quarters i n the Semi-Private P a v i l i o n i n 1943, another f o r t y - s i x beds became a v a i l a b l e . The General Hospi ta l planned to tear down the Annex at t h i s t ime. The C i t y S o c i a l Service Department persuaded the hosp i t a l to continue operating the Annex on the condit ion that the C i t y S o c i a l Service Department pay the f u l l cost of the pa t ien ts ' care. A l l admissions to the i n s t i t u t i o n were t o be through the Medical Section of the C i ty S o c i a l Service Department. This arrangement has been continued t o the present day. In 1948 Heather Street Annex was l icensed as a pr ivate h o s p i t a l . Heather Street Annex (how known as Heather Annex) was closed from June to November 1948, so that the buildings could be moved from t h e i r old l oca t ion on the corner of Twelfth Avenue and Heather Street t o make way for a new nurses home. The present loca t ion i s at Thir teenth Avenue and Willow Street . F i f t y - s i x of the patients were housed i n the Infect ious Diseases Hospi ta l u n t i l the Annex was re-opened, The remaind-er were placed i n various c i t y boarding homes. When the bu i ld ing was re-opened, the twenty-four patients placed i n the boarding homes were l e f t there because there was more urgent need for the beds for more ser ious ly i l l p a t i e n t s . ^ As before, the Vancouver General Hosp i t a l (1) At the time of wr i t ing nearly a l l of these patients l e f t i n the boarding homes have been re-admitted to the Vancouver General Hospi ta l as they were i n r e a l i t y too d i f f i c u l t t o care for i n boarding homes. - 50 -retained i t s twelve-bed genito-urinary pre-operative and post-operative ward as part of the acute hosp i t a l f a c i l i t i e s , administered quite separately from the eighty bed chronic h o s p i t a l . Except for a short period during the war, Heather Street Annex has always used male o rder l i es instead of nurses. The hosp i t a l has always f e l t that male o rder l i es are much more capable of caring for the needs of chron ica l ly i l l o l d men than nurses. The s t a f f appears t o be w e l l t r a ined and quite capable, and most important of a l l the patients seem to be get t ing the ind iv idua l care and at tent ion that they want and need. More order l ies are needed but the present s ta f f of s ixteen, assis ted by kitchen s ta f f and cleaners, apparently manage f a i r l y s a t i s -f a c t o r i l y considering the handicaps under which they work. Being si tuated just across the road from the General H o s p i t a l , the patients i n the Annex receive considerably more medical care than the patients i n Glen and Grandview Hospi ta l s . The doctor i n charge v i s i t s the patients at least once a day and sometimes oftener. Internes and spec i a l i s t s from the General Hospi ta l are r ead i ly ava i lab le and are ca l l ed i n when needed. The C i ty S o c i a l Service Department pays the General Hospi ta l $105 per month for each patient that i s a Vancouver r e s p o n s i b i l i t y , jus t as i t does for those patients that are Vancouver r e s p o n s i b i l i t i e s i n Glen and Grandview Hospi ta l s . There are many things wrong wi th Heather Street Annex neverthe-l e s s , ch ie f amongst them being the s ize of the wards. There are four large publ ic wards wi th twenty-f ive, twenty-two, twenty-one and th i r teen beds. The wards are extremely p l a i n and u t i l i t a r i a n and rather depressing - 51 -i n appearance. The beds are placed quite close t o each other and the only-privacy that a patient can have i s when the curtains are drawn around the bed. There are few patients under the age of s i x t y - f i v e i n the whole i n s t i t u t i o n and the number of men who are qui te seni le i s rather h igh . I t i s most depressing t o hear an o ld man at one end of the ward moaning loudly wi th pain while the whole ward must l i s t e n to him. The patients have nothing t o occupy t h e i r time and do nothing more than l i e around. The whole atmosphere of the place seems t o be one of hopelessness. These are o ld men who are about to die so nothing more i s done for them than i s absolutely necessary. The food i s goodj i t i s brought over to the Annex i n steam t r o l l e y s from the main h o s p i t a l . Heather Street Annex provides better phys ica l f a c i l i t i e s than the other two i n s t i t u t i o n s , but, even though i t i s not operated for prof i t , there i s not enough difference to show the advantages of a p u b l i c l y operated non-profi t i n s t i t u t i o n over a privately-owned profit-making i n s t i t u t i o n . Any super ior i ty that the Annex has over the other two i n s t i t u t i o n s i s purely the resu l t of i t s proximity to the resources of the General H o s p i t a l . Mount S t . Joseph's Or ien ta l Hosp i t a l (Chronic Section) In October, 1946 the S i s t e r s of the Immaculate Conception opened t h e i r new 100 bed hosp i ta l at 3080 Pr ince Edward Avenue. The o ld S t . Joseph's Or ien ta l H o s p i t a l , operated on Campbell Avenue for over twenty years, was made in to a tuberculosis hosp i t a l for Or i en t a l s . The top f l o o r of the hosp i t a l wi th t h i r t y - f i v e beds i s devoted to the care of the chronica l ly i l l men. The remaining s i x t y - f i v e beds are used as - 52 -an acute hosp i t a l fo r maternity and su rg ica l cases. The chronic patients are cared for i n large a i r y three and four bed wards with one seven bed ward running the f u l l width of the hosp i t a l . Ambulatory pat ients have s p e c i a l l y b u i l t low beds t o make i t easier for them. There seemed to be a noticeable lack of attendants and nurses when the i n s t i t u t i o n was v i s i t e d . The S i s t e r Superior stated because of s ta f f shortages, the patients received only the minimum amount of nursing and supervisory care . Despite t h i s , however, the wards are spotless and the l i n e n immaculate. The h o s p i t a l , l i k e a l l i n s t i t u t i o n s of t h i s s ize,has no f a c i l i t i e s for the care of pat ients that are suffering from mental d i s -orders. When a patient becomes seni le the hosp i t a l has d i f f i c u l t y caring fo r him u n t i l he can be admitted t o the mental h o s p i t a l . An unusually large number of the patients were hemiplegias but the a r t h r i t i c s were a l so numerous. The s i s t e r s have cared for some of these patients fo r an ex t ra -ordinary long period of t ime. One of the pat ients had spent f i f t een years i n both the old and the new hospi ta ls and looked w e l l enough t o l i v e for quite a few more.^ Ten of the t h i r t y - f i v e patients had been chronic i nva l i d s and incapable of caring for themselves for more than ten years. A l l of the patients are s t a f f pat ients except four who are being paid for by a benevolent soc ie ty . The other th i r ty-one patients are considered to be Vancouver r e s p o n s i b i l i t i e s but the C i t y S o c i a l Service Department accepts only twenty of them as e l i g i b l e fo r payments from that department. The C i t y S o c i a l Service Department pays f i ve d o l l a r s l e ss than the current standard boarding home rate for those whom - 53 -they accept as Vancouver r e s p o n s i b i l i t i e s ; at present the hosp i t a l i s paid f i f t y d o l l a r s per month per pa t ient . Th is lower rate i s paid because of an agreement whereby the hosp i t a l receives a substant ia l t ax exemption as a hospi ta l and chari table i n s t i t u t i o n . Because the hosp i ta l and the C i t y S o c i a l Department are not i n agreement and a l so because the hosp i t a l f inds i t easy t o f i l l i t s beds wi th i t s own acute patients who develop in to chronic i n v a l i d s , few Orienta ls are accepted i n the hosp i t a l from other outside agencies. A l l of the chron ica l ly i l l Or ienta ls i n t h i s hosp i t a l are advanced i n years , most of them being over seventy years of age. The majority of the patients have wives and fami l ies i n China and many of them have no fr iends or r e l a t i v e s here i n Vancouver t o v i s i t them. At one time attempts were made t o provide occupational therapy f a c i l i t i e s for the pat ients . Few of them were able to make use of these services and they were discontinued, so that now no rec rea t iona l , occupational therapy or physiotherapy f a c i l i t i e s are provided. The patients are kept clean and comfortable and provided with any medicines that they need; and, as far as the hosp i t a l au thor i t i es are concerned, they need nothing more. These patients are rece iv ing Class n B n or nursing-home care of a minimal nature. The Holy Family Hosp i t a l This small i n s t i t u t i o n , although at present caring for only f i f t een chron ica l ly i l l pat ients , w i l l i f i t s plans mater ia l ize , play an extremely important part i n the care of the ch ron ica l ly i l l i n the future. - 54 -In April, 1946, four Sisters of Providence purchased a large private residence at 7801 Argyle Street in South Vancouver. The poor location of the hospital is a definite limitation upon the use that could be made of its services. The hospital is about ten blocks from the near-est bus stop. It is so far away from the city centre that the patients' private physicians come to visit only when they become acutely, i l l . The new Fraserview housing project is now being built up around the hospital so that its location will no longer hinder its effectiveness as a hospital. There" are four Sisters and two nurses' aides caring for the fifteen female patients. The patients, although crowded, appear to receive good nursing care and the food they receive is excellent and attractively served. Since the original building was bought, the roof has been raised and an extension built on to one side to provide more room for patients. No further expansion is contemplated until the projected two hundred-bed hospital, for which the land has been already purchased, can be built. This order of nuns operates several large chronic hospitals in other parts of Canada and the United States. A short time ago the Sisters opened a new two hundred-bed chronic hospital in Edmonton, operated in conjunction with the University of Alberta Medical School. It is regarded as one of the most up-to-date hospitals of its kind in North America. The Sisters have already run into financial difficulties with three of their fifteen patients. Like typical chronics they were able to pay their bills for a while but they and their relatives soon ran out of money. The Sisters are now faced with the problem of what to do with the patients who are s t i l l in need of continual nursing care for - 55 -which they cannot pay, and for whom the C i t y S o c i a l Service Department w i l l not as yet accept r e s p o n s i b i l i t y . The s i s t e r s have come to Vancouver at the request of t h e i r r e l i g i o u s superiors t o set up a chronic hosp i t a l without su f f i c i en t information regarding the ex i s t i ng s i tua t ion i n Vancouver. I f the projected two hundred-bed chronic hosp i t a l i s construct-ed, i t seems highly improbable that t h i s number of paying pat ients can be found. For the non-paying patient the C i t y S o c i a l Service Department w i l l have t o enter i n to the p ic tu re , and i t would be w e l l for t h i s i n s t i t u t i o n t o work out a l l of these problems of l i a i s o n and r e f e r r a l while the i n s t i t u t i o n i s s t i l l smal l . This i n s t i t u t i o n provides good n B n c lass care although i t i s not l icensed as a nursing-home. The Pr iva te Nursing-Homes and the Small Pr iva te Hosp i ta l s . In Vancouver, as i n a l l other large centres, numerous small p r iva t e ly owned and operated hosp i t a l s , or as they are more popularly known, "nursing-homes" have sprung up. These smal l i n s t i t u t i o n s play an important r o l e i n the treatment of the chron ica l ly i l l i n that t h e i r c l i e n t e l e includes many of the more affluent people a f f l i c t e d wi th chronic i l l n e s s , who are unknown t o the acute hospi ta ls or tb the p u b l i c l y subsidized i n s t i t u t i o n s . At present the demand for beds i n these pr iva te i n s t i t u t i o n s i s so great that they are able t o charge unreasonably high rates and are i n a pos i t ion t o decide which patients they w i l l accept and which they w i l l refuse. A se r ious ly i l l patient wi th a small bank account, unless placed through the C i t y S o c i a l Service Department, has l i t t l e chance of being admitted. The C i t y S o c i a l Service Department i s so hard pressed for accommodation fo r the patients referred t o them that they sometimes have t o pay the rates demanded, no matter how high they are. - 56 -The lowest ra te i n the nursing-homes i s $4«50 per day for a semi-private room, wi th $8.00 a day the average rate fo r a pr ivate room. These rates do not include the services of a physician or any extras . One nursing--home charges the patients extra fo r laundry serv ice . One day i n January, 194-9, the nurse of the C i t y S o c i a l Service Department made a telephone survey to f i n d how many beds were ava i lab le and vacant. She found only two vacancies, both of which were $8.00 -a-day beds. The proprietors of Glen and Grandview Hospitals cont inua l ly emphasize that they could tu rn out every c i t y case they havey increase t h e i r rates by $50 a month, and f i l l , t h e i r beds i n a couple of days, without adver t i s ing . While the c i t y i s paying $105 a month for t h e i r patients i n Glen and Grandview Hospitals they must pay from $120 to $180 for a considerable number of patients i n these pr ivate nursing-homes. I t i s understandable why the c i t y au thor i t ies have not been pressing Glen and Grandview Hospitals too hard to have t h e i r standards improved; i f they d id so they would probably lose what few beds they already have. I t must be s a id , however that a few of the nursing-homes such as Oakhurst (37 beds) and the Bayview (23) cooperate by taking many c i t y cases at a spec ia l rate of $120 per month. The assured income makes these arrange-ments p rof i t ab le to them. Every nursing-home has the patient who came i n t o the i n s t i t u t i o n wi th a few thousand do l l a r s i n the bank but who, af ter a year or so of heavy medical and nursing-home b i l l s , ran out of money. At one time the pract ice was t o refer these patients to the C i t y S o c i a l Service Department i f they were Vancouver r e s p o n s i b i l i t i e s , and have them transferred t o other nursing-homes where the rates were not so high and where the c i t y - 57 -was willing to pay the b i l l * At the present time, the shortage of beds has become so acute that the city has no place to which to transfer these patients, and they are forced to leave them where they are and pay the rates demanded by the institution. The City Social Service Department has almost one hundred patients waiting, in their homes or. in rooming houses for admission to nursing homes as well as the considerable number of patients in boarding homes that should be in nursing homes. The General Hospital also has about twenty patients that could and should be cared for ia nursing homes; The situation has become so desperate that the city i s seriously considering erecting Some Quonset huts to provide temporary accommodation. With conditions as they are today, the private nursing; homos can ask what they please and get i t * In Vancouver there are nine main private hospitals other than those already described.^ Eight of these are licensed to care for "medical, chronic and convalescent cases" and one for surgical and maternity cases as well* Table H Private Hospitals (Feb. 194-9) Same Capacity Lowest Rate (per day) Oakhurst 37 14.50 Bayview 23 #4.50 Athlon© IS 14*50 Houghton 18 $4.50 Packenham 18 §5.00 Kitsilano 17 $7.00 Margaret 17 $6.00 Kerrisdale Chatham flouse^2' 24 $6.00 21 $6.00 Total 193 (l) With these there must be included four other nursing homes (cont'd) - 58 -Under the regulations covering the l i c e n s i n g of these i n s t i t u t i o n s , a graduate nurse must be i n attendance at a l l t imes. The nursing-homes f i n d i t advantageous and extremely economical t o employ only three or four graduate nurses wi th most of the work being done by nurses' aides and attendants at h a l f the cost . P r iva te physicians seem to lose interest i n t h e i r patients when they are admitted t o nursing-homes. In a group of patients interviewed i n a pr iva te nursing-home, i t was found that the pa t ien t ' s doctors paid them a v i s i t on an average of once every two weeks. Several of the patients had not seen t h e i r doctor for over a month. The furnishings of these nursing homes range from a p l a i n hosp i t a l bed with a bare table beside i t t o elaborate and luxurious rooms wi th everything that a patient could possibly want. The r e a l tragedies behind these places l i e i n the fact that dozens of sons and daughters, f ee l ing a moral ob l iga t ion to provide a s i ck parent with the best care poss ib le , use up a l l of t h e i r savings, mortgage everything they have, to pay t h e i r hosp i t a l and medical b i l l s rather than accept c h a r i t y . F i n a l l y , when the burden becomes i n t o l e r a b l e , they ask the C i t y S o c i a l Service Department to help them pay part of the cos t . Gradually they sh i f t more and more of the burden t o the C i t y S o c i a l Service Department u n t i l eventually the t o t a l cost i s being paid by the c i t y . i n adjoining munic ipa l i t i e s and accepting some Vancouver cases. These are: Kingsway Nursing Home (Burnaby) Capacity 45 McKay Nursing Home (New Westminster) " 25 Melrose Park Nursing Home (New " ) " 3 7 Seaview Nursing Home (West Vancouver) " 8 T o t a l 119 (2) Mostly s u r g i c a l and maternity but a few chronics . - 59 -Under the present regulat ions of the Hospi ta l Insurance Scheme, patients who pay t h e i r f i f t een d o l l a r premium receive free hosp i t a l i za t ion as long as they are acutely i l l . As soon as they are diagnosed as being chronica l ly i l l , however, they are no longer e l i g i b l e fo r care i n an acute h o s p i t a l . They are then discharged t o a nursing-**-home or. t o t h e i r own homes. I f they are admitted t o a nursing-home they must pay a minimum of $4.50 a day for much l e s s care, when they are just as s i ck ( i n t h e i r opinion) as they were i n the acute h o s p i t a l . Natura l ly t h i s does not seem r ight to the pat ient . As i n the other i n s t i t u t i o n s described previously , these nursing--homes are almost completely lacking any rec rea t iona l , occupation-al-therapy and physiotherapy f a c i l i t i e s . Many of the patients need them but t h i s i s a secondary consideration t o making a p r o f i t . The Marpole Infirmary and I t s Subsidiar ies The accommodation for the chron ica l ly i l l so far reviewed i s that i n p r iva te ly owned and operated i n s t i t u t i o n s , and i n those i n s t i t u t i o n s which the c i t y controls e i ther d i r e c t l y or i n d i r e c t l y . The p r o v i n c i a l government a lso accepts r e s p o n s i b i l i t y for a ce r t a in number of chron ica l ly i l l people i n i t s i n s t i t u t i o n s at Marpole, Mount S t . Mary and A l l e o . The p r o v i n c i a l government does a very good job i n car ing for the ch ron ica l ly i l l i n i t s i n s t i t u t i o n s . With more extensive f i n a n c i a l resources ava i l ab le , the p r o v i n c i a l government has taken the f i r s t steps toward the implementation of treatment program for the chron ica l ly i l l . Marpole Infirmary and i t s subsidiar ies are designed t o provide i n s t i t u t i o n a l care fo r the ch ron ica l ly i l l whenever the munic ipa l i t i e s - 60 -are unable to do so. In exchange for this provision of accommodation by the provincial government, the municipalities are expected to share the costs. The system of hospital clearance, operated by the provincial government, channeled through the Inspector of Hospitals Office and used to remove patients who are not acutely i l l from acute hospital beds, is based on the premise that i f there is no other place for the chronically i l l patient then theoretically he or she can be placed in the Infirmary. The Marpole Infirmary and its subsidiary, Mount St. Mary at Victoria, have become the only real chronic hospitals in B.C. When the institutions were originally set up they were designed to provide custodial care with some nursing care. Unintentionally the provincial institutions have become the only treatment centre in the province for the treatment and rehabilitation of the chronic invalid. A remarkable number of patients admitted to Marpole Infirmary as hopelessly incurable, have walked out of the institution, able to live normal active lives* In February, 1917, a bankrupt hotel at the intersection of Hudson and Marine Drive in Marpole was taken over by the Vancouver General Hospital to provide a place for its chronically i l l . The provincial government took over the institution in July, 1923 and has operated i t continuously ever since. Between 1923 and 1937 the standards of care and treatment were very low and i t was not until the institution was completely re-organized in 1937 that the institution began to achieve its present status. In that year also, the name was changed from the Marpole Home for Incurables to the Marpole Infirmary. The requirements for admission set up in 1937 are s t i l l applicable: "The Infirmary was established for the care of any person, who being a chronic patient affected with some body disease, does not require or is not - 6 1 -l i k e l y to benefit from care or treatment i n a general hosp i t a l or other spec i a l h o s p i t a l , but nevertheless requires i n s t i t u t i o n a l care . S i x types of patients are barred from admission; habi tual drunkards, drug add ic t s , e p i l e p t i c s , patients suffering from infec t ious or contagious disease or needing i s o l a t i o n for any reason, and patients suffering from sen i le dementia or unsound mind .d) In J u l y , 1 9 4 1 the p r o v i n c i a l government contracted for 1 0 0 beds i n the Mount S t . Mary Hospi ta l i n V i c t o r i a , operated by the S i s t e r s of . S t . Anne. That contract has now been extended to cover 1 0 5 beds. In August, 1 9 4 3 A l l e o was taken over t o care for inf i rmary type patients but i t was not u n t i l . 1 9 4 4 - that t h i s i n s t i t u t i o n came under the Marpole Infirmary for adminis t ra t ion. In 1 9 4 - 7 , because of the danger of f i r e i n the bu i l d ing , the capacity of the Marpole i n s t i t u t i o n was reduced from 144- t o 1 2 4 - , leaving only one large ward of male ambulatory patients on the t h i r d f l o o r . In 194-8 the use of A l l o o has been r e s t r i c t e d to 1 0 0 beds, due to the unsu i t -a b i l i t y of the bui ldings and f a c i l i t i e s fo r the care of the bed-ridden chronic pat ient . Mount S t . Mary and A l l e o are operated as subs id iar ies of the Marpole Infirmary wi th a l l admissions and discharges made through Marpole. The Superintendant of Infirmaries has her of f ice at Marpole. The sex, phys ica l condit ion of the patient (whether he i s ambulatory or no t ) , the loca t ion of a pa t ien t ' s home and r e l a t i v e s , and whether he i s a p r o v i n c i a l or a municipal r e s p o n s i b i l i t y determine the i n s t i t u t i o n i n which the patient w i l l be placed, e . g . , a bed-ridden ch ron ica l ly i l l person from Vancouver Is land i s almost invar iab ly placed i n Mount S t . Mary, ( l ) Annual Report of the Marpole Infirmary, 1 9 4 - 7 . - 62 -Marpole Infirmary i t s e l f , located at one of the busiest i n t e r -sections i n Vancouver, i s t o t a l l y unsuitable and inadequate as f a r as the ac tua l bui ld ing i s concerned. The bui ld ing i s a f i r e - t r a p and fo r t h i s reason non-ambulatory patients are kept on the two lower f l o o r s . The wards are large (al lowing the pat ients no privacy at a l l ) . One ward has t h i r t y patients i n i t . The service f a c i l i t i e s are hopelessly inadequate, and accommodation for the s ta f f and administrat ive off ices are very l i m i t e d . The occupational therapy department i s i n the basement along wi th the dining h a l l for ambulatory pat ients . A large well-equipped.and wel l - s ta f fed ki tchen on the main f l o o r serves the whole i n s t i t u t i o n . Food for the pat ients i s taken around the wards on steam t r o l l e y s . The food i s exce l len t , a t t r a c t i ve ly served and var ied i n menus. Graduate nurses are i n constant attendance, wi th numerous nurses ' aides and order l ies t o a s s i s t them. The s t a f f i s of an except ional ly high ca l ib re and take an unusual in teres t i n the patients under t h e i r care. The s ta f f caters t o the i n d i v i d u a l needs of the pa t ien ts , and patient after patient when interviewed was high i n h i s praises fo r the care and at tent ion that he received. The pat ients are kept clean and the l i nen spot less . The place i s f i l l e d wi th a var ie ty of frames and gadgets which the patients use t o get around w i t h . I f a spec ia l type of backrest i s needed so that a patient can s i t up i n bed, (1) then that contrivance i s provided without quest ion. ( l ) The Marpole Infirmary has an except ional ly ac t ive Women's A u x i l l i a r y which provides many extras for the pat ients . The A u x i l l i a r y sponsored the f i r s t . phys io the rap i s t i n the i n s t i t u t i o n t o convince the government of the necessi ty of such a se rv ice . The Marpole Infirmary A u x i l l i a r y i s an outstanding example of how a p r o v i n c i a l i n s t i t u t i o n can employ volunteer groups t o the best advantage. - 63 -Medical care i s provided by a young general p rac t i t i one r who v i s i t s the i n s t i t u t i o n three times a week and i s on constant c a l l , day and n igh t . The very l a tes t medicines are used and i n the provis ion of medical or treatment services there seems to be no l i m i t t o what w i l l be t r i e d . Pat ients needing X-ray services are taken t o the Vancouver General Hospi ta l by ambulance. Pat ients are a l so taken t o the Vancouver General Hosp i t a l t o see spec ia l i s t s i n the Outpatients ' Department. An eye s p e c i a l i s t and a dentis t v i s i t the hosp i t a l r egu l a r l y . Several patients are receiving treatment at the Cancer C l i n i c and a l l patients receive an annual chest X-ray as a check on tubercu los i s . Occupational therapy and physiotherapy are used extensively and have become an i n t e g r a l part of the treatment program. A de ta i l ed analysis of the patients i n the Infirmary was made even though a l l of the patients were not Vancouver r e s p o n s i b i l i t i e s . The i n s t i t u t i o n provided an excel lent opportunity t o study the age d i s t r i bu t i on , the length of stay i n hosp i t a l , and the medical diagnosis of a large group of chronic p a t i e n t s . ^ The Infirmary provides an i l l u s t r a t i o n of the types of patients that would normally be cared for i n a chronic h o s p i t a l . The majority of the patients i n the i n s t i t u t i o n have spent some time i n nursing-homes and boarding-homes before being admitted t o the Infirmary. The ages of the pat ients vary widely from twenty t o several over ninety with an average age of 67.2 years . The vast majority of the patients were i n the s i x t y t o ninety group. (1) T h i r t y - f i v e of the 126 patients i n the i n s t i t u t i o n on February 1, 1949 were Vancouver r e s p o n s i b i l i t i e s . - 6 4 -Table I Age D i s t r i b u t i o n of Pat ients i n the Marpole Infirmary-Age No. Age No. Under 2 1 1 6 0 - 6 9 28 2 1 - 2 9 1 70 - 7 9 28 30 - 3 9 4- 80 - 8 9 28 £ 0 - 4-9 18 Over 9 0 6 _ 5 0 - 5 9 1 2 T o t a l 1 2 6 The length of stay of the patients i n the i n s t i t u t i o n has var ied from twenty-five years to one month, w e l l over ha l f of the patients having been admitted wi th in the past f i v e years. (See Appendix B, Page 1 6 8 ) In terms of medical diagnosis , the a r t h r i t l c s predominate, and patients suffer ing from degenerative diseases are a close second because of the advanced age of some of the pa t ien ts . (See Appendix B, Page 1 6 9 ) Interviews wi th the patients and discussion of t h e i r problems and experiences brought fo r th almost unbelievable hardships - the s i tuat ions these people had t o face and work out on t h e i r own - great insecur i ty , fear of becoming completely he lp less , d i s l i k e of being so dependent and s e n s i t i v i t y about t h e i r i l l n e s s e s . The pat ients l i k e the loca t ion of the Infirmary and enjoy a part of the busy community where they are located rather than being i so la t ed i n some suburban d i s t r i c t , completely i so l a t ed from the world . A l l of the patients were loud i n t h e i r praises of the s ta f f and of the Superintendant i n p a r t i c u l a r . None of the patients had any complaints about the food or the phys ica l f a c i l i t i e s of the inf i rmary. A l l f e l t that they were rece iv ing the best medical care that they had ever received and that everything that could poss ib ly be done for them was being done. The occupational therapy f a c i l i t i e s of the i n s t i t u t i o n s were p a r t i c u l a r l y praised as a service that helped them t o keep t h e i r minds occupied. An a r t h r i t i c pat ient , completely r i g i d wi th a Marie-Strumpel spine making do l l furni ture wi th the a i d of mi r ro rs , a young man of for ty wi th advanced Parkinson's Disease doing, beau t i fu l o i l paintings and a man paralyzed for twenty years as the resu l t of an accident who was taking a high school correspondence course, were a l l eloquent testimonies to the effect ive and enlightened treatment program car r ied on i n the Infirmary. Mount S t . Mary This i n s t i t u t i o n i n V i c t o r i a , wi th a poss ible capacity of 1 0 5 pat ien ts , had s ix ty male and forty-two female bed pat ients on February 1 , 1 9 4 - 9 . Most of the patients i n the i n s t i t u t i o n are from Vancouver Is land or from the i n t e r i o r of the province. F ive out of the 1 0 2 pat ients were Vancouver r e s p o n s i b i l i t i e s . Mount S t . Mary was b u i l t t o be a chronic h o s p i t a l . There are small wards, even anfew pr ivate ones, and the whole place i s spot less ly clean and very e f f i c i e n t l y run. Infirmary cases are mixed i n wi th other pr ivate pa t ien ts . The S i s t e r s , ass is ted by nurses' aides and o rde r l i e s , give the pat ients excellent nursing care. A pr ivate phys ic ian , on continuous c a l l , v i s i t s d a i l y . P h y s i c a l l y the i n s t i t u t i o n i s incomparably better than the Marpole Inf irmary. The bu i ld ing was b u i l t fo r chronic pat ients and contains spec i a l innovations fo r t h i s p a r t i c u l a r type of pa t ien t . The occupational therapist from Marpole gives part of her time at Mount S t . Mary but the use of these services are a much smaller part of the - 66 -treatment program than at Marpole. Mount St. Mary prefers to take bed patients and consequently gets more of the type of patient that is completely helpless. The provincial government pays a per capita per diem rate for the patients placed there with provisions for a yearly revision of the rate paid. Excellent supervised nursing care sfthe "Class B" type is provided here. Allco Allco started as a logging camp; during the depression i t was used to accommodate physically incapacitated relief recipients and now i t has been converted into a subsidiary of the Marpole Infirmary to house ambulatory male patients who are chronically i l l but need "Class C" or custodial care. Theoretically, only ambulatory cases are kept here, but ambulatory chronically i l l patients have a propensity for becoming complete bed patients, especially in a place such as Allco. With a nominal capacity of 120 and an accepted capacity of 100 there were eighty-three patients in the institution on February 1, 194-9. Allco is totally unsuited for its purpose. It is seven miles from the nearest town of Haney and too far from the city for friends and relatives to vis i t . The patients live in small cottages or huts that were once loggers' shacks. Only about half of the cabins have inside bath or toilet facilities. The patients are supervised by male orderlies and are visited at least once a week by a doctor from Haney j he is on call twenty-four hours a day however. A "sick-bay" is provided for the more acutely i l l patients who are too sick to stay in their own cabins. Needless to say - 67 -this "sick-bay" i s always f i l l e d . It i s f e l t by the Infirmary administrative staff that many of the patients occupying nursing-home and boarding-home beds in Vancouver could be placed at Alleo i f the institution wss properly interpreted to the patients. The medical social workers in the hospitals consider that i t i s not reasonable to ask a patient to go to a place like this; but in any case patients who have heard about Alleo or. have friends and relatives in Vancouver cannot be swayed by persuasion to go to Alleo. Theoretically men who have been loggers, miners and fishermen are supposed to want to stay i n the outdoors u n t i l they die. But i n practice, men of this type who become chronically i l l and unable to manage for themselves, want to stay i n town close to c i v i l i z a t i o n just as much as a Vancouver man. On February 1, 194-9, eight out of the eighty-three patients i n the institution were Vancouver responsibilities. These patients had an average age of seventy-six. Four out of the eight had been admitted from Heather Street Annex. An occupational therapy hut has been built and a full-time occupational therapist i s employed. Some beautiful pieces of cabinet work have been made by the patients despite their d i s a b i l i t i e s . A recreation hut has been built so that the patients do not have to stay in their living quarters when i t rains. Alleo does provide "ClassCC"custodial care. From a humanitarian point of view the place should be closed and a proper institution built in Vancouver. The provincial government has provided excellent services at the Marpole Infirmary and at Mount St. Mary but i t s thinking as far as Alleo i s concerned i s far back in the depression period. - 68 - i i A l l e o has been used, despite i t s proven inadequacy, t o care for chron ica l ly i l l o ld men. L i k e many others, bui ld ings taken over as "a temporary measure" remain i n operation cont inual ly and i t seems that patients w i l l be housed at A l l e o i n d e f i n i t e l y . - 69 -C h a p t e r I V S o c i a l A s s i s t a n c e and t h e C h r o n i c a l l y 111 U n d e r t h e p r o v i s i o n s o f t h e V a n c o u v e r I n c o r p o r a t i o n A c t t h e c i t y i s h e l d r e s p o n s i b l e f o r t h e s u p p l y i n g o f f a c i l i t i e s and c a r e f o r i t s s i c k a n d i n f i r m , i t s p o o r and i t s d e s t i t u t e . T h e a d m i n i s t r a t i v e body s e t u p b y t h e c i t y t o d e t e r m i n e n e e d and t o p r o v i d e f i n a n c i a l a i d t o t h o s e p e r s o n s who a r e u n a b l e t o c a r e f o r t h e m s e l v e s i s known as t h e C i t y S o c i a l S e r v i c e Depar tment o f t h e C i t y o f V a n c o u v e r . T h e i n c a p a c i t a t e d a n d c h r o n i c a l l y i l l p e r s o n s who a r e c l a s s i f i e d a s u n e m p l o y a b l e a r e p r o v i d e d w i t h m o n t h l y c a s h payments f o r r e n t , f o o d a n d f u e l . I f t h e y a r e p h y s i c a l l y i n c a p a b l e o f c a r i n g f o r t h e m s e l v e s t h e c i t y assumes t h e r e s p o n s i b i l i t y o f p r o v i d i n g c u s t o d i a l o r n u r s i n g c a r e f o r t h e m . I n V a n c o u v e r , a s i n e v e r y t o w n o r c i t y i n C a n a d a , s o c i a l a l l o w a n c e payments now c o n s t i t u t e one o f t h e m a j o r i t e m s o f c i t y e x p e n d i -t u r e s . I n V a n c o u v e r a l o n e l a s t y e a r , s o c i a l a s s i s t a n c e payments t o V a n c o u v e r r e s i d e n t s t o t a l l e d $1,475,416 w i t h a n a d d i t i o n a l $ 3 , 6 7 5 , 0 0 0 i n o l d age p e n s i o n s and $145,000 f o r m o t h e r ' s a l l o w a n c e s . ^ A p p l i c a n t s f o r s o c i a l a s s i s t a n c e c a n be d i v i d e d i n t o two m a i n g r o u p s . T h e l a r g e s t g r o u p c o n s i s t s . o f men and women between t h e ages o f s i x t y and s e v e n t y who a r e t o o o l d t o f i n d employment b u t a r e n o t o l d enough t o q u a l i f y f o r o l d age p e n s i o n . I n 194-8, a l m o s t h a l f o f t h e 2860 c a s e s ( r e p r e s e n t i n g 3780 p e r s o n s ) , i n r e c e i p t o f s o c i a l a s s i s t a n c e i n V a n c o u v e r were i n t h i s g r o u p . A s e c o n d a n d v e r y l a r g e g r o u p a r e t h e ( l ) A n n u a l R e p o r t , C i t y S o c i a l S e r v i c e Department , - 194-8, Page 2 . - 70 -persons who are unemployable for medical reasons. The vast majority of these people are chron ica l ly i l l persons i n every sense of the term. A person i n t h i s group rece iv ing s o c i a l assistance over a period of years for medical reasons (except for cases of orthopedic impairment), i s a chronic i n v a l i d whose i l l n e s s has reached such a stage that he has t o (1) become completely dependent upon the community for care . In August and September of 1948, a worker of the C i ty S o c i a l Service Department made an analysis of the approximately 1400 cases who were i n receipt of s o c i a l assistance at that time fo r reasons other than old age. Of these 1400 cases, 247 were receiving s o c i a l allowances because of tuberculos is , 108 for mental conditions (mental def ic ien ts and psychotic disorders) and twenty-six for incapaci ty from cancer. The others were receiving s o c i a l assistance for a wide v a r i e t y of other ailments wi th a majority of them suffer ing from seven major complaints. C i rcu la to ry disorders headed the l i s t wi th a r t h r i t i s and rheumatism a close second. The seven major groups i n t o which f o r t y per cent of the o t o t a l cases f e l l were as fo l lows: Ci rcu la tory and cardiac disorders 222 A r t h r i t i s and rheumatism 189 P a r t i a l or complete pa ra lys i s 58 Chronic asthma 56 Epilepsy 31 Diabetes 30 Anaemia 23 T o t a l 609 The remainder included small numbers of persons i n different categories, i . e . , three persons receiving assistance because of kidney disorders , two for hyperthyroidism, ten for sk in diseases, four for lumbago, and f i v e ( l ) There i s ac tua l ly a t h i r d group which includes deserted wives and ch i ld ren , unmarried mothers, and wives whose husbands are imprisoned i n Oakal la P r i s o n . Th i s group i s small and seldom numbers more than 150 cases i n the whole c i t y . - 71 -fo r eczema. What i s the cost of t h i s burden of i l l n e s s ? Assuming for the sake of s i m p l i c i t y that a l l of the 609 persons i n the seven main categories were without dependents and were i n receipt of the maximum allowance of t h i r t y - f i v e do l l a r s fo r a s ingle person with no dependents, the C i ty S o c i a l Service would provide them wi th $21,315 a month or #255,780 i n ac tual assistance payments i n one year . The cost of the medical services t o these people and the maintenance of t h e i r dependents i f they had any, would increase t h i s f igure considerably. From these f igures alone i t can be seen that the maintenance of the ch ron ica l ly i l l i s a heavy f i n a n c i a l burden i n Vancouver. I t i s t rue that the c i t y actual^ l y only pays twenty per cent of these s o c i a l assistance costs and the p r o v i n c i a l government eighty per cent, but i t i s s t i l l the tax payer of Vancouver who foots a large part of the b i l l no matter which l e v e l of government arranges the disbursements. The C i t y S o c i a l Service Department and C i t y Boarding Homes I t was not u n t i l 1937 that the C i t y S o c i a l Service Department became involved i n the placement of chron ica l ly i l l people i n boarding and nursing homes t o any great extent. In that year a scheme of h o s p i t a l clearance invo lv ing the C i t y S o c i a l Service Department, the Vancouver General Hosp i ta l and the P r o v i n c i a l Tuberculosis Uni t i n Vancouver was set up, under the supervision of a phys ic ian , for the purpose of moving long-term patients occupying • acute beds i n the two i n s t i t u t i o n s to nursing homes and boarding homes. The system set up i n 1937 i s i n operation today with only a few modif icat ions. P r i o r to t h i s date the only outlet that the General - 72 -Hospital had for the disposal of its chronically i l l was in whatever beds i t could get in Glen, Grandview and Bayview Hospitals, these being used as annexes of the main hospital. Because of the excessively long occupancy of acute beds by non-paying patients in the Vancouver General Hospital, many of whom did not need hospital care, there was an extreme shortage of beds and the hospital f e l l deeply in debt. The hospitals were in danger of becoming boarding homes or convalescent homes for unfit (1) indigents, particularly old people. Marpole Infirmary was supposed to provide for the chronically i l l incurable but this institution was hopelessly overcrowded and had a long waiting l i s t . The annexes - Glen, Grandview, and Bayview Hospitals-were also f i l l e d to capacity. As part of the program of hospital clearance, the city social service took over Bayview Hospital and along with i t two other nursing homes, Oakhurst and Houghton. These three institutions had a total capacity of 100 patients. The owners were paid thirty dollars per patient per month. Patients who were occupying acute hospital beds and were no longer in need of this type of care were moved to these institut-ions . In July 1941* Mount St. Mary was opened as an institution for the care of the chronically i l l and operated as a subsidiary of the Marpole Infirmary. Patients from the three city-operated nursing homes were transferred to Mount St. Mary and the city withdrew from any further (l) A Vancouver Hospital Clearance Plan; a report by Dr. J. Moscovitch, after one year's operation of the plan, issued through the Social Service Department, City of Vancouver (mimeographed) Pages 9-10. - 73 -nursing-home r e s p o n s i b i l i t y ; at the same time i t continued t o provide boarding-home care when c a l l e d upon t o do so. Within a year, the C i ty S o c i a l Service Department was ggain faced with the problem of what t o do wi th the large numbers of ch ron ica l ly i l l people occupying acute beds. To care f o r some of these pat ients , Heather Street Annex was taken over and devoted e n t i r e l y t o the care of chron ica l ly i l l male patients who were no longer i n need of acute hosp i ta l care. In 194-3 the Vancouver General Hospi ta l entered i n t o an agreement wi th the C i t y S o c i a l Service Department whereby the hosp i ta l agreed to operate Heather Street Annex and the C i ty S o c i a l Service agreed to pay the cos ts , on the condit ion that a l l admissions t o the i n s t i t u t i o n would be made through the Medical Section of the C i t y S o c i a l Service Department. This scheme i s s t i l l i n operat ion. In the meantime, the C i t y S o c i a l Service Department developed i t s numbers and standards of care i n boarding homes. For some time a fu l l - t ime s o c i a l worker was employed by the Department t o search out boarding-home accommodation for those persons who needed cus tod ia l care but not necessar i ly nursing-home care. Rates of payments were ra ised and some attempt was made to place ind iv idua l s i n boarding homes most l i k e l y t o su i t t h e i r needs. A number of the boarding homes that were opened during t h i s period are s t i l l i n operat ion. Since J u l y , 1941, the p r o v i n c i a l government has paid up to eighty per cent of boarding-home costs up t o a specif ied maximum (at present $50 per month). Any costs above t h i s maximum were to be a f u l l charge upon the c i t y of Vancouver. For pat ients i n nursing homes, however, the p r o v i n c i a l government contributed nothing. This created an unusually - 7A -confused administrative situation, and accentuated the hospital problem by making i t cheaper for the city to maintain a person in an acute hospital bed than in a nursing-home bed. The Goldenberg Report recommend-ed that the provincial government contribute toward nursing-home care on (1) the same eighty-twenty basis as i t did for boarding-home care. As a result of these recommendations, the provincial government agreed to pay eighty per cent of the cost of boarding-home care up to a maximum of ninety dollars. The City Social Service Department entered the nursing-home field again. Effective January 1, 194-8, the City Social Service Department paid the Vancouver General Hospital ninety dollars per month for every patient in Glen and Grandview Hospitals that was found to be eligible for social assistance. The hospital in turn paid the nursing-home owners. The City Social Service agreed to pay for these patients on the understanding that a f u l l investigation into the financial circumstances of each patient would be made, and residence, income and assets checked as in any ordinary social assistance application. The same arrangement for- Heather Street Annex was made and the hospital was paid ninety dollars per patient per month for these patients as well. Since December 1, .194-8 the cost of care in these three institutions has been set at $105 per month. The provincial government s t i l l pays only eighty per cent of the ninety dollars, the payments in excess of this (l) Goldenberg, H. Carl - Provincial-Municipal Relations in British  Columbia, Report of the Commissioner, Victoria, King's Printer 194-7, Page X 91. - 75 -being a hundred per cent Vancouver charge. For the month of November 1948, the City Social Service Department paid the Vancouver General Hospital $11,770.32 for the patients in Glen, Grandview and Heather Street Annex. Patients placed in private nursing homes for lack of other places to put them, cost the City anything from $120 to $160 per month, with a l l charges over ninety dollars being borne entirely by the City. On January 1, 1949 there were approximately sixty patients in these private nursing homes that were paid for by the City Social Service Department. Using the minimum rate of $120 per month, these patients' care is costing $7200 a month, with a more likely figure being" $10,000. The province's share of the minimum would only be $4,320. As a contrast in costs, patients placed in Gleri and Grandview Hospitals in 1937 were cared for by these institutions for forty-five dollars a month. Custodial Care in the Boarding Homes Acting as "half-way houses" to the nursing homes are the city boarding homes that supplement the nursing homes and provide custodial care for those people who are unable to manage on their own but do not need supervised nursing care. These boarding homes provide the physical necessities of l i f e , namely, food, warmth and shelter but l i t t l e more. In the City of Vancouver there are about 490 boarding'-home (2) beds licensed under the Welfare Institutions Licensing Act. A l l institutions or homes caring for the aged and handicapped adult in receipt (l) Effective April 1, 1949, the provincial government has agreed to pay eighty per cent of costs up to $105 per month per patient for nursing-home care. In cases where the private hospitals can show that they are operating at a loss the provincial government will pay up to eighty per cent of $120 per month per patient after an inspection of their(cont.) - 76 -of some form of social assistance must be licensed under this act. A boarding home is defined as a home where an individual receives custodial care, but is quite capable of being up and about and able to clean and dress himself. Not a l l of the licensed boarding homes will take "city cases". Some take only patients placed by the Medical Section of the City Social Service Department; some take only a few city cases and have private cases as wellj some take city cases only when they can not get private cases. However, even i f they have only two "city cases", they must conform to the regulations laid down by the Welfare Institutions Licensing Act. Some boarding homes take only special types of cases. One proprietor takes only arrested tuberculosis casesj another takes only old age pensioners by private arrangement, asking only their old age pension and not the regular boarding home rate that could be demanded from the city; some take only certain ethnic or religious groupsj some take only men, some only women and some both. Some of the boarding homes are well furnished and comfortable and provide many extras for the patients. Others are very poor, providing only the absolute minimum of facilities, a bed, a chair and a corner in which to put the patient's belongings. In some, the food is excellent and is attractively served; in others the patients slowly die of malnutrition. There are good boarding homes and very poor boarding homes; some are operated by the owners to make as much money as possible books has been made by the Hospital Insurance authorities. (2) Boarding homes that do not take people in receipt of some form of assistance are not covered by the Welfare Institutions Licensing Act. These homes must however conform to city licensing regulations. - 77 -with the leas t possible expense; others are operated by conscientious proprietors who provide t h e i r patients w i th as many extras as poss ib le , leaving themselves only a modest re turn . The boarding homes care for three to for ty pa t ien ts , the average being about twelve. Most of the boarding home operators started out w i th two or three pat ients . Very quickly they learned that i t d id not cost f i ve times as much to care for f i v e times as many pat ients and that they could make more p ro f i t wi th ten patients than wi th two. The majority of the homes have found i t p ro f i t ab le t o take c i t y cases despite the fact that they could get higher rates from private cases. From c i t y cases they have an assured, dependable income. The C i t y S o c i a l Service has recent ly ra ised boarding-home rates from f i f t y do l l a r s to f i f t y - f i v e d o l l a r s per patient per month. Boarding homes caring for T . B . cases receive s ix ty d o l l a r s per month. The Medical Section of the C i t y S o c i a l Service Department, working i n close co-operation wi th the Ass is tant Inspector of Welfare I n s t i t u t i o n s , has been s t r i v i n g desperately to increase the number of beds that are avai lable but with l i t t l e success. U n t i l the housing s i tua t ion becomes less acute there i s not much hope of any subs tant ia l increase i n the number of beds. The demand for beds has become so acute that the C i t y S o c i a l Service Department has had t o pay s o c i a l assistance up t o f i f t y do l l a r s per month for a ch ron ica l ly i l l person i n an ordinary rooming or boarding house. By doing so the landlady can be persuaded t o provide extra f a c i l i t i e s and a cer ta in amount of care fo r t h i s person. In t h i s way the chron ica l ly i l l assistance rec ip ient can carry on a l i t t l e longer and not need to be admitted to a nursing home or boarding home. - 78 -The few ava i lab le boarding-home beds can then be used for more urgent cases. Recently the C i t y S o c i a l Service Department has been paying a t ra ined medical orderly to v i s i t numbers of these people i n t h e i r boarding houses and ho te l rooms, preparing a meal fo r them, helping them clean up, doing such things as changing dressings e t c . This i s another attempt to keep these o l d , and i n most cases chron ica l ly i l l , people where they are for as long as possible because there are no boarding-home beds avai lable to put them i n . In short , the nursing homes are f i l l e d wi th people who would normally be cared for i n a chronic or convalescent hosp i t a l ; the boarding homes are f i l l e d wi th people who need more than cus todia l care and should r e a l l y be i n nursing homes. In the cheap rooming houses i n every part of the c i t y ; i n the rooms of the "skid-road" ho te l s , and i n the back room of r e l a t i v e s ' homes there are hundreds of men and women who are get t ing along the best they can u n t i l some proper provis ion can be made for t h e i r care. In 194-7, the P r o v i n c i a l Supervisor of the T . B . S o c i a l Service , working i n close co-operation wi th the C i t y S o c i a l Service Department and the Inspector of Welfare I n s t i t u t i o n s , made a survey of boarding homes i n Vancouver fo r the p r o v i n c i a l Director of Welfare. This survey threw some in te res t ing s ide l igh ts on the boarding-home s i t u a t i o n . At the time the survey was conducted i t was found that 78.4 per cent of the residents of the boarding homes were over the age of s i x t y , and 27.4 per cent of the patients had reached such an advanced stage of mental de te r iora t ion that they could be c l a s s i f i e d as s en i l e . The survey estimated that 40.8 per cent of a l l the occupants of the boarding homes were po ten t i a l - 79 -cases for the Marpole Infirmary, the Home for the Aged (Essondale) or the Provincial Mental Hospital. Only 7.5 per cent of the occupants were considered suitable for rehabilitation. The survey also found that most of the vacancies in the boarding homes were caused by deaths, rather than the recovery or an improvement in the patients' conditions. A considerable number of these boarding homes have been visited personally by the writer. It would be fair to say that the main disease most of the occupants are suffering from is old age. Too many of the occupants seemed • to do nothing more than l i e around on their beds a l l day. Few of the women were knitting or sewing and for the men there were not even cribbage boards or playing cards. These people were constantly complaining about their food, the facilities provided by the boarding home and the mistreatment they had received from the staff. This continual complaining could be traced back to the fact that the .patients had nothing to occupy their minds. Many of the boarding homes did not have even a radio for the patients to listen to. Unless a patient is able to visit the doctor on his own, he seldom sees one. Several of the patients interviewed had not seen a doctor for six months or more. Many of the patients feel that they have been left there to die and recent i t bitterly. Very l i t t l e active treatment for the patients' illnesses is available because the boarding-house operators, except in fare instances, are not nurses. Referrals to the Medical Section of the City Social Service t Department for boarding home placement are made by the workers in the four different units of the City.Social Service Department, the hospitals, doctors, public health nurses and in a few cases by the Provincial Medical - 80 -Services D i v i s i o n . Four nurses are kept busy arranging placements i n boarding homes and nursing homes and doing the routine-work of arranging for glasses, dentures and appliances fo r assistance r e c i p i e n t s . The demand for beds i s so acute that the se lec t ion of the best type of boarding home for an i n d i v i d u a l i s not poss ib le . When a bed becomes vacant, the person who i s i n the worst condi t ion gets i t , without regard t o the s u i t a b i l i t y of that accommodation for that pa r t i cu la r case. At present, the only sure method of gaining entry t o a boarding home i s t o become so i l l that admission to an acute hosp i t a l becomes necessary. Af te r a stay i n the hosp i t a l , removal of the patient t o a boarding home or nursing home i s arranged. Should the C i t y Take Over Glen and Grandview Hospi ta ls As I t has with  Heather Street Annex? The s i t u a t i o n mentioned above i s one of the main arguments used by the C i t y S o c i a l Service Department fo r the assumption of con t ro l over Glen and Grandview hospitals by that Department. The Vancouver. General Hosp i t a l i s u n w i l l i n g to r e l i n q u i s h i t s cont ro l over the two subsidiary hospi ta l s because i t would lose the only outlet i t has for i t s chronic pa t ien ts . The hosp i t a l wants t o continue using Glen Hospi ta l : as a convalescent h o s p i t a l as i t has i n the past. The C i t y S o c i a l Service Department contends that most of the patients moved from the hosp i t a l are-ones that have been known to that Department for a long t ime, and, the only reason that they have had t o be admitted to the hosp i t a l was because t h e i r condi t ion became acute while wai t ing for admission t o a boarding home or nursing home. The C i t y S o c i a l Service Department would l i k e t o regulate admissions to the nursing homes as they do for the - a -boarding homes so that a patient could get in to a nursing home and receive suf f ic ien t care without becoming acutely i l l . In ac tua l pract ice the C i t y S o c i a l Service Department controls the discharges from the two hosp i t a l s . I f a patient i n Glen or Grandview Hospitals recovers s u f f i c i e n t -l y t o be moved t o a boarding home i t i s necessary that appl ica t ion be made t o the C i t y S o c i a l Service Department for a bed. By c o n t r o l l i n g the boarding-home beds the con t ro l of discharges becomes an accomplished f a c t . The C i t y S o c i a l Service would l i k e to con t ro l admissions t o Glen and Grand-view Hospi ta ls so that i t could f reely move patients from boarding homes t o nursing homes. I f there was a patient i n a nursing home who could manage i n a boarding home, then that pat ient could be exchanged very r ead i ly wi th a patient i n a boarding home who needed nursing-home care. By t h i s arrangement, placements could be co-ordinated and developed in to a treatment program. The General Hospi ta l believes that i f they keep cont ro l over the i n s t i t u t i o n s they can provide higher standards of care than the C i t y S o c i a l Service Department. C i t y S o c i a l Service con t ro l over Heather Street Annex appears t o have been more bene f i c i a l than detr imental . I f the C i t y Soc i a l Service Department took over con t ro l of admission to Glen and Grandview a dupl ica t ion of accounting services would be el iminated. In the same way a dupl ica t ion of services provided by the two s o c i a l service departments could be prevented. At present each patient i s asked the same questions by two di f ferent workers. I t i s the duty of the medical s o c i a l worker i n the Vancouver General Hospi ta l to determine each pa t ien t s ' e l i g i b i l i t y for assistance before r e fe r r ing the case t o the C i t y S o c i a l Service Department. Th is Department has found the hospi ta ls standards of e l i g i b i l i t y are fare^more len ien t than lyS" - 82 -those acceptable t o the C i t y S o c i a l Service Department. The hosp i t a l often allows a $250 exemption for a pa t ien t ' s funeral expenses but the C i t y S o c i a l Service Department al lows a maximum of only $150. More d i f f i c u l t y i s experienced with o ld age pensions. Under the o ld age pension regulat ions , the pensioner can have w e l l over one thousand do l l a r s i n the bank and s t i l l receive free medical se rv ice . But, as soon as he i s admitted to the nursing home, he must surrender h i s pension cheque and f o r f e i t h i s savings u n t i l he has only $150 l e f t i n the bank. I f he was i n the General Hosp i ta l for a short period of time he d id not have t o surrender h is cheque. He received i n f i n i t e l y bet ter care i n the hosp i t a l than he d id i n the boarding home. Why does he have to surrender h i s pension cheques and h i s savings when he i s rece iv ing less expensive and poorer care than before? So far no-one has provided any answer except that nursing-home care i s not covered by the new system of compulsory hosp i t a l insurance. • I t often happens that the General Hosp i t a l refers a case to the C i t y S o c i a l Service Department for payment. The C i t y S o c i a l Service worker f inds out that t h i s patient has some assets or income that makes the pat ient i n e l i g i b l e for a f u l l allowance. In some cases i t i s f e l t that a husband, son or daughter could make some contr ibut ion toward the patientte care . The case i s referred back t o the hosp i t a l fo r the c o l l e c t i o n of that port ion of the cost for which the C i t y S o c i a l Service Department i s not responsible. The hosp i t a l i s not able to co l l e c t these cont r ibut -ions from the pa t ien t s ' fami l ies and the two accounting sections refer the case back and f o r t h . I t would obviously be simpler to have one accounting section to deal with the accounts fo r Glen and Grandview Hospi ta ls as w e l l as for Heather Street Annex. I t i s no small advantage - 83 -that i t would permit the one s o c i a l worker seeing the patient to do a l i t t l e s o c i a l work instead of being nothing more than an inves t iga tor i n to the f i n a n c i a l circumstances of the pat ient . These are but a few of the administrat ive problems involved , but every one of them prevents the working out of an e f f i c ien t and smooth-running program for the most ef fec t ive care and treatment of the ch ron ica l ly i l l . - 84 -Chapter. V The Chronically 111 as Individuals Up to this point the chronically i l l have been discussed only as a group. The main features in caring for the chronically i l l have been pointed out, along with some of the implications of chronic diseases. They had to be supplemented by case illustrations to show the individual-ity of chronic disease. These cases show also that chronically i l l people are normal human beings with the concerns of ordinary people added to those which result from the chronic illness. Their stories reveal vividly the heavy economic cost of chronic illness; this falls on the families and individuals involved, but is also borne in part by the community at large. In choosing the group of cases, an attempt has been made to show the experiences of a representative aggregation of chronically i l l . people; there is a variety of ages; there is a variety of medical diagnosis and diseases; there is a wide variation in family and economic backgrounds, and in the amount of medical care and hospitalization experienced. None of the cases summarized are presented in a true case study form. An attempt has been made to bring out some of the important emotional implications of chronic illness for both the individual and (1) his family. (l) The majority of the cases presented are secured from personal interviews with these people and gaps in information f i l l e d in from agency records. - 85 -Keeping the Home Together: The case of Mrs. G. is representative of thousands of low-income families in the city who have received medical care from the Vancouver General Hospital Outpatients' Department over a period of many years. Mrs. G., now aged forty-seven, was born in Scandinavia. At the age of seven she had an attack of rheumatic fever with no apparent after-effects. Mrs. G. was married in 1920 and came to Canada in 1926. It was not until Mrs. G. applied for entry to the United States the following year that she discovered that she had a serious heart condition. In the next few years she found that she had to restrict her activities more and more as her condition became progressively worse. In 1933, Mrs.. G. became pregnant and came to the Outpatients' Department for examination. The specialist who examined Mrs. G. advised her to allow her pregnancy to be terminated and to be sterilized to prevent any further pregnancies. Due to the condition of Mrs. G's heart, her l i f e was in danger i f the child should prove difficult to deliver. Mr. G. would not consent to this, and, contrary to a l l expectations, Mrs. G. safely delivered a baby boy a few months later. At this time the family were in desperate financial straits. Mr. G. could find no employment and was suffering from an acute eye infection, but, because he had no money, he refused to go to a doctor. Finally he was brought to the hospital by the V.O.N, nurse, by which time the infection had developed to such an extent that Mr. G's eye had to be removed. Much against the will of Mr. and Mrs. G., the family was forced to go on relief. After about one month, Mr. G. found a job peddling fish. He earned only three or four dollars a week but somehow or other - 86 -the family made valiant efforts to l i v e on this amount. The family, i n order to keep their home, sold most of their personal belongings, includ-ing their clothes, to pay the taxes. For several years the family eked out a bare subsistence from the f i s h business but were never far from starvation le v e l . Mrs. G. continued to attend the Outpatients' cardiac c l i n i c regularly and received medicines and periodic check-ups from the doctors there. Mrs. G. was continually warned by the doctor against doing so much heavy work around the home and at various times she was actually ordered to stop a l l work and spend most of her time in bed. The family had opened a l i t t l e f i s h store and were l i v i n g in rooms behind i t . As Mr. G. was sick most of the time himself, Mrs. G. operated the store as well as doing a l l of the housework. In 1939 Mrs. G. had a severe heart attack and was confined to the hospital for three weeks. In order to get bed rest, Mrs. G. was moved to Glen Hospital where she stayed for three and a half months. She returned to her home and the following year the doctor at the Outpatients' Department again had to order Mrs. G. to stop doing so much work about the home. To supplement the family income, Mrs. G. had been caring for two foster children. In 194-1, at the request of the doctor looking after Mrs. G. in the Outpatients' cardiac c l i n i c , the hospital social service department arranged with the Family Welfare Bureau for a v i s i t i n g home-maker to spend three days a week in the home. When this service was terminated however, Mrs. G. went back to doing as much work as before, i f not more. By this time Mr. G. had secured employment in a down town hotel but as his salary was s t i l l only $60 a month, Mrs. G. continued to operate the f i s h store. After about a year of this arrangement, Mr. G. - 87 -.received a slight increase in salary and they were able to close the store. Mrs. G. continued to do her own housework and visited the Outpatients' Department regularly for her medicines and periodic examin-ations. Mrs. G. had another heart attack in 194-7 but was not admitted to the hospital. Since then her condition has gradually deteriorated and she is only able to do light duties about the home. The husband now gets approximately $100 a month wages and with the assistance of the son they are able to carry on. Mrs. G. will undoubtedly continue on in the home until her condition reaches such an acute stage that hospitalization or nursing-home care will be essential. Mrs. G. has kept going as long as she has because of her devotion to her family and the strength that this family gave to her. This is an interesting case because i t seems evident that institutional care would have made a helpless invalid out of the patient rather than improve her condition. On the ofeher hand, an adequate visiting nurse and visiting physician service could have done much to retard the development of her illness; probably also a more prolonged visiting homemaker services would have aided in the alleviation of this patient's condition. The low income of the family wage-earner has contributed considerably to the intensification of the patient's difficulties in accepting the limitations placed upon her by her chronic cardiac condition. Old Age Brings Additional Difficulties Mrs. H. represents the hundreds of chronically i l l older people who are cared for and maintained by a son or daughter for many years. - 88 -Eventually, an impending break-up of the son or daughter's own family, resulting from the insatiable demands of the chronic invalid, necessitates the removal of the chronically i l l parent to a boarding home or nursing home. Mrs. H., now aged seventy-three, has been a diabetic for twenty-two years. Her three daughters (one of whom is also a diabetic) are a l l married with families. After divorcing her husband in 1936, Mrs. H. went to live with her'youngest daughter. Within a short time, this daughter separated from her husband who refused to have Mrs. H. in the house any longer. The daughter insisted on keeping her mother with her. Originally Mrs. H. had been fairly financially secure but gradually a l l of her resources were used up and she and her daughter were forced to.sell many of their personal belongings to pay the rent and to buy food. They moved from an apartment to cheap housekeeping rooms. The other two daughters of Mrs. H. refused to help the younger sister in caring for the mother. The youngest daughter soon could not carry on any longer. Her mother tormented her continually and made l i f e miserable for her by her unreason-ableness and unending demands upon her. When the daughter injured her knee and incurred heavy doctor's b i l l s she refused to care for her mother any longer. In November, 194-3, Mrs. H. was placed in Glen Hospital, where the daughter paid for one month's care. But, since the daughter was only earning $80 a month and paying $70 a month for her mother's nursing-home care, the General Hospital agreed to assume the responsibility for Mrs. H?;s care. After two months in Glen Hospital Mrs. H. was transferred to the Vancouver General Hospital to have a gangrenous toe amputated. Mrs. H. refused to allow the doctors to perform the operation. Mrs.-H. - 89 -spent two months in the hospital before been_transferred to a boardingt""^ home. Six days later she was readmitted to the hospital in a diabetic coma. Mrs. H. and the boarding home owner had clashed continually during that six days because Mrs. H. claimed that she did not get the attention that she needed. The boarding home owner stated that Mrs. H. would hot follow her diet and disturbed the other residents of the boarding home to such an extent that the place was in a continual uproar. After eight days in the hospital, Mrs. H, was again transferred to Glen Hospital. Applicantion for her admission to the Marpole Infirmary was made in October, 1945. Twelve months later, the doctor said that Mrs. H. was no longer in need of nursing-home care and was capable of managing in a boarding home. Mrs. H. did not want to go to a boarding home but she went anyway. She stayed in the boarding home for five weeks and no boarding home was ever so glad to see a patient leave. During her stay in the boarding home, Mrs. H. refused to take her insulin, fought continually with the other patients and kept the place in a perpetual uproar. She was admitted to the General Hospital in a diabetic coma. After spending another seven months in the Vancouver General Hospital, she was again transferred to Glen Hospital where she s t i l l remains. Mrs. H. now has her hands and feet terribly crippled and deformed by arthritis and she also has Parkinson's disease at an advanced stage. Actually this white haired old woman, sitting on the edge of her bed «n day, presents a pi t i f u l spectacle, but what she lacks in physical ability to get around" she makes-up for with her tongue." She is very unpopular in the hospital because she takes a sadistic pleasure in tormenting the other patients in the ward until they are reduced to tears. - 90 -Mrs. H. considers the medical and nursing care that she i s receiving t o t a l l y inadequate to her needs and she i s very h o s t i l e toward the- medical s o c i a l worker because'she has not been admitted to the Infirmary. Mrs. H. i s rather ah unusual case i n that she i s suffering from three major chronic diseases a l l at once, i . e . , diabetes, a r t h r i t i s and Parkinson's disease. Mrs. H., being over seventy years of age, i s t y p i c a l of the effects of chronic i l l n e s s on the older person with no income or f i n a n c i a l resources. When a son or daughter i s no longer f i n a n c i a l l y able to support the parent, application f o r s o c i a l assistance must be made. Mrs. H's main trouble i s that she has nothing to occupy her time or her mind. She could c e r t a i n l y benefit from the f a c i l i t i e s that are available at the Marpole Infirmary. Much of her behaviour i s a symptom of her Parkinson's disease. Medical Care Is Not Always What i s Needed The case of Mr..J. i s a glowing example of the need of a d e f i n i t e and co-ordinated treatment program. The constant shuttling of a chronical-l y i l l patient from hospital to nursing home and then to the hospital again can be nothing other than detrimental to the patient. Mr. J . , aged forty-nine and sing l e , i s a former logger. He would spend a few months i n one logging camp and then move on to another. He usually spent his winters i n a Dunlevy Street Hotel. Mr. J . was admitted to the Vancouver General Hospital i n January 1944 with osteo-myelitis of the right hip. Af t e r two weeks i n the General Hospital he was transferred to Glen Hospital for a two week period of convalescence. This period of convalescence was extended t o two months. By the end of March, 1944, the doctor considered that Mr. J's condition had improved sufficiently for him to be moved to a boarding home. Mr. J. refused to go and later walked out of the hospital. He paid $124 out of his last $160 toward his account. For the next two years Mr. J. made a living by doing odd jobs. He lived in a cheap water-front hot el. In October, 1946, Mr. J. was again admitted to the Vancouver General Hospital, this time with a diagnosis of T.B. of the hip. After five months in the Vancouver General Hospital, Mr. J. was again moved to Glen Hospital. Within a short space of time he became the most unpopular patient in the institution. He refused to co-operate with the nurses and did not get along with the other patients. Glen Hospital put up with him for two months and then had him transferred back to the Vancouver General Hospital. One month later he was transferred back to Glen Hospital again where he remained for another five months. Once more his diseased hip required acute hospital medical treatment; he returned to the Vancouver General Hospital for another two month's stay and again he was transferred back to Glen Hospital. Here he stayed until March, 1948, at which time the doctor decided that Mr. J. was no longer in need of nursing-home care and could be moved to a boarding home. Mr. J. emphatically refused to go. He asked the social worker to get him a room in the hotel in which he had been living prior to his admission to hospital. The hotel refused to have him back because of the trouble they had had in providing extra services for him while he was living there. Mr. J. left the hospital on his own and managed to find a room by himself. In may, 1948, he was re-admitted to the Vancouver General - 92 -Hospital with a diagnosis of osteo-myelitis of the right hip. Three months later, after a great deal of interpretation by the social worker, Mr. J. was persuaded to go to a boarding home. Mr. J. was just getting used to the place and beginning to get adjusted to boarding-home l i f e , when the City Social Service Department decided that he was to be moved to Mrs. S's boarding home where the rates were not so high. Three weeks later Mr. J. was re-admitted to the Vancouver General Hospital. One month later Mr. J. was declared ready for transfer to Glen Hospital by the attending doctor. Mr. J. refused to go to Glen Hospital but he was willing to return to Mrs. S's boarding home. As there were no vacancies in Mrs. S'3 boarding home at that time, Mr. J. asked the social worker to find a hotel room for him. This the worker was unable to do, so accommodation in a church hostel was arranged. Mr. J. did not like the place and stayed there only two nights. Finding himself a cheap room in one of the poorest districts of the city, Mr. J. continued to receive medical treatment at the Outpatients' Department from where he was admitted to the hospital again in October, 194.8. One month later i t was again suggested that he be transferred to Glen Hospital. Mr. J. again refused to go, giving as his reason that he did not get enough to eat there. He asked to go to Mrs. S's. boarding home but there were no empty beds available there. Mr. J. stayed in the Vancouver General Hospital until the first of December at which time the doctor asked that Mr. J. be transferred to Heather Street Annex where he could receive more active medical treatment than he could at Glen Hospital. This was arranged and there Mr.. J. remains, for how long, nobody knows. - 93 -Mr. J. is only one of hundreds of single, unattached men living in cheap hotels and rooming houses, who should be in a properly constitut-ed chronic hospital. Because Mr. J. comes from, the "skid-road", 'and is destitute the attitude has been: "just put him any old place, what does it matter?" Any hospital or nursing home or boarding home is supposedly superior to anything that he has been used to. Little consideration is given to the actual needs and desires of the individual. Any trace of planned treatment for this patient is hard to find. After four years of shuttling back and forth between nursing home, board-ing home and hospital, no-one has taken the time to find out why Mr. J. refuses to go to a nursing home or boarding home. An attempt was made to determine the total cost of Mr. J's care in the hospital, nursing home and boarding home but since staff patient's accounts are not computed separately, i t was impossible to do so. However, the cost must have amounted to .many thousands of dollars. It would be much cheaper to have a chronic hospital to care for patients such as Mr. J. What will become of Mr. J.? Mr. J. appears to have another five or ten years of hospital and nursing-home care to look forward to. Will he spend the rest of his l i f e being shuttled from one institution to another and finally end up in the Marpole Infirmary? In the meantime, Mr. J. remains an embittered, unhappy and unco-operative man who is fighting the world that does not make any attempt to understand him. Somewhere along the line, the casework services that should have been made available to this man were not provided. - 94 -Some Never Give Up Hope Nothing i s more devastating to a family than to have the main wage-earner struck down with a chronic i l l n e s s . The whole family i s forced into a state of des t i t u t i o n and eventually, as a l a s t r esort, they are forced to apply f o r s o c i a l assistance.. Mr. S. aged 35 and a former longshoreman, has been bed-ridden because of an a r t h r i t i c condition since 1940. During the early stages of hi s i l l n e s s Mr. S. invested his savings i n a small confectionary store, which he was able to operate u n t i l he became too badly crippled. He then, .sold his business and his wife went to work i n a factory. He and his wife l i v e d with his parents. In 1941, Mr. S. was hospitalized f o r nine and one half months, during which time his condition became progressively worse, despite the use of every known method of treatment • f o r a r t h r i t i s . Mr. S. returned home and received further treatments by h i s family physician with no noticeable improvement i n his condition. Mr. S. was confined t o the Vancouver General Hospital f o r f i v e days i n 1942 and two weeks i n 1943 when h i s a r t h r i t i c condition f l a r e d up again. Mr. S. was admitted to the Vancouver General Hospital again i n 1944, where he. received extensive fever therapy treatments without any improvement i n his condition. By the summer of 1945, Mr. S's body had become completely r i g i d and he was only able t o move h i s head. His wife found that she could not work and provide her husband with the care that he Reeded so she quit her job. About a year previously, they had purchased a small, three-roomed cottage with the l a s t of t h e i r savings. F i n a l l y they reached the stage where Mrs. S. had t o apply f o r s o c i a l assistance so that they would not starve to death. A short time l a t e r , the doctor who - 95 -had been caring f o r Mr. S. t o l d him that his case was hopeless and that there was l i t t l e more that could be done for him. Mr. S. became very depressed and morose. For two months during the summer of 1946 Mrs. S. was able t o secure s u f f i c i e n t part-time work t o allow them to go o f f s o c i a l assistance. Although Mr. S's condition was steadily getting worse, he refused to have any outsider come i n to stay with him while h i s wife was working. He brooded a great deal while she was absent and became most unreasonable i n his demands upon her. In September, 194-6, IMr. S. was admitted t o the Vancouver General Hospital with i n t e r n a l haemorrhages. He returned home a f t e r three weeks h o s p i t a l i z a t i o n . By 194-7 Mrs. S. had decided that i t was her duty i n l i f e t o stay at home and care f o r her husband and t o make the remaining years of his l i f e as comfortable as possible. Mrs. S. scarcely leaves her husband's side now. She reads to him by the hour and t r i e s to s a t i s f y every demand. Throughout the City S o c i a l Service Department's four years contact with t h i s family, the d i f f e r e n t workers who have come i n contact with Mr. S. have taken an unusual interest i n his case. The Medical Section of the City S o c i a l Service Department has provided Mr. S. with extra medicines, clothing and various a r t i c l e s that he has requested; no other assistance recipient has ever received the extras that have been provided f o r Mr. S. However, Mr. S. remains extremely unhappy; he does not think that the medical treatment that he i s receiving i s satisfactory and he i s continually requesting new treatments f o r a r t h r i t i s : ; that he reads about i n papers and magazines. He w i l l not consider going to the Infirmary as he believes t h a t . i t i s a place f o r old men. Mr. S. spends - 96 -h i s days l y i n g i n a bed by a window, watching the people going by on the street and envying them because they are not helpless and dependent as he i s . His wife , now aged 28, hovers at h i s side refusing to leave the house for fear that he should want something. This young couple are forced to spend the rest of t h e i r l i v e s on s o c i a l assistance because of the husband's incapaci ta t ing chronic i l l n e s s . This i s a case where i n s t i t u t i o n a l i z a t i o n i s opposed by the pa t ien t . He might benefit great ly from such care as there i s ava i lab le at the Marpole Infirmary. I n s t i t u t i o n a l i z a t i o n of Mr . S. would free h i s young wife from the r e s p o n s i b i l i t i e s she has assumed, and she would be able to l i v e a more normal l i f e . Surely i f s o c i a l casework services are of any value at a l l then something could and should be done to work out a better arrangement than t h i s fo r the young couple. I t Takes Time to Be Admitted t o the Infirmary The length of time that a patient has to wait t o get in to an i n s t i t u t i o n for the chron ica l ly i l l i s extremely demoralizing. By the time admission can be arranged, the pa t i en t ' s condi t ion has deteriorated so much that there i s no p o s s i b i l i t y of r e h a b i l i t a t i o n . Mr. H . , aged f o r t y - s i x and s ing le , was o r i g i n a l l y a farmer i n the Edmonton d i s t r i c t . In 1934- he had a stroke which hospi ta l ized him for several weeks. He recovered s u f f i c i e n t l y to go back to work on h i s farm. He moved out to Vancouver to l i v e wi th h i s s i s t e r i n 1937. In 1938 he had another stroke which l e f t him helpless and bed-ridden. The doctors t o l d him that there was nothing more that they could do for him. Mr. H . , s t i l l a young man, refused to concede that h i s condit ion was incurable . He t r i e d everything t o effect a cure; he went to - 97 -chiropractors; he went to a Japanese e l e c t r i c a l therapy centre f o r numerous treatments; he went from doctor to doctor; nobody could do anything f o r him. In the meantime he had used up a l l of his money and had to go on r e l i e f . Five years ago Mr. H. contracted a severe case of influenza which l e f t him even more helpless than before. He was admitted t o the Vancouver General Hospital and remained there f o r ten days before being transferred t o Grandview Hospital. Mr. H's condition improved s l i g h t l y there and by the time he l e f t , nine months l a t e r , he was able to walk several blocks. The doctor decided that he no longer needed nursing-home care and he was transferred t o Mrs. B's boarding home where he remained f o r over a year. Mr. H. was placed i n the f i r s t boarding home that had a vacant bed without any consideration of h i s needs. This p a r t i c u l a r boarding home was i n a rather i s o l a t e d part of the c i t y and was set a long way back from the street. Mr. H. laughed when he was asked what medical treatment he had received while he was i n the "boarding home. He said that the only medical treatment he had received was a few laxative p i l l s . Mr. H. described i n some d e t a i l how lonely and isolated he had f e l t , i n t h i s place. His one desire was to see the cars that he heard passing by on the distant street. Mr. H's condition deteriorated gradually and eventually he became completely bed-ridden again. He was transferred to Heather Street Annex i n 1945. Three years and two months a f t e r his application f o r admission to the Infirmary was approved, he was admitted to that i n s t i t u t i o n . Although Mr. H. has only been i n the Infirmary since the f i r s t - 98 -of January, his condition has started to improve already. He is able to get around quite well in a wheel-chair now and he hae become less incontinent. Mr. H. now realizes that there is l i t t l e that can be done medically for his condition but he is determined to use the Infirmary's occupational therapy and physiotherapy facilities to the utmost extent. Any patient who must wait three or four years for admission to the Marpole Infirmary after his f i r s t application is made, loses any interest in the transfer and becomes so resigned to living in other institutions that actual admission to the Infirmary comes as an anti-climax. His physical condition retrogresses so much that he may not be able to take advantage of the facilities offered by the Infirmary when he does get there. Great harm may have been done to this man by denying him the occupational therapy and physiotherapy treatments that he should have had. Mr. H. is a quiet likeable patient who got along well wherever he was placed and for this reason his transfer to the Infirmary was not pushed. Continued Institutionalization Can Be Harmful The case of Miss D. illustrates how many chronically i l l people become so institutionalized that they become completely dependent and unable to manage on their own even though they should be able to do so. This is a case also where existing nursing homes and boarding homes could not provide sufficient medical care to allow the patient to be transferred from an acute hospital. Miss D., aged twenty-three, lived with her mother, seventeen year old sister and thirteen year old brother in a small two-roomed suite in the West End prior to her admission to the Vancouver General Hospital - 99 -in September. 194-6. Because of poor health, Miss D. had not been able to go to work after leaving school at the age of sixteen. She had a small income of $30 a month from a D.V.A. pension which she received after the death of her father. Miss D. was admitted to the hospital with a diagnosis of empyema and broncheastisis, which condition necessitated the surgical removal of part of a decomposed lung. After twenty-four days in the hospital she was discharged to her home. Her condition became steadily worse. Because the mother worked during the day, and the brother and sister were at school, there was no-one at home during the day to care for Miss D. Her relations with her family were not too cordial. Miss D. was re-admitted to the Vancouver General Hospital again in January 1947. After a month in hospital, Miss D. was again discharged to her home. Again she did not receive the proper food, rest and care that she needed and her lung began to haemorrhage again. Three months after discharge to her home Miss D. was re-admitted to the hospital again in June, 1947. In October, 1947 the doctor referred Miss D. to the social worker for placement in a boarding home. As no boarding-home beds were available i t was suggested that Miss D. be placed in a nursing home until a boarding-home bed was vacant. Miss D. refused to go to a nursing home and made arrangements to live with a married sister. One month later she was back in hospital with a haemorrhaging lung. Her condition was critic a l and she was not expected to live. In January, 1948 the doctor again considered her ready for discharge to a nursing home or boarding home. As Miss D. was.still haemorrhaging slightly and she had to have a supply of oxygen available at a l l times, the hospital did not press for her discharge. In the - 100 -meantime, Miss D's mother was showing l i t t l e interest in having her daughter return to the home and refused to accept any responsibility in planning for her future care. Miss D. enjoyed her stay in the hospital tremendously. She was known a l l over the hospital for the beautiful paintings that she did. In December, 194-S, the doctors decided that they could do nothing more for Miss D. and the social worker was asked to arrange for Miss D. to go to a boarding home. After much procrastination, Miss D. finally agreed to go to a boarding home. Miss-D. went to a boarding home where there were several other young people like herself. The social worker arranging the placement did not expect Miss D. to stay in the boarding home very long. She was very unsettled there i and complained that she did not get sufficient attention or care. Miss (1) D. lacks self confidence and is s t i l l very apprehensive about her health. Miss D. obviously needed medical care that was not availahle in a nursing home or boarding home but she.was becoming so institution-alized that a l l of her initiative and independence was being destroyed. Should she be confined to an institution at the age of twenty-three when she could lead a more normal l i f e , under proper care, outside of the hospital? A chronic hospital with occupational therapy facilities would be the ideal place for Miss D. to spend the rest of her l i f e but is institutionalization of every chronic invalid to be the objective of a program for the care of the chronically i l l ? (l) Miss D. has recently died very suddenly while at the Vancouver General Hospital receiving treatment. - 101 -Poverty Accentuates the Problem The case of Mr. 0. is one in which maladministration in the past has made a chronic invalid out of a person who might well have become a useful, self-supporting man i f he had been given a better chance. This is an example of how chronic illness can be incurred as a direct result of a family's continued poverty over a period of years. Mr. 0., aged thirty-five, has spent almost the whole of his l i f e on social assistance. Mr. O's father died in 1914, leaving his mother with three dependent children and no money. From 1916 to 1918 the family were on relief; from 1919 to 1921 the mother received mother's assistance. For a few years after this the family was support-ed by the oldest son. Eventually this son could support his mother, brother and sister no longer. The younger sister was picked up on a sexual immorality charge by the police and committed to the Girl's Industrial School. The mother and Mr. 0. continued to live under appalling conditions, never far above the starvation level. They lived in any cheap room they could get and at one time the mother and her sixteen year old son were forced to sleep together on a single cot. At the age of fifteen, Mr. 0. had contracted rheumatic fever and spent three months in the hospital with the permanent heart impair-ment that resulted from the disease. In 1930, Mr. 0., then aged 16 was declared to be unemployable for the rest of his l i f e by the doctor. Neither Mr. 0. nor the City Relief Department accepted this verdict. Mr. 0. would find a job and earn a few dollars and immediately the Relief Department would cut off relief payments for the mother. Being - 1 0 2 -single, Mr. 0 . was considered to be responsible for his mother's mainten^ . ance. The mother was sick most of the time and was confined to bed almost continually. The whole depression period was a constant war between the Relief Department and Mr. 0 . He and his mother continued to live under deplorable conditions, s t i l l sharing a single room and never knowing from one day to the next whether they would have their relief allowance of groceries or not. Because of Mr. 0's gradually worsening heart condition, he was only able to hold jobs for a few days before being laid off. In 1936, to complicate things s t i l l further, the relief authorities decided that Mrs. 0's ninety-four year old father should move in with the mother and son. He was destitute and no place else to go* Naturally Mr. 0 . objected to having to accept this additional responsib-i l i t y . In 1937-, much against his mother's wishes Mr. 0 . got married. Four months later a child was born and three years later another. Mr. 0 . left his mother and he and his wife went to live in a couple of small rooms. The mother would have nothing to do with the new wife. Mr. 0 . continued to receive social assistance until June, 194-0. For the next four years, Mr. 0 . managed to find sufficient employment to keep him off of assistance. For two years he worked in the shipyards. Throughout this four years, however, Mr. 0 . spent many weeks in bed because of his heart condition. In 1944-, Mr. 0 . suffered two severe heart attacks and was ordered to bed by the doctor for an indefinite period. For the next two years the family lived on social assistance with Mr. 0's condition - 103 -continuing to be unchanged. In 1946, Mr. 0. secured some part-time casual work and for another nine months he was off of social assistance. When Mr. 0. was again forced to apply for assistance, his condition had become extremely bad. In March, 194-7, Mr. 0. was declared to be permanently unemployable by the doctor, and.the family were put on mother's allowance. Mr.. 0. and his family are s t i l l on mother's allowance and as Mr. 0. is s t i l l confined to his bed for most of the day, i t looks as i f this thirty^ five-year-old man, along with his wife and two children are going to be public charges for the rest of their lives. Any casework services that have been given this family has been purely accidental. What might have been done for this family with a more enlightened relief department during the early days is only problematical. This case illustrates the long-term nature of chronic illness and the need for a treatment program. Low income and loss of earning power are inseparably linked to chronic illness. The lack of foresight of the relief authorities in the 1930's has been one of the direct causes of this man's present dependency upon public assistance. Chronic Illness Breaks up a Family 1 The case of Mr. M. is one of many where the family splits up and goes different ways after the main wage-earner is removed from the home by chronic disease. Older children are forced to leave school to support the family. This is one of the few examples that could be found of a person who was admitted directly to the Marpole Infirmary from the home. Almost every present-day admission to the Infirmary is directly from a hospital or a nursing home. - 104 -Mr. M., aged sixty-seven, is married with three children, aged twenty-nine, twenty-six, and twenty-two years. The family formerly lived on a farm in Alberta and came to B.C. in 1939. Mr. M. had a severe attack of lumbago and arthritis in 1932. These were symptoms of a post-infectious disease condition. The family bought a farm on the outskirts of Vancouver. Mrs. M. and the son did most of the work. In October, 1939 Mr. M. became acutely i l l again and he was confined to the Vancouver General Hospital for ten days. Mr. M. felt very keenly about his inability to support his family. He did not like to see his wife do a l l of the work that i t was necessary for her to do. Mr. M. became very irritable and practically unbearable about the home. He became very sullen and refused to speak to his family for weeks at a time. Finally the family was forced to ask for the admission of Mr. M. to the Infirmary. He had lost the use of his lower limbs and was too difficult to care for in the home. When Mr. M. was admitted to the Infirmary in November, 1939, the son aged 17 quit school and went to work to support the family. This boy had been an exceptionally clever student and he had p%anned to continue his education on into University. He supported his mother and sister for several years before going out .on his own. He is now a logger on Vancouver Island with no hope of continuing his education. The mother and two daughters have moved to California and the oldest daughter has managed to work her way through University and expects to receive her degree this spring. Mr. M. is left here alone. Mr. M. feels very guilty about being the cause of the break-up of the family. •Mr. M., with a diagnosis of tabes dorsalis is able to get - 105 -around the Infirmary on crutches. His condition has improved since his admission there but i t will never improve sufficiently for him to leave the institution. Mr. M. has become one of the Infirmary's most active participants in a l l of its many activities. Institutionalization in this case has been beneficial to both the patient and his family in that the family have not been forced to support and care for him for the rest of their lives. Permanently Unemployable at the Age of Twenty-Two Mr. A. and his wife, a young self-supporting couple with no savings, are typical of the families that are forced to apply for social assistance as soon as the husband becomes chronically i l l . Mr. A., aged twenty-two was married three years ago to his attractive nineteen year old wife. They have one child two years old and a baby two months old. Mr. A. was apprenticed as an aeroplane motor mechanic at the age of fourteen. At the age of sixteen he went to work as a mechanic in one Of the largest garages in the city and worked there at a salary of approximately $210 a month until the onset of his illness. The family rent a small four-room bungalow in a good district. In 1942, Mr. A. was in a motor accident where he fractured a couple of ribs. Since he felt no pain, the doctor taped up his ribs without having an X-ray done to see i f there were any internal injuries. In the spring of 1947 Mr. A. began to have pains shooting up his back and to have severe attacks of nausea. His doctor could not find the exact cause of his illness. Finally after numerous X-rays, blood tests and examinations, the doctor decided that he had T.B. of the kidneys. Once - 106 -this diagnosis was made, his Blue Cross insurance payments were dis-continued. The doctor ordered Mr. A. to stay in bed until noon every day and not to do work of any kind. The A's were financially destitute and had no alternative to applying for assistance. A l l Mr. A's earnings had been, used to buy household furnishings. To complicate the situation, Mrs. A. was expecting her second child in about three months time. It was arranged for.Mr. A. to receive about $700 worth of streptomycin through the Outpatients' Department of the Vancouver General Hospital. His doctor hoped to arrest the infection in his kidney sufficiently so that i t could be removed. Unfortunately Mr. A. built up an immunity to streptomycin and the T.B. infection spread to his other kidney. As Mr. A. did not feel i l l , he did not spend the mornings in bed as the doctor i had ordered. He was working about the home continually. Mr. A. had considerable difficulty living on the $60 a month social assistance after the comparatively high standard of living he had been used to. Neither he nor his wife were able to budget their small income. Finally Mr. A. refused to try and live on social assistance any longer and went back to work. He felt that i t was better to go to work than to have to try and live on social assistance. He worked for one month and his condition immediately became much worse. He was forced to apply for social assistance once more. Mr. A. is supposed toi. have extra food but anything extra in the family is given to the baby or the two year old girl..Mr. A's condition is getting steadily worse and the infection in his kidneys is spreading to other parts of his body. Within a short time he will be completely incapacitated. The doctor does not give him more than another two years to live. The doctor does not feel that hospitalization will serve any useful purpose. - 107 -With a proper treatment program for the care of chronic illness, coupled with social assistance payments according to need, this man1 s condition might have been so improved that he could lead a normal l i f e for many more years. What this family needs most of a l l is sufficient social assistance to buy enough food, clothing and fuel to carry on until Mr. A's death. In the meantime the young nineteen year old wife and two children must get along the best they can with no future to look forward to. Institutionalization would remove the husband from the home but would i t serve any useful purpose at this stage of the man's illness? Existing social work agencies could perform a valuable service in assist-ing this man in planning for the future of his family and for his own care when his condition becomes more acute. Disabilities Can Be Overcome Mr. T. is a case where a chronic invalid has been able to adjust his l i f e to his illness and to direct his activities accordingly. This is a striking example of the value of occupational therapy facilities to a chronically i l l person. Mr. T., aged fifty-three, was a former railwayman. He was born in the United States but moved to Canada when s t i l l a boy. He lived in various towns in B.C. before moving to Vancouver in 1931. He is single with no close relatives in this province. The first symptoms of Mr*. T's arthritis appeared about 1925. Gradually his joints began to stiffen and become inflamed and, within a short time, every movement gave him great pain. Eventually he was forced to quit his job. The railway brotherhood to which he belonged helped him financially for some time but finally he was forced to go on relief. - 108 -Before applying for relief, he sold a l l of his personal belongings, even some of his clothing to be independent as long as possible. As his arthritis became more crippling he found i t almost impossible to manage on his own in the cheap rooming houses he was forced to live in. A specialist in arthritis had become interested in Mr. T's case -and he tried out every drug and treatment for arthritis known to medical science at the time on Mr. T. In May, 1934, Mr. T. was admitted to the Vancouver General Hospital. During his two and one half year stay there he received fourteen series of Gold treatments. In January, 1937 after 956 days in the acute hospital, Mr. T. was transferred to the B. Nursing Home. He spent almost a year there before he was transferred to the H. Nursing Home where he remained until he was admitted to the Marpole Infirmary in July 1941» While in the B. Nursing Home he received two more series of Gold treatments. Since admission to the Marpole Infirmary, the inflamation and pain in his joints has abated and he has now complete-ly rigid with a "Marie Strumpel" spine, being able to move only his head and hands. Mr. T. has been the special exhibit at the Infirmary for many years. Every visitor to the place has been taken to see the wonderful miniature doll furniture that Mr. T. is able to make with the aid of mirrors and with specially made tools and equipment. Any skilled crafts-man would be proud to say that he made these exquisitely carved and fashioned articles. The patient is kept so busy with his work that he has l i t t l e time to worry about his illness. He also finds that he is physically tired by night and is able to sleep and eat better. Mr. T. won a special award at the Pacific National Exhibition for his work last year. - 109 -Because of the physiotherapy treatments that Mr". T. receives, he is able to make the maximum use of his hands. This man, although terribly crippled and bed-ridden enjoys l i f e to the f u l l because he realizes that everything that could be done for him medically is being done, and he is kept so busy that he has not time to let his condition get him down. Mr. T. is looking forward to at least another ten years of l i f e in his busy corner in the Infirmary. Mr. T. has experienced a l l of the difficulties that chronic illness brings with i t . The only thing that he has missed is a boarding home placement. If a proper chronic hospital had been available i t is possible that Mr. T. would not be as badly crippled as he is now. These studies point out the total inadequacy of present facilities in Vancouver for the care of the chronically i l l and the urgency for a complete revision of our social casework concepts as regards the chronically i l l . The insufficiency of present social assistance payments are evident. Until there is a change of policy in this respect, no treatment program for the care of the chronically i l l in the home can ever be implemented. The pressing need for a chronic hospital for active treatment of chronic diseases is brought out very clearly in these studies. - 110 -Chapter VI The Essentials of a Community Program "The chief aim of the treatment of chronic d i s a b i l i t i e s i n which complete restoration t o normal can no longer be expected i s to arrest the progress of the disease and t o enable the patient to maintain or resume his accustomed place i n society and i n h i s family. The patient must be taught t o regard his i l l n e s s , not as the focus of h i s l i f e , but as a (1) handicap to overcome." I f t h i s p r i n c i p l e , l a i d down by Dr. Boas i n his valuable study, was followed even i n part t h i s would be a much happier world f o r the chronically i l l . The E f f e c t of Divided Responsibility Upon Existing F a c i l i t i e s Judging from the picture which has been described for Vancouver, there are two fundamental problems involved i n the provision of the necessary diagnostic, treatment, and i n s t i t u t i o n a l care of the chronically i l l . I s the provision of these f a c i l i t i e s primarily the r e s p o n s i b i l i t y of the hospital or i s i t s t r i c t l y a public welfare problem - one of s o c i a l assistance cases who also need medical services? This i s important since i t has been made abundantly clear that the majority of people suffering from chronic i l l n e s s eventually are forced to r e l y upon public assistance f o r t h e i r care. I f i t i s a public welfare r e s p o n s i b i l i t y , who i s responsible f o r the f i n a n c i a l cost? Should i t be the p r o v i n c i a l government, or the municipality j or, i f both, how should the costs be divided. ( l ) Boas, Ernst P., M.D., The Unseen Plague. Chronic Disease. J . J . Augustin Inc. 1940, Page 22. - I l l -Unfortunately the C i t y of Vancouver, with i t s l i m i t e d taxation resources and an increasing public demand f o r roads, sewers and other public u t i l i t i e s , has had to decide on a s t r i c t l y dollars-and-cents basis when i t came to the matter of providing any f a c i l i t i e s f o r the sick and indigent of Vancouver. Instead of asking what i s needed and what can be done f o r these people, the C i t y and i t s administrative bodies have had t o ask: how much w i l l i t cost; i s i t reasonable to ask the p r o v i n c i a l government to sharej and, not infrequently - i s i t an expense that can be postponed f o r a few years? I t has been d i f f i c u l t f o r the h o s p i t a l administrators and pr o v i n c i a l welfare authorities to convince the c i t y of i t s r e s p o n s i b i l i t y f o r the provision of nursing-home and boarding-home care f o r the chronically i l l . For many years the c i t y f e l t that i t s r e s p o n s i b i l i t y ended with the provision of s o c i a l assistance f o r them i n t h e i r homes. Af t e r i t s experiences during the depression with mass unemploy-ment and r e l i e f , with a l l of i t s attendant e v i l s , the City S o c i a l .' Service Department was reluctant to participate i n any large scale . program f o r the care of the chronically i l l . In 1937 however, the C i t y S o c i a l Service Department was one of the i n s t i g a t o r s of the plan f o r the removal of long-term hospital patients to nursing homes and boarding homes, and eventually became an i n t e g r a l part of the t o t a l program. At f i r s t the c i t y had t o assume the f u l l cost of the whole project. I t was not u n t i l 1939 that the p r o v i n c i a l government accepted r e s p o n s i b i l i t y f o r eighty per cent of s o c i a l assistance costs. This did not include boarding-home or nursing-home care. Had the war not intervened there might w e l l have been developed a co-ordinated program f o r the care of the chronically - 112 -i l l . But, the enlistment of large numbers of the medical profession, the shortage of housing accommodation and the cessation of any new building prevented any action being taken f o r s i x years. However, i n 1942 the pro v i n c i a l government assumed eighty per cent of the cost of boarding-home care and provided an additional one hundred beds f o r the chronically i l l at Mount St. Mary. As a result of the recommendations of the Goldenberg Report i n 194-7, the p r o v i n c i a l government agreed t o assume eighty per cent of the cost of nursing, home care. The situation as i t exists today i s that the c i t y and the p r o v i n c i a l government are each delaying action hoping that the other w i l l assume the r e s p o n s i b i l i t y f o r providing the necessary f a c i l i t i e s and accommodation f o r the care of these . unfortunate chronic cases. Within the c i t y i t s e l f three d i s t i n c t l y separate agencies have provided most of the f a c i l i t i e s at present available f o r the chronically i l l . This has been one of the main reasons for the lack of a sound treatment program for the chronically i l l of Vancouver; and the separation of f a c i l i t i e s between the City S o c i a l Service Department, the Vancouver General Hospital and the P r o v i n c i a l Infirmaries has probably helped t o postpone the construction of a central, properly equipped hospital i n t h i s c i t y . This d i v i s i o n of r e s p o n s i b i l i t y has worked out somewhat i n t h i s way; The Vancouver General Hospital provides medical care, treatment and accommodation f o r the largest number of the c i t y ' s chronically i l l ; the City S o c i a l Service Department assumes the f i n a n c i a l r e s p o n s i b i l i t y f o r the care and maintenance of dependent persons whethei? i n the home, boarding home or nursing home; the government admits to the P r o v i n c i a l - 113 -Infirmary those chronica l ly i l l persons who are no longer able to care for themselves and for whom there i s no sui table accommodation i n c i t y i n s t i t u t i o n s . Admissions to the Infirmary from Vancouver wi th in recent years have been so few that the C i ty S o c i a l Service Department and the Vancouver General Hospi ta l hesi ta te to take the time to wri te up such cases for Infirmary admission. .Any admissions that are made are regarded as inconsequential i n r e l a t i on to the o v e r - a l l problem To add to the confusion different arrangements have been made by the p rov inc i a l and c i t y governments for the care of the acutely - i l l i n the general hosp i t a l s . U n t i l the inception of the new hosp i t a l insurance scheme.the annual d e f i c i t of the Vancouver General Hospi ta l was made up by a s traight grant from the C i t y of Vancouver. Most of t h i s d e f i c i t was incurred by the hosp i ta l through i t s provis ion of outpatient services , acute hosp i ta l care for the c i t y ' s indigent and the cost of nursing-home care i n i t s s a t e l l i t e hospi ta ls of Glen , Grandview and Heather Street Annex. At one time i t was estimated that i t was costing the hosp i t a l $35 a month more than i t was rece iv ing from the C i t y S o c i a l Service Department for the care of each patient i n the annexes. These small def ic ienc ies soon added up t o one large def ic iency . For a short time the p r o v i n c i a l government made a spec i a l per-diem payment for every rec ip ien t of s o c i a l assistance cared fo r by the General Hospi ta l as an acute case. This grant was made without reference to the C i t y S o c i a l (1) Service Department. / ,•('2) Then, too, cases that were the r e s p o n s i b i l i t y of the federal govern-ment were being cared for by the Vancouver General Hospi ta l without f i n a n c i a l a i d . The war veteran i n receipt of War Veterans 1 Allowance received medical and hosp i ta l care at the Vancouver General Hospi ta l and not at Shaughnessy Hosp i ta l u n t i l about a year ago. The pensioner i s now e n t i t l e d to care at the m i l i t a r y hosp i t a l but h i s wife(cont) To add to the administrative tangle there is the provincial Inspector of Hospitals Office whose duty is to act as a clearing-house for chronically i l l patients occupying acute hospital beds in every part of the province. If a patient is a "Vancouver responsibility" then the Medical Section of the City Social Service Department is asked to find alternative accommodation. But the removal of non-residents of Vancouver from beds in Vancouver hospitals is a different problem altogether. These patients s t i l l need nursing-home or boarding- home care and services that are available only in Vancouver; but because of the shortage of custodial beds in Vancouver, the City Social Service Department is unwilling to provide accommodation for non-residents. The problem of what to do with the out-of-town residents that are flocking to Vancouver .for such specialized services as are provided by the B.C. Cancer Society, the Canadian Arthritis and Rheumatism Society and the Rehabilitation Centre for the Physically Handicapped is apparent-ly only beginning. At present the City of Vancouver is paying a large percentage of the cost of several services, which to become effective, must become provincial responsibilities. In addition there are voluntary services that play an important role in caring for the chronically i l l in the city. Outstanding among and dependents must s t i l l come to the Vancouver General Hospital. There are hundreds of War Veterans' Allowance recipients attending the Vancouver General Hospital Outpatients' Department, partly because they have been going there for so long that they do not wish to change, and also because they think they get better care and attent-ion at the Vancouver General Hospital. Temporarily at least, the city has been relieved of the responsibility of providing institutional care for these people by the opening up of special chronic wards at Shaughnessy Hospital and the provision of custodial care at Hycroft and the George Derby Health and Occupational Centre in Burnaby. - 115 -these are the Victorian Order of Nurses who are supported by the Community Chest, by grants from the provincial government and by an annual grant by the city. This is a self-contained organization and functions independ-ently of the hospitals, the City Social Service Department and the provincial institutions. A closer integration of service seems to be. necessary. Somewhat similar considerations apply to such services as the visiting homemaker services provided by the Family Welfare Bureau for families with, for example, a chronically i l l mother or father. The original plan in setting up the Children's Hospital was that i t would be able to care for a considerable number of chronically i l l children of Vancouver as well as to provide a generalized hospital service for children. The demands made upon i t has forced the hospital to curtail the services they offer chronically i l l children, The Preventorium has taken an occasional chronically i l l child as has the Queen Alexandra i ^Solarium on Vancouver Island, but other than these there is no place for the long-term treatment of the chronically i l l child. What services these institutions do provide are not correlated into any treatment program nor integrated in any way with other services provided for the chronically i l l . The private hospitals and nursing homes in Vancouver, the boarding homes, whether city or provincially licensed, each go their own way. Among them there is a wide variation in services provided and no one body determines exactly the institution in which a patient should or could be placed. These private institutions play an extremely valuable role in caring for the chronically i l l and they should be utilized to their f u l l extent. But some central body is needed to weld these various institutions into an effective and planned treatment service for the - 116 -chronically i l l . The wide diversion i n services offered, sources of f i n a n c i a l support, ownership, operation and administrative practice w i l l preclude any solution of the problem of the chronically i l l u n t i l they have been merged in t o a harmonious group working toward a common objective. The present system leads to a constant overlapping of services, and i n the important area of bed care, a competition among the various groups f o r what beds are available, that only i n f l a t e s costs and increases the l i k e l i -hood of emergency additions. The Required F a c i l i t i e s f o r Effective Care These are some of the hindrances that already stand i n the way of the implementation of a long-term treatment program f o r the chronically i l l . There are also, however, some f a c i l i t i e s that are lacking altogether, though they are essential to any program i n Vancouver. These deficiencies have been the main causes for the d i v i s i o n of r e s p o n s i b i l i t y within the c i t y ; they have forced the authorities t o resort t o improvisation, and have encouraged the use of temporary measures t o cope with the urgency of the problem. The major needs are threefold. F i r s t and undoubtedly foremost, Vancouver needs a chronic h o s p i t a l . Secondly i t needs a s o c i a l assistance program that pays s o c i a l allowances on the basis of need rather than only up to a maximum that allows bare subsistence. Thirdly, a single administrative body i s needed for the organization of f a c i l i t i e s and accommodation f o r the chronically i l l of the whole c i t y , a body with an advisory council composed of representatives of a l l interested groups i n the c i t y . Operated i n conjunction with the chronic h o s p i t a l as a u x i l i a r y - 117 -units there must be such resources as a v i s i t i n g nurse and v i s i t i n g physician service, an outpatients' department and a homemaker service. The Need f o r a Chronic Hospital In the 1930 survey, conducted by Dr. Haywood, of the hospital situation i n Vancouver, i t was estimated that 500 convalescent and chronic beds were urgently needed at that time.f""^ I f 500 beds were needed at that time i t i s probable that double that number are an urgent necessity now. I t i s generally considered that one chronic hosoital bed i s needed (2) f o r every 1000 population i n any area. On t h i s basis a minimum of 500 chronic hospital beds are urgent-l y needed i n Vancouver. With the inception of the medical school at the University of B r i t i s h Columbia f o r which a teaching hospital f o r chronic diseases w i l l be needed and the development of special services f o r persons suffering from cancer, a r t h r i t i s and the after-effects of p o l i o -m y e l i t i s , i t seems reasonable to expect that even more than 500 beds w i l l be needed. In Vancouver at present the only i n s t i t u t i o n , other than the acute hospitals, which provides active treatment f o r chronic diseases, i s the Marpole Infirmary. The Infirmary, however, was designed to provide custodial care only and was not intended to become a treatment centre. The Vancouver General Hospital has already become too large and too d i f f i c u l t to administer without further additions but any chronic h o s p i t a l (1) Haywood, Dr. A.K. and associates Report of the Hospital Survey Commis-sion Upon The Hospital Situation of Greater Vancouver (1930)• Vancouver, 1930, Page 166. (2) See f o r example, Care of the Chronically 111 and Aged; Proposed Recommendations of the Inter-departmental Co-ordinating Committee, Province of Saskatchewan, September 194-8. Recommendation IV, section 3. - 118 -that i s b u i l t i n Vancouver should be b u i l t close t o the Vancouver General Hospital. The Montreal survey of chronic diseases made t h i s recommendation: "From an administrative standpoint a hospital for chronic i l l n e s s should be maintained i n close relationship with the other types of hospitals which now exist i n the c i t y . This would allow f o r free and easy transfer of patients from the chronic hospital to the general hospitals, and also to the custodial homes now available. Patients would have t o be transferred from time to time to one or another i n s t i t u t i o n depend-:'. ing on changes i n t h e i r c l i n i c a l condition."^ 1' Most experts on chronic diseases are unanimous i n approving t h i s plan. I f a chronic hospital i s set off somewhere by i t s e l f i t soon becomes i n f l e x i b l e i n i t s relationship with other community services and gradually becomes s t a t i c i n regard to the treatment of the chronically i l l . Many hospitals compromise and operate one wing as chronic hospital with a considerable degree of success. There i s , however, universal acceptance of the fact that "most patients with chronic i l l n e s s requiring h o s p i t a l -i z a t i o n are best cared f o r i n a unit of a general hospital especially designed t o meet t h e i r needs. This arrangement encourages patients to seek and use care since i t i s near t h e i r homes, families and friends, makes available existing f a c i l i t i e s of general hospitals, provides opportunity to internes, nurses and s t a f f f o r experience and teaching i n chronic disease; avoids expensive duplication of existing general hospital f a c i l i t i e s , and affords the most ready means of transfer to and (2) from the acute and chronic disease sections of the hospital when needed." (1) The Care of the Chronically 111 i n Montreal. 1941, Page 24. (2) Planning f o r the Chronically 111 - Public Welfare Vol. 5 Wo. 10, October 1947, Page 221. The work of the j o i n t committee composed of representatives of the American Hospital Association, the American Medical Association, the American Public Health Association and the American Public Welfare Association. - 119 -The Saskatchewan Inter-Departmental Co-ordinating Committee emphatically declared that hospitals f o r the chronically i l l should be developed within the framework of the existing general hospital. I f a separate building i s constructed, i t should be on the same grounds as a general hospital, i n order t o insure j o i n t administration and the common use of f a c i l i t i e s / 1 ^ The present plan drawn up by the Vancouver General Hospital i s to b u i l d a 300-bed convalescent h o s p i t a l i n 194-9 i n a location adjacent t o the present h o s p i t a l . Within the next f i v e years a new 800-bed acute wing i s planned. After these two buildings have been b u i l t i t i s proposed that the present main building, b u i l t i n 1906, be converted into a chronic h o s p i t a l . This plan i s sound and progressive i n scope but hundreds of chronically i l l people need i n s t i t u t i o n a l care r i g h t nowj they cannot wait for f i v e years ot even one year. I f a chronic hospital i s constructed, a portion or wing of i t should be devoted t o the care of chronically i l l children. In Vancouver there i s no accommodation for the chronically i l l c h i l d under the age of eighteen except i n the Children's Hospital, though actually t h i s i n s t i t u t -ion takes only children under sixteen. The Marpole Infirmary cannot take them u n t i l the age of eighteen. The Preventorium, although intended primarily f o r the care of children exposed to T.B. has taken a few chron-i c a l l y i l l children, usually those recuperating from rheumatic fever. But t h i s i s the exception rather than the r u l e . When a chronically i l l c h i l d i s admitted t o a ho s p i t a l at present, he either remains there i n d e f i n i t e l y ( l ) Care of the Chronically 111 and Aged: Proposed Recommendations; Inter-Departmental Co-ordinating Committee, Government of the Province of Saskatchewan, September 194-8. Recommendation IV. - 120 -or returns to his home no matter how desperate his need f o r special i n s t i t u t i o n a l care. One nine-year-old boy with chronic nephritis spent almost s i x months i n the Vancouver General Hospital because there was no other place he could go; f i n a l l y he had to return to a very inadequate home i n which there were absolutely no f a c i l i t i e s f o r his proper care. In Glen Hospital at present there i s a sixteen-year-old paraplegic boy who has had to be placed there f o r lack of accommodation elsewhere. This boy i s i n the same ward as about twelve old men, some of whom are quite se n i l e . There are numerous children suffering from rheumatic fever who are discharged to poor environmental surroundings and inadequate care with the f u l l knowledge that t h e i r condition w i l l worsen because there i s no hos p i t a l or i n s t i t u t i o n to accommodate them. In addition to accommodation f o r chronically i l l children there w i l l have to be some provision f o r the i n s t i t u t i o n a l care of the e p i l e p t i c who cannot be adequately controlled from a medical point of view i n the home. Vancouver (and B r i t i s h Columbia) has been very backward i n recognizing the needs of e p i l e p t i c s f o r care and treatment i n special institutions... I t i s estimated that there are at the present time f i f t y e p i l e p t i c s i n Vancouver alone i n desperate need of i n s t i t u t i o n a l care. Undoubtedly there are twice that number who would benefit from care and treatment i n a chronic hospital. A chronic hospital should not degenerate into a purely custodial i n s t i t u t i o n f o r the chronically i l l . I t should be used primarily f o r the diagnosis, treatment and a l l e v i a t i o n of chronic disease. When only custodial care i s necessary, the patient should be transferred to an '. i n s t i t u t i o n such as the Marpole Infirmary. - 121 When the building of a chronic hospital i s suggested the f i r s t question raised i s who should finance h o s p i t a l construction? Undoubtedly the p r o v i n c i a l government w i l l have to provide most of the construction (1) costs but there are d i s t i n c t p o s s i b i l i t i e s of aid by federal subsidies. The provincial government i s the oniy l e v e l of government i n the province able t o finance a large construction program such as t h i s and to maintain the i n s t i t u t i o n properly. Since the p r o v i n c i a l government already assumes complete r e s p o n s i b i l i t y f o r two large groups of chronically i l l people, namely the tubercular patient and the mentally i l l , i t does not present any insurmountable d i f f i c u l t y f o r them t o take over t h i s closely related group. Only by having a provincially-operated program for the diagnosis, treatment and i n s t i t u t i o n a l care of the chronically i l l can an effective and co-ordinated program be developed. The provincial T. B. Hospital operated on the grounds of the Vancouver General Hospital has the f a c i l i t i e s of the Vancouver General Hospital at i t s disposal but s t i l l remains a treatment and i n s t i t u t i o n a l care centre f o r the tubercular patient from many parts of the province. The effect of the greater sources of revenue of the p r o v i n c i a l government i s c l e a r l y seen at the Marpole Infirmary, where every f a c i l i t y that can be used i s made available t o the patient with l i t t l e consideration as to the cost. In a p r o v i n c i a l l y -operated chronic i n s t i t u t i o n i t s f a c i l i t i e s w i l l be available t o every resident of the province and not only to those who l i v e within the c i t y l i m i t s . Because certain medical programs are available only i n Vancouver, ( l ) I t i s expected that the federal government w i l l contribute up to $1000 per bed toward the cost of construction of chronic hospital f a c i l i t i e s . Such a course of action was proposed at the 194-5 Dominion P r o v i n c i a l Conference. - 122 -the c i t y has borne more than i t s share of the f i n a n c i a l burden i n caring f o r the chronically i l l . This s i t u a t i o n , b i t t e r l y c r i t i c i z e d by the Vancouver c i t y council, w i l l continue to exist u n t i l the chronic hospital i s operated as a pr o v i n c i a l i n s t i t u t i o n . The p r o v i n c i a l government could construct a chronic h o s p i t a l s i m i l a r t o the new C l i n i c of Psychological Medicine at Essondale which i t s e l f could be used as a chronic hospital without a single a l t e r a t i o n . Among i t s many advanced features are the public wards divided by waist-high par t i t i o n s i n t o semi-private accommodation providing a patient with some degree of privacy without completely i s o l a t i n g him from the other patients. The pro v i n c i a l government has already erected two i n s t i t u t i o n s f o r the care of the senile aged which are perfectly designed chronic custodial units with a l l of the most modern ideas f o r the care of one par t i c u l a r type of chronic i l l n e s s . These units have been mentioned only to show that the pro v i n c i a l government can and does provide the best type of i n s t i t u t i o n f o r certain kinds of chronic i l l n e s s . I t should do the same for other chronic diseases. Without doubt i t w i l l be found that the vast majority of chronically i l l people seeking admission to a chronic hospital are either indigent or of the lower income groups. I f a proper approach t o the problem of chronic disease and i t s accompanying economic e v i l s i s not established from the very f i r s t , the chronic h o s p i t a l may soon become, i n the mind of the public, a charitable i n s t i t u t i o n designed primarily f o r the care of the indigent sick. In the c i t i e s that operate chronic hospitals, i t has been found that many people are forced t o be i n s t i t u t i o n -a l i z e d f o r no other reason than that they are poor and there i s no other - 123 -place where they can get adequate care. Chronic disease strikes a l l classes and the lack of proper care and treatment is as serious for those who are able to pay as for those who cannot. A chronic hospital should be a community institution serving a l l sections of the population, rich and poor. In this way the hospital may achieve a greater degree of financial stability because of the additional income from those able to (1) pay, resulting, of course, in a s t i l l higher quality of service to a l l . The Marpole Infirmary is operated very successfully on this principle. The paying and the non-paying patients receive exactly the same care and treatment, with only the office knowing a l l the facts. The joint committee, before mentioned, made further recommendations regarding the financial ability of the chronically i l l to pay for their care: "Under no circumstances should chronic disease hospitals or units be limited to the indigent. The lack of facilities is felt by a l l sections of the population. High standard will be maintained most effectively i f the facilities are geared to meet the requirements of the entire community. Also the admission of patients who are able to pay will reduce the need for tax funds. It must be recognized however that prolonged illness exhausts the financial resources of many patients, necessitating payment from tax funds for their care."(2) It is reasonable to envisage what would be the effect of the opening of a 500-bed chronic hospital in Vancouver. In a l l probability every bed in the institution would be f i l l e d within a matter of weeks. In the fi r s t place, a considerable number of acute beds occupied by chronic-ally i l l people would immediately become available for the accommodation of acutely i l l people that have not been able to gain admission to the (1) Planning for the Chronically 111, Public Welfare. Vol. 5, No. 10, October 194-7, Page 220. (2) Ibid.. Page 222. - 124 -h o s p i t a l because of lack of beds. Secondly, the pressure upon and the demand f o r private nursing-home care would abate somewhat, and some attempt could be made to select the nursing home that best meets the patient's needs. Pressure upon the boarding homes would also be lessened and there could be a more concerted attempt t o be selective i n the accommodation used. Boarding homes could then be used more f o r the care of people suffering from nothing more than old age who need only custodial care. What would be most important would be the effect of decreased demand for nursing-home and boarding-home care. One o f f i c i a l i n the City S o c i a l Service Department made the statement that there was nothing wrong about the nursing homes and boarding homes i n Vancouver that a l i t t l e competition could not cure. Places that provided i n f e r i o r services would either have to improve t h e i r standards or go out of business. Nevertheless, no matter how large a chronic h o s p i t a l was b u i l t , there would s t i l l be a need for nursing-home and boarding-home care t o provide custodial accommodation for those patients who can no longer benefit from the treatment services of a chronic hospital. The infirmary type of i n s t i t u t i o n would continue t o play a v i t a l part i n the ov e r - a l l program i n that there would be several hundred patients f o r whom only custodial care was necessary. Care For Those Not In Need of Chronic Hospital Care A chronic hospital may greatly benefit those i n need of t h i s p a r t i c u l a r type of care but what of those chronically i l l people who do not need i n s t i t u t i o n a l care? Chronic ho s p i t a l care i s not always the • type of care that best sui t s the patient's needs. Dr. Boas has t h i s t o say about t h i s p a r t i c u l a r aspect of chronic i l l n e s s : - 126 -"Manifestly a chronically i l l patient should receive the type of care that he actually requires. His needs will vary from time to time. Often after a period of medical care improvement occurs so that custodial care becomes sufficient. On the other hand a patient who has been adequately served by custodial care may experience a sudden progress of his disease that demands medical care. Some of the chronic sick receive unnecessarily expensive care; they are in a hospital when a custodial home would be sufficient j they are served byva visiting nurse rather than by an attendant. In the case of others the picture is reversed and the care they receive is insufficient. Care ill-suited to the needs of the patient results in economic loss to the community and often unfairness to the sick."(l) The essence of a good system is one in which there is no difficulty experienced in achieving the maximum mobility for every patient. It must never be forgotten, however, that medical needs do not always decide what type of care a chronically i l l person should have. Poverty compels many chronically i l l people to seek institutional care. There are hundreds of chronically i l l persons in this city who do not need any type of institutional care and are quite capable of carrying on normal activities in their own homes with only the aid of a visiting nurse service and with regular visits from the family doctor. Eventually the point will be reached where a definite plan of treatment for every chronically i l l person will be laid out by the . community diagnostic and treatment centres from the onset of the illness to death. For the indigent and low income groups an unlimited outpatient diagnostic service should be made available. The implementation of a treatment program for each individual required that early and skilful diagnostic service must be available to a l l without any reference to cost (l) Boas, Ernst P., M.D.; The Unseen Plague. Chronic Disease. J. J. August in Inc., 194-0, Page 25. - 126 -or a b i l i t y to pay. In practice this amounts to a system of pre-paid health insurance. The patient must be encouraged to consult his doctor at the t • ' time the f i r s t symptoms of chronic i l l n e s s occur and not when seeing the doctor can be postponed no longer. Ready access to diagnostic and specialist service i s essential to adequate care for every form of chronic disease. Many of the chronic diseases exhibit complex and varying symptoms that make them d i f f i c u l t to diagnose and treat. A chronic hospital, the services of a physician available at a l l times, or the organization of an outpatient service for the early diagnosis and treatment are helpful to certain categories of the chronic-a l l y i l l . To others:the services of a v i s i t i n g nurse in the home satisfies their wants and needs. At present there are only eighteen V.O.N, nurses in Vancouver to care for every person needing bed-side nursing in the home. Besides the chronically i l l they have large numbers of maternity cases and convalescent people to care for. There should be three times this number for a city this size. Montefiore Hospital for Chronic Diseases in New York operates a home nursing service by v i s i t i n g nurses who follow up patients after their discharge from hospital and provide regular nursing service in the home for those who do not need institutionalization. In England under the new National Health Insurance program, an extremely elaborate system of vis i t i n g nurses and special treatment c l i n i c s has been set up with the purpose of keeping the chronically i l l on their feet as long as possible. Many of the chronically i l l do not even require the services of a graduate nursej a practical nurse or a nurses' aid i s quite capable of giving an insulin injection, giving a bath or changing a dressing. - 127 -Nurses' aides and p r a c t i c a l nurses supervised by graduate nurses spread the v i s i t i n g nurse services over a greater part of the population. The Ci t y Social Service Department has employed a trained medical orderly to v i s i t many of the chronically i l l old men l i v i n g i n cheap rooming houses and hotel rooms. In many cases his services are en t i r e l y adequate t o the patient's need. Under the present set-up i n Vancouver, i t seems best that the V.O.N, continue as an autonomous body without being a f f i l i a t e d with the hospital or C i t y Social Service Department, but there should be a closer co-ordination of services with a representative of the nursing service s i t t i n g upon the inter-departmental committee discussed l a t e r on i n t h i s chapter. The system of purchasing nursing services has more advantages than disadvantages. I t i s much cheaper to purchase service such as that . provided by the V.O.N, than t o set up a s i m i l a r service under municipal control. Most important of a l l , the provision of service would not take on a charity or s o c i a l assistance tinge but would continue to care f o r a l l classes of patients, those without funds, those able to pay something f o r services rendered, and those able t o pay i n f u l l . I f a treatment program for the chronically i l l were set up i n Vancouver, the v i s i t i n g nurse service would have to be augmented by a simil a r v i s i t i n g physician service. There are many chronically i l l people who w i l l not c a l l a doctor u n t i l t h e i r condition reaches an emergent state because they have not the money to pay for h i s services. Besides t h i s , unfortunately, there are some doctors who w i l l not, pay routine- v i s i t s t o chronic i n v a l i d s i n t h e i r homes because they f e e l that they are wasting t h e i r time v i s i t i n g these people f o r whom they can - 128 -do l i t t l e or nothing. Then there are the few doctors who lose interest when they f i n d that chronically i l l people are usually less able to pay t h e i r b i l l s than others. A properly organized treatment program provides for the setting up of a panel of doctors who are constantly on c a l l f o r the care of the chronically i l l i n t h e i r homes or i n the i n s t i t u t i o n s serving them. A rotation system i s frequently used to d i s t r i b u t e the burden and thus keep up the doctors' i n t e r e s t . The new system of Health Insurance i n England provides f o r quite an extensive system of v i s i t i n g physician services f o r the chronically i l l . The Montreal survey of chronic diseases strongly recommended the implementation of such a service f o r the care of the chronically i l l of Montreal who had to remain i n t h e i r own homes and who were unable to pay f o r medical c a r e . ^ Such a system i n Vancouver would be a tremendous aid to the chronically i l l . The system could and should be operated as an i n t e g r a l part of the chronic h o s p i t a l and i t s outpatients' department. To round out a complete program f o r the care of the chronically i l l i n the home, a highly specialized and centrally controlled v i s i t i n g housekeeper or homemaker service i s necessary. At one time the C i t y S o c i a l Service Department employed a considerable number of v i s i t i n g housekeepers to care f o r family groups, finding that i t was cheaper to pay a house-keeper's salary and keep the family together than i t was to have the home s p l i t up and provide maintenance f o r each i n d i v i d u a l . Gradually the c i t y has withdrawn from t h i s f i e l d and the majority of such housekeepers (now known as homemakers) are provided by the Family Welfare Bureau of ( l ) The Care of the Chronically 111 i n Montreal. 194-1, Page 24-- 129 -Vancouver. This type of service i s provided only when there are children i n the family. The work of the Family Welfare Bureau has certainly been highly satisfactory except that there are not nearly enough of the home-makers available for the number of people who need t h e i r services. There are hundreds of older chronically i l l people who need nothing more than someone to keep the home clean and cook a meal; with just t h i s l i t t l e extra help they are able t o carry on without seeking i n s t i t u t i o n a l i z a t i o n . Mary J . Jarrett made a very detailed study of the v i s i t i n g housekeeper services i n operation i n New York for the care of the chronically i l l , She said: "How a chronic patient i s t o be cared f o r depends not only upon the type of medical and nursing service he requires but also upon the degree of his capacity and upon the resources of h i s home. Patients who are capable of attending a c l i n i c with assistance may have to go to a hos p i t a l because there i s no-one at home to look a f t e r him. Those who might be treated by v i s i t i n g physicians may be i n hospitals because the family i s not able to give the necessary care. Sometimes lack of f i n a n c i a l support forces a patient into an i n s t i t u t i o n There can be no doubt that home care i s an essential part of a humane and economical system of provision f o r the chron-i c a l l y i l l f o r both adults and childr e n . " ( l ) A large proportion, probably a majority, of the chronic patients who must have some kind of personal attention t o t h e i r physical needs do not require s k i l l e d nursing. In a great many cases, the family can give the necessary care. Some patients need the type of care that i s given by a trained attendant. Others need only to be waited upon or t o be assisted (2) with household tasks, that i s , such help as a housekeeper can give. (1) J a r r e t t , Mary C , Housekeeping Service f o r Home Care of Chronic Patients; Report of a W.P.A. Project i n New York C i t y , October, 1935 to J u l y , 1938. New York 1938 Page 4-. (2) I b i d . . Page 6. - 130 -Chronic I l l n e s s and Compulsory Hospital Insurance Eventually some provision f o r the care of the chronically i l l w i l l have to be made under the new system of compulsory hospital insurance i n B r i t i s h Columbia. I t i s a basic prerequisite to the success of the whole scheme that accommodation for the chronically i l l be found so that every acute bed may have the greatest possible turnover i n patients. I t has been estimated that from twenty t o f o r t y per cent of a l l h o s p i t a l beds are constantly being used for patients suffering from chronic diseases. I f separate accommodation for the long-term convalescent and chronically i l l person i s not found, the whole system w i l l founder. In Great B r i t a i n the f i r s t step taken by the National Health Insurance aut h o r i t i e s , before inaugurating t h e i r scheme of free h o s p i t a l i z a t i o n , was to make special provision f o r the removal and accommodation of the chronically i l l elsewhere, so that the maximum use of the available acute h o s p i t a l accommodation could be made. The present system of hospital insurance i n B.C. provides payment f o r only that period i n the hospital during which i l l n e s s i s at an acute stage; and as soon as the patient i s no longer acutely i l l he must either pay the f u l l h o s p i t a l rates or leave the h o s p i t a l and perhaps t r y to gain admittance t o a nursing home. The patient may f e e l little better although the doctor and the hospital administration have decided .' that he has improved s u f f i c i e n t l y to leave. A new policy w i l l have to be developed next year when the new convalescent hospital i s opened at the Vancouver General Hospital. W i l l hospital insurance cover stay i n a convalescent hospital? How much difference i s there between a chronic i n v a l i d and a patient needing s i x months or more convalescence. A l l \ - 131 -groups need hos p i t a l i z a t i o n equally as bad and i t does not seem right that one group should be discriminated against because t h e i r period of sickness i s of a long-term nature while others recover i n a week or ten days. I t . i s r e a l l y the long-term or chronic patient who should have h i s hospital payments cared f o r . In view of the above situation i t seems es s e n t i a l that the pro v i n c i a l government appoint a man or a woman, not necessarily a doctor, to act i n an advisory capacity to the administrator of the hospital insurance scheme with a view to the establishment,of a p r o v i n c i a l chronic hospital f o r the diagnosis, treatment and care of the chronically i l l of B.C. This person should be f a m i l i a r with medical s o c i a l work technique and with the public welfare organizations i n the province. This person c should act as a l i a i s o n o f f i c e r between the Social Welfare Branch of the Department of Health and Welfare of B.C. and the newly created Hospital Insurance Branch. With t h i s as a beginning, a program f o r the proper care of the chronically i l l can be developed i n B.C. A Scale of S o c i a l Allowances Based On Need The present scale of s o c i a l assistance payments provided f o r the chronically i l l i n the home i s hopelessly inadequate. Instead of helping the chronically i l l person t o stay out of an i n s t i t u t i o n the meagre grant forces him to seek hospital, nursing-home care or boarding-home care. The City S o c i a l Service Department has very d e f i n i t e l y recognized t h i s situation by the present pol i c y of supplementing s o c i a l allowances f o r a few chronically i l l people so that they may have a l i t t l e extra attention and consequently remain at home f o r a l i t t l e while longer. At present a single man i s expected to provide food, clothing - 132 -and shelter f o r himself out of his $35 allowance. Even the cheapest room now costs at least $ 1 2 a month and more l i k e l y $ 1 5 . Twenty d o l l a r s for food alone spread over t h i r t y days allows only about si x t y cents a day f o r food with nothing f o r f u e l , clothing, l i g h t , etc. A married couple receives only $50 a month instead of the $70 that one might expect they should get. For each additional dependent the parent receives a small additional allowance. The additional amount received w i l l hardly buy milk f o r a c h i l d nowadays. The s o c i a l assistance recipient and his family get unlimited free medical care but i t does not help very much i f the environmental d i f f i c u l t i e s tinder which he l i v e s make i t impossible f o r him to benefit from these medical services. The chronically i l l person w i l l go to any lengths to postpone the day that he has to apply f o r assistance. The usual pattern i s f o r the chronically i l l person to s e l l everything he owns to obtain extra money t o carry on f o r a l i t t l e while longer. Patients are unwilling to go to Glen and Grandview Hospitals, u n t i l they are forced to because they do not want to become assistance r e c i p i e n t s . The present inadequate rates of s o c i a l allowances make i t a degrading experience f o r an i n d i v i d -u a l to apply f o r assistance. There are hundreds of chronically i l l people barely existing on small pensions or annuities who are not e l i g i b l e f o r s o c i a l assistance. These persons are i n e l i g i b l e f o r the free medical care provided f o r the assistance recipient. A person has t o be absolutely destitute, besides being unemployable, before any assistance can be provided. Since the City S o c i a l Service Department controls a large number of the nursing and boarding home beds available for the care of the - 133 -chronically i l l , the standards and p o l i c i e s of t h i s agency determine what standards s h a l l exist i n these i n s t i t u t i o n s . As long as the care of the chronically i l l remains a charity or s o c i a l assistance domain, large numbers of chronically i l l people w i l l be i n e l i g i b l e or unwilling t o apply for the care that i s available, no matter how good i t i s . There are many people who would t r y t o exist on- a few dollars a week rather than apply f o r assistance. At present there i s no attempt to provide s o c i a l assistance according t o need. In some cases, where the rent paid i s higher than the allowable maximum, a small r e n t a l average i s granted. A few fortunate chronically i l l people, needing boarding-home beds that are not available, get a supplementary allowance to recompense the landlady f o r extra services. At no time i s an attempt made to f i n d out exactly how much a family needs to l i v e on and that amount of allowance granted. No treatment program f o r the chronically i l l can hope t o be eff e c t i v e without a r a d i c a l a l t e r a t i o n i n the present scales of s o c i a l assistance. A l l of the v i s i t i n g nurse services, v i s i t i n g physician services and other treatment services f o r the chronically i l l w i l l be useless u n t i l some attempt i s made to provide s o c i a l assistance according to need so that the chronically i l l l i v i n g at home are not forced t o l i v e i n absolute poverty. An Improved Administrative Structure Despite the t e r r i b l e shortage of f a c i l i t i e s f o r the care of the . chronically i l l i n Vancouver, there i s much that can be done to straighten out the administrative tangle that prevents what resources there are i available from being used to t h e i r f u l l extent. - 134 -A great deal could be accomplished by the organization of an inter-departmental committee to co-ordinate the whole program f o r the care of the chronically i l l . Up u n t i l the present time the main trouble has been that each i n d i v i d u a l agency has been running i t s own independent program. How much better i t would be to have them working toward one common objective — to provide the best possible care f o r each i n d i v i d u a l chronically i l l person by the most e f f i c i e n t mobilization of a l l available resources. I t might be surprising t o discover how much could be accomplished by having the present departmental heads, both p r o v i n c i a l and municipal, s i t down around a conference table at least once every two (1) weeks and thresh out t h e i r differences and a i r t h e i r problems. This group should include the following: The Inspector of Hospitals, the Inspector of Welfare I n s t i t u t i o n s , the Superintendent of Infirmaries, the Administrator of the City S o c i a l Service Department, the nurse i n charge of the Medical Section of the City S o c i a l Service Department, the S o c i a l workers i n charge of placements at the Vancouver General Hospital and St. Paul's Hospital, and a representative of the V.O.N, nursing service. I t would be an achievement i n i t s e l f to get these people together. Such a policy-making committee could accomplish much. F i r s t , a much more ef f e c t -ive system of r e f e r r a l s from one agency to another could be effected. Thare could be a common sharing of information among the various agencies and much unnecessary f i l e and record duplication would be eliminated. Chronic-a l l y i l l individuals needing' s o c i a l assistance would have t h e i r e l i g i b i l i t y f o r s o c i a l assistance determined only once. The medical s o c i a l workers • (l ) Such a body did function f o r a short time but was disbanded during the war. - 1 3 5 -in the hospital would cease to be mere placement officers and would not have so much of their time taken up with determining financial eligibility for different types of care. Some method could be devised whereby there would be one statistician to do the vast amount of statistical work. necessary. A much closer relationship between the Provincial Infirmaries and the other agencies would develop and in time these agencies would come to realize why the Infirmary has to give preference to provincial rather than municipal cases. Some understanding of each others problems-and limitations would be bound to have a salutory effect. Most important of a l l , the chronically i l l would take on the identities of individuals and cease to be just cases with names and numbers. An inter-departmental committee such as this could work out some form of treatment program with even the present limited resources at their disposal. Mary C. Jarrett found that the same situation existed in Cleveland. She made this recommendation in her study of chronic diseases in that city: "A community plan for the control and care of chronic illness will be a program of many unrelated parts. It will include many different services for prevention, recovery, rehabilitation and care. It must be planned for children, youth, the middle-aged and the aged. It must be organized on a broad scale, for the total problem of chronic illness is not a series of problems that can be met by one but a complex of interrelated problems that require simultaneous solution. "(1) In addition to the inter-departmental committee described above, a central planning and advisory body is essential as an advisory group to develop and plan a program for the chronically i l l as visualized by the (l) Jarrett, Mary C, Care of the Chronically 111 of Cleveland and Cuyahaga County. Cleveland, The Benjamin Rose Institute, 1944, Page 3 6 . - 136 -community as a whole. I t should include representatives of the p r o v i n c i a l and municipal governments i n a consultative capacity, the main body of the group to be made up of representatives from the medical and nursing professions, representatives from the Community Chest and Council, and such organizations as the Family Welfare Bureau, the Vi c t o r i a n Order of Nurses and the Children's Hospital. Most important of a l l i t should have representatives of the non-professional groups such as trade unions, parent-teacher associations, service clubs and other public bodies interest-ed i n the problems of the chronically i l l . In other words, a good cross section of the community should be represented. This large planning or advisory body could set up sub-committees to study the m u l t i p l i c i t y of problems involved, t o educate the p u b l i c , t o suggest improvements i n standards and scope of existing f a c i l i t i e s , and to assist' i n securing new and improved f a c i l i t i e s . An advisory body such as t h i s would j u s t i f y i t s existence e n t i r e l y i f i t did only one thing — to delineate just where the r e s p o n s i b i l i t i e s of the public welfare authorities began and where they ended. This committee could act as an advisory body to an administrat-ive group set up by either the municipal or preferably, the p r o v i n c i a l government to operate the whole program of caring f o r the chronically i l l of Vancouver. A compact organization of four persons, aided by a c l e r i c a l s t a f f , could go a long way toward by-passing many of the administrative c o n f l i c t s that at present strangle anything that approaches a workable program. Since chronic i l l n e s s i s primarily a medical f i e l d , t h i s administrative group should be headed by a doctor whose duty would be to determine what type of treatment the in d i v i d u a l chronically i l l person - 137 -i requires. The second member of the group should be a medical s o c i a l worker, f a m i l i a r with the emotional problems of chronic i l l n e s s , whose function would be to make available the casework services that the chronically i l l person often so urgently needs, and to mobilize every available community resource f o r the e f f e c t i v e treatment and care of the i n d i v i d u a l patient. The medical s o c i a l worker would also be i n a position t o protect the interests of the h o s p i t a l when necessary. The s o c i a l worker from the City S o c i a l Service Department should be the t h i r d member of the group and he should be responsible f o r determining the f i n a n c i a l circumstances of every patient i n need of f i n a n c i a l a i d , and should also be the representative of the public welfare services of the province i n general. The fourth member of t h i s administrative body should be a public health nurse, responsible f o r v i s i t i n g nurse services, v i s i t i n g homemaker services as wel l as f o r the supervision and a l l o c a t i o n of a l l available nursing-home and boarding-home f a c i l i t i e s . To t h i s administrative group should be referred every chronically i l l person admitted to an acute h o s p i t a l , every chronically i l l person i n need of some form of i n s t i t u t -i o n a l care and every person known t o be suffering from a chronic disease, irrespective of hi s f i n a n c i a l circumstances. A system of r e f e r r a l s from private physician, public health nurses and every s o c i a l agency i n the c i t y would have to be developed. Obviously the setting up of such an administrative group w i l l not work unless the agencies already involved i n the problem can be persuaded to give up some of t h e i r jealously guarded prerogatives and pr i v i l e g e s . But i t i s only by working together and by integrating and co-ordinating every resource of the community that the care of the chronically i l l w i l l cease t o be a major problem. - 138 -Chapter VII The Social Worker and the Chronically 111 In the implementation of a program for the care of the chronically i l l , the trained and s k i l l e d s o c i a l worker plays an important part. Adequate medical service, proper i n s t i t u t i o n a l care and an administrative structure designed to meet the needs of the chronically i l l person w i l l be inoperable unless some attempt i s made t o interpret these resources so that the ind i v i d u a l i n need of them can appreciate t h e i r purpose. This i s the point at which the s o c i a l worker plays an important r o l e . The inclusion of the s o c i a l worker i n the team of doctor, nurse and ho s p i t a l administrators makes i t possible to t r e a t the person with a chronic ailment as an i n d i v i d u a l , so that his needs can be considered, his cooperation i n treatment won and his morale bolstered. The Saskatchewan Inter-Department-a l Co-ordinating Committee i n i t s recommendations f o r the care of the chronically i l l and aged of that province, regarded the establishment of adequate medical s o c i a l services as a basic pre-requisite to the development of any program designed to meet the needs of the chronically i l l . As a r e s u l t of studies made i n various c i t i e s i n the United States, Mary C. J a r r e t t came t o the conclusion that the medical s o c i a l worker was the key to any community program f o r the care of the chronically ( l ) Care of the Chronically 111 and Aged. Proposed Recommendations; Inter-departmental Co-Ordinating Committee, Government of the Province of Saskatchewan, September, 194-8. Page 1. - 139 -i l l . Her observations can be paraphrased i n t h i s way: "In view of the fact that chronic diseases a l l involve medical, s o c i a l and economic factors, the care of the chronic s i c k must include adequate s o c i a l casework services as w e l l as suitable medical and nursing service. The special treatment f a c i l i t i e s required for patients are often determined as much by t h e i r s o c i a l as by t h e i r medical needs, and the proper a l l o c a t i o n of patients t o one or the other of the available i n s t i t u t i o n a l or agency services depends upon the judgement of the trained s o c i a l caseworker as w e l l as upon that of the physician. The services of the trained s o c i a l caseworker are valuable i n ass i s t i n g the patient i n the early stages of a chronic condition t o carry out the medical plan and care which w i l l contribute t o hi s recovery i f he remains at home, or i n arranging f o r h i s return t o the community, i f he . » requires i n s t i t u t i o n a l care f o r a l i m i t e d period only."* ' Unfortunately there i s s t i l l too great a tendency t o lump the aged, incurables, and the chronically i l l i n t o a special category, about whom not much i s known and fo r whom s o c i a l casework services are considered inapplicable. S o c i a l workers themselves have not always r e a l i z e d that the s o c i a l adjustment problems of the chronically i l l are great and i n need of constant attention and understanding. A large part of the public welfare worker's caseload i s made up of chronically i l l people, but few public welfare workers have analyzed these cases car e f u l l y t o f i n d out exactly why most of these chronically i l l people continue t o be problem cases year a f t e r year and why t h e i r medical treatment does not a l l e v i a t e the c l i e n t ' s condition. The emotional components of chronic disease are far-reaching. By the same token, the provision of case work services f o r the chronically i l l i s p a r t i c u l a r l y challenging. The chronically i l l person ( l ) J a r r e t t , Mary C , The Care of the Chronically 111; Reprinted from the Hospital Survey for New York. New York, United Hospital Fund, Vol. I I , Chapter X I , 1937, Page 684. - " U O -demands much more intensive casework than the average family or acute ho s p i t a l case. The contacts with the case may be f o r long periods stretch-ing over many years, and work with the family of the chronically i l l person w i l l be as essential as the work with the chronically i l l i n d i v i d u a l himself. The s o c i a l and economic problems that a r i s e as a r e s u l t of chron-i c disease require s k i l l and resources t o be by-passed or overcome. In a family or c h i l d welfare case, the caseworker gets s a t i s f a c t -ion and keeps up interest i n the case from some v i s i b l e signs that progress i s being made. Working with the chronically i l l , the caseworker must be prepared t o wait f o r long periods of time before any response t o the caseworker's ministrations becomes evident; indeed,"no v i s i b l e improve-ment, despite the most d i l i g e n t u t i l i z a t i o n of case work s k i l l s , may be expected. Plan a f t e r plan may be rejected, the c l i e n t may show i n d i f f e r - - -ence and even violent h o s t i l i t y , and the worker may have continual feelings of f r u s t r a t i o n because of the absence of community resources fo r the adequate care of the chronically i l l . Nevertheless the caseworker can gain great s a t i s f a c t i o n from the immediate response and appreciation which some of the chronically i l l show toward anyone who i s genuinely interested i n t h e i r welfare and the solution of t h e i r problems. The families and dependents of the chronically i l l r e a d i l y respond t o and accept any services which are offered t o them. Only recently have studies been made into the emotional implications of chronic disease and the effect of a proper mental attitude upon the treatment and care of the disease i t s e l f . The emotional component i s now regarded as a d e f i n i t e syndrome of the diseases nature. I t has been d e f i n i t e l y proven that a flare-up or recurrence of a - 141 -chronically i l l p a t i e n t 1 s acute symptoms can be linked i n every case t o an environmental or family relationship d i f f i c u l t y . Dr. Boas emphasized t h i s point very strongly i n a l l of h i s writings and he says: "Chronic i l l n e s s has so profound an e f f e c t upon the patient's external l i f e , upon his career, on his occupation, h i s economic status, his amusements, his hobbies, on his family relationships, on his habits of eating, drinking, sleeping and s o c i a l intercourse, that he i s often overwhelmed by the necessary readjustment of h i s mode of l i v i n g . 1 ^ 1 ) Casework Services Available In the main, any caseworker services that have been directed toward the solution of some of the problems encountered by the chronically i l l have been provided by the l i m i t e d number of medical s o c i a l workers i n the Vancouver General Hospital and to a much lesser extent by the s o c i a l worker-investigators of the City S o c i a l Service Department. In both cases any services provided are a by-product of the worker's i n d i v i d u a l interest i n p a r t i c u l a r cases rather than the setting up of sp e c i a l organizations or agencies to serve the chronically i l l . For several years there has been a medical s o c i a l worker on the s t a f f of the Children's Hospital but few of her e f f o r t s are s p e c i a l l y directed toward the provision of casework services f o r the chronically i l l c h i l d and h i s parents. I t must be c l e a r l y recognized, however, that the extremely l i m i t e d number of s o c i a l workers i s the biggest handicap to improved service i n t h i s f i e l d i n p r a c t i c a l l y every h o s p i t a l . The Vancouver General Hospital has appointed one s o c i a l worker to be responsible f o r Glen and Grandview hospitals, and t o provide some of the casework services required by the patients i n these i n s t i t u t i o n s , ( l ) Boas, Ernst P., M.D., The Unseen Plague. Chronic Disease. J . J . Augustin Inc., 1940, Page 20. - 142 -but her time i s so taken up with arranging accommodation f o r patients i n the nursing homes, and with doing routine s t a t i s t i c a l work, that she spends very l i t t l e time ^ a c tually with the patients and knows many of t h e i r families only by the sound of t h e i r voices over the telephone. The other s o c i a l workers i n the h o s p i t a l divide t h e i r time between the Outpatients' Department and the acute wards of the h o s p i t a l . Part of t h e i r time i s spent determining applicants' e l i g i b i l i t y f o r treatment at the Outpatients' Department. In the same way the largest proportion of the C i t y S o c i a l Service worker's time i s spent doing semi-clerical work - f i l l i n g out forms and making routine investigations into the f i n a n c i a l e l i g i b i l i t y f o r some form of f i n a n c i a l assistance, leaving very l i t t l e time f o r the provision of casework services. The Ci t y Social Service worker, because of his extremely heavy caseload, picks out about a dozen special cases which he considers he can help. He gives them spec i a l attention and attempts t o provide extra services f o r them. Almost invariably these are cases with children, with special problems (such as epileptics) or with young people having a personal appeal t o the worker. The older, chronically i l l person or the old age pensioner sees the s o c i a l worker only when a routine v i s i t i s made to determine continuing e l i g i b i l i t y at regular six-month or yearly i n t e r v a l s . I t i s inconceivable that very many emotional problems w i l l come to the worker's attention i n a half hour interview every s i x months or so. A worker may not even be aware of the fact that most of his s o c i a l assistance cases are chronically i l l people. When a s o c i a l worker finds a c l i e n t i s too sick t o carry on i n the home any longer, he reports the fact to the Medical Section of the Department or - M 3 -he may recommend that the cl i e n t see a doctor immediately or apply f o r ; treatment at the Outpatients 1 Department. From t h i s point on the worker ceases t o be responsible for following up the case t o see what treatment was provided. For the patients i n the hoarding homes and nursing homes, other than Glen or Grandview Hospitals, the nurses i n the Medical Section of the C i t y S o c i a l Service Department or the d i s t r i c t worker who pays a monthly v i s i t t o deliver comfort-allowance cheques are the only contacts that they have with s o c i a l service f a c i l i t i e s . The Marpole Infirmary and i t s subsidiaries have no provision f o r a s o c i a l caseworker to provide services f o r the chronically i l l of these i n s t i t u t i o n s . Actually the Superintendent functions as a s o c i a l worker i n that she maintains an unusual personal interest i n every patient and i s constantly available f o r consultation with the patients and t h e i r families when needed. Within the past year a one-person s o c i a l service department has been set up at St. Paul's Hospital to as s i s t i n placing the chronically i l l i n boarding homes and nursing homes and to provide casework services wherever the doctor considers i t to be necessary. Some of the c l i e n t s of the Family Welfare Bureau are chronically i l l people. Casework services as well as a v i s i t i n g homemaker service fo r families with children are made available t o a l i m i t e d number of chronically i l l i n the home by t h i s agency. Each of the Children's Aid Societies carry several cases i n which children have been placed i n a foster home because of the chronic i l l n e s s of a parent or of the children themselves. - H4 -On the whole, the casework services that are available to the chronically i l l are very dispersed, t e r r i b l y inadequate, and limited in scope and application. Any casework services that have been made available for the chronically i l l person have come from a variety of unco-ordinated sources with no defined course of action or planned purpose. Actually the chronically i l l have never been identified as individuals and marked out for special attention. The need of the chronically i l l for special services and special appreciation of their problems has yet to be acknowledged. The Vancouver General Hospital Social Service Department In 1937 the Social Service Department of the Vancouver General Hospital was set up as a separate department of the hospital with a budget of i t s own. Since that time the numbers of qualified social workers, have been steadily increased u n t i l the staff now consists of a director, a casework supervisor and six graduate workers. Five of the workers, including the casework supervisor, have their offices in the Outpatients' Department and the remainder have their offices in the main building of the hospital. The duties of these workers are many and varied so that only those that bring the worker in contact with the chronically i l l person w i l l be discussed. Four of the social workers divide their time between the cl i n i c s of the Outpatients' Department and the two or more wards i n the main hospital for which they are responsible. Until recently the practice has been for every new admission to the Outpatients' Department to be interviewed and, i f possible, every staff patient on the wards to be seen by the social worker. Non-staff patients are interviewed only on the - H5 -request of the patient himself through the head nurse of the ward. Unfortunately, many of the doctors at the ho s p i t a l regard the s o c i a l work-ers as l i t t l e more than placement o f f i c e r s t o whom they turn only when they cannot make t h e i r own arrangements f o r the discharge of a patient to a nursing home or to the patient's own home. Referrals by doctors of non-staff patients to s o c i a l workers f o r casework services are fewer than they should be. Constant interpretation of available services t o the doctors i s the only way i n which t h i s can be overcome. Some of the s o c i a l workers are not too happy about having t o see s t a f f patients on the assumption that because they are s t a f f patients they automatically have problems that people i n the Private Ward Pa v i l i o n or the Semi-Private P a v i l i o n never have. There are remarkably few requests from doctors f o r chronically i l l patients i n the Private Ward P a v i l i o n t o be seen by the s o c i a l workers. This seems t o indicate that the doctors do not know what services, other than arranging alternative accommodation fo r t h e i r patients, can be provided by the s o c i a l workers. Again, there seems to be a greater devotion of such time as the s o c i a l workers have to give casework services, to the younger.and i n a sense more appealing patient. The old chronically i l l person from the "skid road" or the "East End" f o r whom nobody thinks anything can be done comes off second best. I t must be emphasized, however, that the s o c i a l worker 1 s. period of contact with the patient i s very b r i e f — some-times only a few days, and the s o c i a l worker naturally l i k e s to concentrate on those cases f o r which the most can be done i n a short space of time and to help those who most r e a d i l y respond to her interest and services. The older chronically i l l person has probably had some - 146 -unpleasant memories" about. another kind of s o c i a l worker that he met during the depression i n the r e l i e f line-ups. He takes a l o t longer t o accept the services offered by the s o c i a l worker and does so with suspicion. These same workers must spend at least h a l f of t h e i r time i n the Outpatients' Department interviewing patients there and determining the e l i g i b i l i t y of new applicants. The s o c i a l workers must spend a considerable time approving applications f o r glasses and s u r g i c a l appliances. The worker has to determine the resources of the family and to decide whether they could pay f o r t h e i r own or not. I t appears that some of t h i s work could be done by a trained clerk. One worker stated that she had been so busy i n the Outpatients' Department that she had only been able to get up to her wards and v i s i t her patients once i n the previous week. A l l of t h i s points to one t h i n g ; that the s o c i a l worker has l i t t l e time t o do r e a l casework. When she does, she naturally concentrates on those patients that w i l l most readily accept her services and stand to gain most from her plans and arrangements. A great deal of interpretation i s s t i l l needed t o convince the doctors that the s o c i a l worker r has a function, especially with chronically i l l patients, other than to provide alternative accommodation.^ Another f a u l t of the present arrangement at the Vancouver General Hospital i s that because of lack of s u f f i c i e n t time, and too few ( l ) What casework services are provided are of an exceptionally high q u a l i t y but the s o c i a l worker's services are so divided and the demands upon her l i m i t e d time so great, that what she does do i s negated by what she can not do. - 147 -workers, very few cases are followed up outside of the hospital or Outpatients' Department. The caseworker i s handicapped when she sees only the patient and not the familyj she i s equally handicapped when she sees the patient only i n the hosp i t a l setting and not i n his natural environment. Most of the v i s i t i n g of patients i n the home i s done by student trainees. An adequate s o c i a l casework service f o r the chronically i l l should take i n the home and family of the chronically i l l person and not be l i m i t e d to the confines of the i n s t i t u t i o n a l setting. I f the patient i s referred to the City S o c i a l Service Department or to a private agency, such as the Family Welfare Bureau, there i s no follow up unless the patient i s reporting back to the Outpatients' Department. As the Soc i a l Work Department of the Vancouver General Hospital i s now operating, the chron-i c a l l y i l l person i n one of the acute wards or attending the Outpatients' Department i s not getting casework services adequate to his or her heeds due to the unnecessary demands upon the caseworker's time and services i n other administrative f i e l d s where casework s k i l l s are not a necessity. There i s one fu l l - t i m e medical s o c i a l worker from the Vancouver General Hospital responsible f o r the 14-0 patients i n Glen and Grandview Hospitals. A l l arrangements f o r transfers and admissions are arranged by t h i s one worker. When the doctor decides that a patient i n one of these i n s t i t u t i o n s can manage i n a boarding home or i n the patient's own home, i t i s the r e s p o n s i b i l i t y of the worker t o arrange t h i s placement. The s o c i a l worker has had to spend most of her time arranging placements rather than doing s o c i a l casework. - IAS -The" worker's services t o the patients i n the two i n s t i t u t i o n s are seriously c u r t a i l e d by a single geographic fact — that the hospital and the two nursing homes are about three miles apart. Because of t h i s , the worker i s only able to v i s i t . each i n s t i t u t i o n two afternoons a week. Everything that must be done, every interview that she must have with the i n d i v i d u a l patients, and every discussion that she has with the doctors and nursing s t a f f about the patients must be accomplished i n the two afternoons. The s o c i a l worker accompanies the doctor on ward rounds and with the time that she has l e f t , she must t r y t o squeeze i n her interviews with the i n d i v i d u a l patients. She i s very fortunate i f she can see ten patients f o r any length of time during one afternoon. There are so many patients and so l i t t l e time that the caseworker has very l i t t l e time t o devote to the i n d i v i d u a l problems of most of the patients. Most of her work has to deal with "problem cases", patients who w i l l not cooperate with the s t a f f , patients who are not s a t i s f i e d with the treatment that they receive, patients whose r e l a t i v e s demand spec i a l care or attention f o r themj patients who have become senile and d i f f i c u l t to handle i n the i n s t i t u t i o n , and patients who do not need nursing-home care any longer but refuse to go to a boarding homej the docile co-operative patient who may have many problems but does not l e t anyone know about them gets a minimum of attention from the caseworker. This separation of the two i n s t i t u t i o n s has another bad effect. The s o c i a l worker finds i t very d i f f i c u l t t o see the r e l a t i v e s and frien'ds of the patients because they are seldom at the i n s t i t u t i o n s at the same time. I f the s o c i a l worker wants to see a patient's r e l a t i v e s or family, she must arrange f o r them to v i s i t on one of the afternoons - H9 -that she i s i n the i n s t i t u t i o n s or have them come t o the h o s p i t a l to see her. At the same time that the medical s o c i a l worker i s working with a patient, another s o c i a l worker from the City S o c i a l Service Department may be seeing the same patient and seeing the same r e l a t i v e s to determine the patient's e l i g i b i l i t y f o r s o c i a l assistance. Most of the patients' r e l a t i v e s and f a m i l i e s are known to the medical s o c i a l worker only over the telephone. The remainder of the s o c i a l worker's time i s spent i n the main o f f i c e of the hospital s o c i a l service department doing the large amount of routine c l e r i c a l and s t a t i s t i c a l work f o r which she i s responsible. Every patient that i s considered e l i g i b l e f o r admission to the Marpole Infirmary must have a detailed s o c i a l history written up by t h i s worker. The f i n a n c i a l circumstances of every patient transferred to Glen or Grandview Hospitals or to Heather Street Annex from the h o s p i t a l must be f u l l y investigated and checked. I f the case i s e l i g i b l e f o r s o c i a l assistance, i t must be referred to the City S o c i a l Service Department and a summary of the hospital's contact written up f o r them. The h o s p i t a l i s fortunate i n having an extremely competent and conscientious worker doing t h i s job. She takes a great interest i n the patients and i s keenly aware of the inadequacies of the two i n s t i t u t i o n s which she v i s i t s . She does a great deal of extra work on behalf of the patients and t r i e s to do the most that she can f o r the patients despite the sheer physical l i m i t s . Experienced and knowledgeable as t h i s worker i s i n the economic problems of the chronic i n v a l i d and the emotional aspects of chronic i l l n e s s , the s i t u a t i o n makes i t impossible f o r her to give the best services where they are professionally needed, or where they would be of the best advantage t o the h o s p i t a l . - 150 -The s o c i a l worker providing casework services to the chronically i l l persons i n the two subsidiary hospitals i s doing an excellent job but the physical location of the hospitals prevent the chronically i l l from receiving the services that they need. The medical s o c i a l worker v i s i t i n g these i n s t i t u t i o n s i s not i n the best position to arrange for a d e f i n i t e treatment program f o r the chronically i l l person. She i s under constant pressure by the h o s p i t a l authorities to discharge patients from the two i n s t i t u t i o n s as fast as possible so as t o allow f o r more transfers of chronic patients from acute beds i n the Vancouver General Hospital. Almost as soon as any patient i n one of the two subsidiary hospitals shows any sign of improvement, he or she i s discharged t o make way f o r another case i n more urgent need of the bed. This has an unfortunate repercussion since the patients i n the two i n s t i t u t i o n s , as w e l l as the doctors i n the h o s p i t a l , come to consider (1) that the s o c i a l worker's only purpose i s as a placement o f f i c e r The problem of providing adequate s o c i a l casework services f o r the chronically i l l i n the Vancouver General Hospital i s not confined to that i n s t i t u t i o n alone. The same s i t u a t i o n exists i n every general h o s p i t a l i n Canada and the United States. Dr. Boas made a statement about the s i t u a t i o n i n New York that i s a l l too readily applicable to Vancouver: "Social workers i n hospitals are engaged i n admitting patients, i n determining how much they should pay f o r t h e i r hospital care, acting as c l i n i c clerks or as administrators. They give r e l i e f t o f a m i l i e s , one of whose members, i s i n h o s p i t a l ; they shuttle patients from hospital to convalescent home, or to a custodial i n s t i t u t i o n f o r the chronic s i c k , but ( l ) The writer has known several patients to break i n t o tears when he approached them to speak to them because they were a f r a i d that they would be moved. "Social worker" merely means the "placement o f f i c e r " to them. With t h i s unfortunate concept i n the patient's mind the handicaps f o r casework are obvious. - 151 -rarely do they work out i n cooperation with the physician a w e l l thought out plan f o r the r e h a b i l i t a t i o n of the patient, with t h e i r employment of t h e i r knowledge of the s o c i a l , economic and emotional factors that condition sickness. "(1) This s i t u a t i o n w i l l not change unless h o s p i t a l administrators and doctors r e a l i z e that the s o c i a l worker has a great deal to offer and can make a great number of resources available i n the drawing up of a plan of treatment f o r the i n d i v i d u a l chronically i l l person. At present, due to the extreme shortage of beds, a h o s p i t a l i s much too commonly a huge machine into which the patients enter, lose t h e i r i d e n t i t i e s f o r a while, receive treatment almost on a mass production basis, and, after they are discharged (providing they have paid t h e i r b i l l ) cease to be any concern of the hospital. In such i n s t i t u t i o n s the s o c i a l worker i s regarded as just another part of the machinery to hasten the discharge of the patient. An interpretation program i s needed i f doctors themselves are not to act, u n w i l l i n g l y or otherwise, as i f they are the only professional persons who can solve the patients 1 problems, and to prescribe treatment on the basis that chronic disease i s s o l e l y a medical problem. In an i d e a l system the s o c i a l worker would be called i n on a consultative basis on every case that was diagnosed as a chronic ailment and the physician would c a l l upon a s o c i a l worker, without hesit a t i o n or need of interpretation, f o r environmental and family circumstance informat-ion which might have some bearing on the patient's condition. From the time that that patient was diagnosed as having a chronic complaint, the s o c i a l worker and doctor could and should work together toward the formulation of a plan of treatment and care that would serve the best ( l ) Boas, Ernst P., M.D., The Unseen Plague, Chronic Disease. J . J . August i n Inc., 194-0, Page 67. - 152 -interests of the patient rather than be the most convenient disposition of the case for the doctor, social worker and institution concerned. The needs of the patient must always come first despite the apparent limitation of community services available for the care of that patient. The social' worker should be employed as the skilled technician that she i s , not as a clerk or a receptionist. To make such a program possible there must be at least one medical social worker to every ten doctors, not one to every fift y as there is now. Several prominent specialists in hospital administration, after concluding a comprehensive survey of hospitals in the United States, recommended the employment . of medical social workers for these purposes: A constant educational program must be carried on to make every doctor aware of the fact that social casework services can help him in his treatment of that patient's illness. It is the primary function of the medical social worker to provide the physician with adequate information concerning the patient's socio-economic status and environment and to interpret to the patient such terms of the physician 1s advice and instructions as may be required and helpful to the alleviation of his condition.' 1' A Newly Instituted Social Work Service The Social Service Department of St. Paul's Hospital has only been in operation for a few months and i t is of course intended to apply to others besides the chronically i l l patients occupying acute beds in this hospital. But there is already evidence that this new social service department has been able to profit from the Vancouver General Hospital's experience. There has been no attempt to do a sudden and spectacular (l) The Commissiomon Hospital Care, Hospital Care in the United States. The Commonwealth Fund, New York, 194-7, Page 108. Recommendation No. 94-• - 153 -job or convert doctors overnight t o the view that a s o c i a l service department can solve a l l of t h e i r problems. A very d e f i n i t e p o l i c y of never contacting a patient without the consent of the doctor or unless at the request of the patient or the patients' r e l a t i v e s has-been worked out with excellent success. Because St. Paul's Hospital i s a private h o s p i t a l which has only twenty-five s t a f f beds, i t does not have the same problems as the Vancouver General Hospital i n finding alternative accommodation for large numbers of indigent chronically i l l persons. The number of cases that have needed the services of the s o c i a l worker has been smallj and some excellent, intensive work has been done. There i s not so much pressure upon the worker to have the patients moved out as quickly as possible. The worker and the doctor have time to work out with the patient a plan of treatment and care that best su i t s the needs of the patient. Because of the small scale of t h i s department's operations and r e s p o n s i b i l i t i e s , i t s e f f o r t s w i l l not influence the t o t a l program f o r Vancouver to any great extent but i t might w e l l become a model of what the function of a hospital s o c i a l service department should be or could be. The Need For a Trained S o c i a l Yiforker i n the P r o v i n c i a l Infirmaries The patients i n the Marpole Infirmary or one of i t s subsidiaries have no casework services available to them at the present time except the services that are provided by the Superintendent, who i s a nurse not a s o c i a l worker. I t has been assumed that a patient ceases to need the services of a s o c i a l worker upon entry into one of the i n s t i t u t i o n s . By some magic process, admission to the Infirmary i s supposed to solve a l l of his problems and to cure a l l of his troubles. In t a l k i n g t o many of the - 1 5 4 -patients t h i s was found to be a f a l l a c y . The Superintendent and her s t a f f are very busy people, and much as they would l i k e t o , i t i s impossible f o r them to become aware of d i f f i c u l t i e s encountered by i n d i v i d u a l patients i n adjusting to i n s t i t u t -i o n a l l i f e and disturbed family relationships and incidents, both inside and outside of the Infirmary, that are emotionally upsetting to the patient. The s o c i a l h i s t o r i e s that accompany the patients to the i n s t i t u -t i o n are very meager and uninformative. I t i s only by having a s o c i a l worker at the Infirmary to do an interpretation job t o the workers i n the d i f f e r e n t municipalities that the Infirmary s t a f f and the Infirmary doctor can f u l l y understand the background of the patients physical condition. & s o c i a l worker i s needed to interpret the patient's background to the doctor but most important of a l l the s o c i a l worker i s needed t o interpret the services and f a c i l i t i e s of the i n s t i t u t i o n s to the workers who are t r y i n g to get t h e i r c l i e n t s admitted to the Infirmary. I t i s quite amazing some of the queer ideas that s o c i a l workers i n the various (1) s o c i a l agencies throughout the province have about the Infirmary. The P r o v i n c i a l Government has been slow i n recognizing the need for a s o c i a l caseworker i n the Infirmaries and i t i s to be hoped that i t w i l l soon see i t s way clear to provide such services f o r the more than 230 patients i n the three i n s t i t u t i o n s . An excellent treatment program for the chronically i l l has been developed at the Infirmaries but s o c i a l casework services are needed to round out the program. ( l ) Harvey, Isobelj Study of Chronic Diseases i n B r i t i s h Columbia. A Report Prepared For the Minister of Health and Welfare, Province of B r i t i s h Columbia, March 27, 1946(typescript) - 155 -Casework Services For Patients In A Chronic Hospital In the not-too-distant future i t i s hoped that Vancouver w i l l have a chronic hospital with a capacity of at least f i v e hundred beds. I f such an i n s t i t u t i o n does come into existence, i t i s e s s e n t i a l that medical s o c i a l workers should participate i n the planning and organization of such an i n s t i t u t i o n . In a chronic h o s p i t a l i t i s t o be desired that the s o c i a l service department w i l l not be relegated to the position of an a u x i l i a r y service but i t w i l l be accepted by the doctors and hospital administrative s t a f f as a separate treatment organ of the h o s p i t a l , helping the other hospital services to function at maximum e f f i c i e n c y . A r a t i o of one s o c i a l worker f o r every f i v e hundred admissionsto the chronic disease hospital i s considered to be the extreme minimum s o c i a l (1) work st a f f that should be available i n a chronic hospital. The duties of a s o c i a l worker i n a chronic h o s p i t a l can be b r i e f l y summarized i n t h i s way: ( l ) to interview every patient when • admitted or shortly afterward, and, with the aid of the patient, h is re l a t i v e s", and other agencies to prepare a complete s o c i a l history f o r the doctor, (2) to use t h i s information t o interpret the patients environmental and family background to the doctor, (3) to make the doctor aware of any emotional factors that have, or are l i k e l y to have, some influence on the patient's condition, (4) to keep i n close touch with the patient's family and fri e n d s , (5) to arrange f o r nursing-home or boarding-home accommodation when the patient no longer needs to remain i n the chronic hospital for treatment, (6) to provide casework services ( l ) J a r r e t t , Mary C , The Care of the Chronically 111, reprinted from the Hospital Survey of New York, New York, United Hospital Fund, Vol. I I , Chapter XI, Page 686. - 156 -f o r the patient and the patient's family after his discharge from hospital, and (7) to mobilize and use outside community resources f o r the provision of the best possible care f o r each i n d i v i d u a l chronically i l l patient. Inter-Agency Referrals And Co-operation In no other sphere, can the s o c i a l worker prove his worth more than i n the u t i l i z a t i o n of the resources and services of other s o c i a l agencies i n the community. A good medical s o c i a l service department could not and should not attempt to meet every need of the chronically i l l but i t should know where i t could refer the patient f o r these services. A medical s o c i a l service department should not attempt to be a.Children's Aid, a Family Welfare Bureau and a Public Welfare Agency, and a Hospital S o c i a l Service Department a l l r o l l e d i nto one. I t should provide complementary services which are available when others are lacking. S o c i a l (services f o r the chronically i l l should not be the exclusive preserve of the medical s o c i a l workers serving a chronic i n s t i t u t i o n but should represent the combined e f f o r t s of every s o c i a l agency i n the community. The impression should never be gained that i t i s only the lower income groups, that form such a large part of many agencies' c l i e n t e l e , that are e l i g i b l e f o r casework services. Social casework services of the community should be available t o every chronically i l l person as a right that accompanies that" same person's right t o the best medical and treatment services that are available. I t w i l l take a great deal of interpretation and education t o make the chronically i l l aware of and desirous of the services of the caseworker and to encourage that same patient to seek help and guidance from a .social worker as readily as he - 157 -or she would go to a doctor. Unfortunately the defeatest attitude - what could a s o c i a l worker do f o r me? - i s a l l too prevalent and most people never come near a s o c i a l agency i f they can avoid i t . I t i s only by the most judicious r e f e r r a l and follow-up of every case that a continuous casework relationship can be provided f o r the chronically i l l . I t does not do the person who has been chronically i l l f o r twenty years much good to only, see the s o c i a l caseworker when he i s admitted to ho s p i t a l , when he has to apply f o r s o c i a l assistance or when he needs to be admitted to a custodial i n s t i t u t i o n . S o c i a l casework t o these individuals should be a continuing service, not just something that he i s provided with at infrequent i n t e r v a l s . The chronically i l l person needs to be made aware that the s o c i a l caseworker i s always available and i s interested i n his progress and circumstances even when he does not need medical or i n s t i t u t i o n a l care. I t i s not enough t o refer a case t o another agency and then, assuming that that agency i s handling i t , forget the case u n t i l i t appears again back at the o r i g i n a l referring agency. Case a f t e r case that was examined showed t h i s lack of continuation of service. One s o c i a l worker might work out a plan or course of action to better the circumstances of the patient and then ^something intervened - the patient was admitted to hospital, the patient moved to another d i s t r i c t or the caseworker was transferred. Probably the next worker did not take the same interest i n the case and either the patient stopped coming to the agency f o r help or the. case was closed or dismissed by the worker as one for which there was nothing that could be done. Coupled with a complete lack of r e a l i z a t i o n of just what the implications of t h i s piecemeal casework •service were to - 158 -the chronically i l l person was the conveying of the idea to the c l i e n t that t h i s was just one more person who considered h i s condition hopeless, incurable and impossible to a l l e v i a t e . The medical s o c i a l workers i n the hospitals cannot v i s i t every chronically i l l person that i s discharged from the h o s p i t a l or t o r e f e r every case that they consider needs continuing casework services to another agency. At the same time, the agencies to whom the cases are referred should not be made t o f e e l that every case that they receive from the hospital s o c i a l service department i s one f o r which the hospital thinks i t can do nothing or a case which the ho s p i t a l s o c i a l workers have not the time to work with. A clear-cut policy has to be worked out to f a c i l i t a t e proper inter-agency r e f e r r a l s which are to the best advant-age of the.patient, rather than to the best advantage of the agencies concerned. In other words, a chronically i l l person i n need of casework services should not be referred to a s o c i a l agency merely because the s o c i a l worker i s unable or incapable of doing anything more f o r that patient, but because that agency i s best able and q u a l i f i e d t o meet that patient's needs. One s o c i a l worker i n one s o c i a l agency can do l i t t l e to help solve the problem of what can be done f o r the chronically i l l , but that one s o c i a l worker, working i n collaboration with every other s o c i a l worker and agency i n the c i t y , can do a great deal toward making the l i f e of the i n d i v i d u a l chronic i n v a l i d more l i v a b l e . The Mobilization of Community Resources The s o c i a l worker can be invaluable' i n the organization and implementation of a community wide program for. the diagnosis, treatment - 159 -treatment and proper care of the chronically i l l . Only the s o c i a l worker i s able t o make community resources and community services available to the doctor and i n s t i t u t i o n as part of the patient's treatment process. In Vancouver the plight of the chronically i l l would not be nearly so hopeless as i t i s now, i f the s o c i a l workers coming i n contact with these people knew what resources there are available i n the community that are never u t i l i z e d or, i f they are u t i l i z e d , i n the wrong manner. The average c i t i z e n i s completely, unaware of the immensity of the problem of caring f o r the chronically i l l . The same people are unaware of the t o t a l inadequacy of the accommodation and services that are available fo r the chronically i l l . A good education campaign needs to be carried out t o point out to the tax payer how much he i s already spending f o r the care of the chronically i l l and how far short of the minimum requirements existing services f a l l . There are thousands of c i t i z e n s who are interested i n providing both money and services toward the a l l e v i a t i o n of suffering of other people. A few examples can be cited f o r i l l u s t r a t i o n . The B.C". Cancer Society finds l i t t l e d i f f i c u l t y i n getting the public to contribute toward the extension of t h e i r services. The B.C. Tuberculosis Society receives contributions from nearly every home i n the province. The recent organization of public support f o r the new Canadian A r t h r i t i s and Rheumatism Society i s an outstanding example of community organization to benefit one group of the chronically i l l . Again, the Women's Aux i l i a r y of the Marpole Infirmary has done a wonderful piece of work i n the provision of extra services and f a c i l i t i e s i n that i n s t i t u t i o n , - 160 -without i n any way in t e r f e r i n g with the p r o v i n c i a l government's r e s p o n s i b i l i t i e s . At present, several women's organizations are becoming interested i n the plight of the patients i n Glen and Grandview Hospitals. There has even been an offer t o form a women's club which w i l l have as i t s main objective the provision of extras and comforts for the patients i n these i n s t i t u t i o n s . A l l of these examples show that the public i s not ind i f f e r e n t to the needs of the chronically i l l . Where the s o c i a l worker and the Community Chest and Council come into the picture i s t o d i r e c t these efforts i n the right d i r e c t i o n and to u t i l i z e them to t h e i r f u l l extent. I t i s d i f f i c u l t to believe that the public as a whole are aware of the fact that there i s absolutely no accommodation f o r the chronically i l l c h i l d i n exi s t i n g i n s t i t u t i o n s i n Vancouver. The public has been very generous i n i t s support of the Children's Hospital and i f itwas made aware of the need of a si m i l a r chronic or custodial i n s t i t u t i o n there i s every p o s s i b i l i t y that one would be b u i l t within a short time. I f every s o c i a l worker and every s o c i a l agency, along with the Community Chest and Council, were to publicise the need of such an i n s t i t u t i o n , and to compile s t a t i s t i c s and case studies proving that need, then i t would not be long before something was done. . A great deal of work remains to be done i n other directions also. The S o c i a l Assistance Act of B.C. lays down no maximum l i m i t t o the amount of s o c i a l assistance that s h a l l be paid t o a person i n need. Eocal regulations decree that .a single man s h a l l receive a maximum of $35 a month s o c i a l assistance i f he i s l i v i n g i n his home. There i s a great job of community organization to be done to convince the tax payer that - 161 -i t i s i n h i s best interest and cheaper i n the end to provide s o c i a l assistance to those that need i t on the basis of need, not just up t o the lowest minimum under which that i n d i v i d u a l can e x i s t . U n t i l s o c i a l workers themselves are aware of the deficiencies and stronger i n numbers, they may be too enmeshed i n day-to-day administration to take the lead i n seeking changes and revisions. The interest of the public and s o c i a l agencies i s there, but i t needs to be awakened and mobilized. F i n a n c i a l support f o r any project only follows the expression of t h i s public i n t e r e s t . - 162 -Appendix A Shaughnessy M i l i t a r y Hospital This m i l i t a r y hospital was not included i n the main study but t h i s b r i e f description of f a c i l i t i e s available there i s necessary f o r the sake of completeness and as a- reminder that there are a number of ex-service men i n the chronic i l l n e s s category, even though t h e i r d i s -a b i l i t i e s are not d i r e c t l y w a r - i n f l i c t e d . Shaughnessy M i l i t a r y Hospital i s maintained e n t i r e l y by federal funds and cares f o r veterans from a l l parts of the province. Since the opening of the m i l i t a r y h o s p i t a l over twenty years ago, i t has been found necessary f o r the federal government to make some provision for the care of the chronically i l l veteran who i s suffering from incapacitating d i s a b i l i t e s other than those that were w a r - i n f l i c t e d . A form of s o c i a l assistance, known as the War Veteran's Allowance has been made available f o r the older chronically i l l war veteran who i s no longer able to work or f i n d employment. This group of veterans i s e n t i t l e d t o free medical and hos p i t a l care, but t h e i r wives and dependents are not. At the Department of Veteran's A f f a i r s o f f i c e s i n Vancouver, a regular outpatients 1 department i s operated f o r those patients that need only medicines and general pr a c t i t i o n e r care. For those requiring active h o s p i t a l care there are approximately 140 beds f o r t h e i r care i n Shaughnessy M i l i t a r y Hospital. Most of the chronically i l l patients are concentrated i n four main wards. Patients occupying these wards were - 163 -suffering from chronic i l l n e s s e s such as a r t h r i t i s , a r t e r i o - s c l e r o s i s , Parkinson's disease and other true chronic diseases and hot because of war - i n f l i c t e d i n j u r i e s . When one of these chronic patients ceases t o require- active medical treatment he i s transferred to either Hycroft or the George Derby Health and Occupational Centre. The equivalent of nursing-home care i s provided i n these i n s t i t u t i o n s . Hycroft has approximately 110 beds available f o r chronically i l l patients. TJie Derby Convalescent Centre has approximately the same number of beds available f o r both convalescents and chronically i l l veterans. A v i s i t was made to the four wards which housed 106 of the 139 patients i n the chronic categories. Medical care i s provided by a c i t y general prac t i t i o n e r who specializes i n g e r i a t r i c s . A l l of the patients seen appeared t o be over the age of s i x t y - f i v e . As i n a l l veterans' hospitals, the patients were i n receipt of every medical necessity that they could use; indeed, some of the equipment that was available f o r the care of the chronically i l l i s more expensive and extensive than that available i n many acute hospitals. Extensive use i s made of occupational therapy and physiotherapy and most inter e s t i n g of a l l , the services of the hospital psychiatrist are used extensively. I t was quite remarkable to see nearly every patient engaged some cr a f t or hobby and many of the patients earn considerable money i n t h i s way. The wards are operated on a very informal basis and from the conversation of the doctors i t was gathered that some of the patients do l i t t l e more than sleep there. Only about half of the patients were on the wards when the doctor made his ward rounds. - 164 -The majority of the patients were completely destitute and the only income that they had, other than t h e i r small comforts allowance, was from the sale of the a r t i c l e s that they made. Shaughnessy M i l i t a r y Hospital i s an excellent example of what can be done for the chronically i l l when there i s no l i m i t t o the money that can be spent on them and no l i m i t t o the f a c i l i t i e s that are made available to them. Expanding Demands Upon the City S o c i a l Service Department The three organizations described i n t h i s section are p r o v i n c i a l i n scope and do not l i m i t t h e i r services to the c i t y of Vancouver. They have not been included i n the main study because of the spe c i a l nature of the services they provided. Within the past few years Vancouver has become the main diagnos-t i c and treatment centre i n several f i e l d s of medicine f o r the whole Province of B r i t i s h Columbia. The expansion of f a c i l i t i e s at the B.C. Cancer I n s t i t u t e , the recent opening of the Rehabilitation Centre f o r the Physically Handicapped, and the opening of the new o f f i c e of the Canadian A r t h r i t i s and Rheumatism Society (B.C. Division) have brought hundreds of patients suffering from these diseases t o the c i t y for treatment and diagnosis. The c i t y ' s overtaxed and i n s u f f i c i e n t boarding-home and nursing-home f a c i l i t i e s have been put under s t i l l more pressure to provide accommodation f o r these people. The B.C. Cancer I n s t i t u t e s ' c l i n i c , adjacent to the Vancouver General Hospital, i s the only place i n the province where the treatment - 165 -and diagnosis of cancer i s carried out to any great extent. The Rehabilitation Centre for the Physically Handicapped i s the only centre of i t s kind i n B r i t i s h Columbia and i n Western Canada. Post-polio cases and paraplegics are trained here to become s e l f - s u f f i c i e n t and useful c i t i z e n s . The B.C. A r t h r i t i s and Rheumatism society has recently received a large grant from the p r o v i n c i a l government to provide special treatment services f o r the a r t h r i t i c . Already several physiotherapists are sent out to v i s i t the chronically i l l a r t h r i t i c i n the home. Several acute ho s p i t a l beds have been made available f o r the treatment of a r t h r i t i s . A complete research and treatment centre i s planned f o r the future. The Cancer Society S o c i a l Service Section has worked out an agreement with the City Social Service Department under which that Department has agreed to administer any out-of-town cases, but w i l l assume no f i n a n c i a l r e s p o n s i b i l i t y or obligation to provide placement f o r these persons i n boarding homes or nursing homes. I f the Cancer Society can f i n d boarding-home or nursing-home beds on t h e i r own without using any of the beds used by the City S o c i a l Service Department, the. c i t y has no objection to these out-of-town patients coming into Vancouver. In January, 194-9, ten boarding-home placements and s i x nursing-home placements were made i n Vancouver by the s o c i a l worker at the Cancer C l i n i c . Patients that are "Vancouver r e s p o n s i b i l i t i e s " are referred d i r e c t l y t o the Medical Section of the City S o c i a l Service Department f o r placement through the normal channels. At the present time no agreement between the p r o v i n c i a l and municipal authorities has been drawn up to determine who s h a l l pay f o r the treatment of patients at the Rehabilitation Centre. Their present - 166 -rates are $180 a month for accommodation with an additional charge of §60 a month f o r exercises. The City Social Service Department i s very reluctant to agree to pay for these patients' care as they do not wish to establish a precedent. I f they should agree t o pay f o r the small number of Vancouver cases receiving care there, i t would presumably be open to the people suffering from heart disease or a r t h r i t i s to ask the same consideration. E f f o r t s are now being made to interest the p r o v i n c i a l government i n paying the f u l l cost of these patients' care with the City S o c i a l Service administering the cases.' I f a research and treatment centre i s b u i l t i n Vancouver by the Canadian A r t h r i t i s and Rheumatism Society, additional boarding-home and nursing-home f a c i l i t i e s w i l l again have to be provided. The case studies made by the Society show that hundreds of a r t h r i t i c persons are l i v i n g i n homes, rooming houses and hotels where they receive very l i t t l e care or attention. Many of these cases are i n urgent need of i n s t i t u t i o n a l • care. I t i s impossible to estimate how many thousands of a r t h r i t i c s could have been prevented from becoming t e r r i b l y deformed and crippled by treatment i n a chronic ho s p i t a l . Soon there w i l l be special centres f o r treating heart disease, as there i s i n the United States!. As Vancouver expands, so w i l l the number of treatment and diagnostic centres. The opening of the medical school at the University w i l l give impetus to t h i s program. - 167 -Appendix B - 168 -Table J Period of Hospitalization of Chronic Patients Marpole Infirmary, Vancouver, February 1, 194-9. Period No. Within present year 4 One year 19 Two years 13 Three years 15 Four years 10 Period 5-10 years 10 - 15 years Over 20 years T o t a l No. 35 24-6 126 / Computed from year of admission on record cards. - 169 -Table K Types of Patients i n Marpole Infirmary Vancouver:- February 1, 1949. C l a s s i f i c a t i o n Patients No. Per Cent Infectious and p a r a s i t i c diseases including the r e s u l t s of encephalitis, V.D., etc. 14 11.1 Diseases of metabolism and deficiency 3 2.4 Tumors-benign and malignant 2 1.5 Congenital malformations 1 .8 Injuries - fractures etc. 3 2.4 Diseases of the cir c u l a t o r y system 13 10.2 Diseases of the blood 3 2.4 Diseases of the nervous system Parkinsonism paraplegia, hemiplegia, etc. 40 31.6 Diseases of the bones, j o i n t s , muscles, etc. a r t h r i t i s , osteomyelitis, etc. 28 14.1 Diseases and i n j u r i e s of the eye, ear, nose, and throat 3 2.4 Diseases of the genito-urinary system 3 2.4 Degenerative changes associated with old age. 11 8.8 Total 126 100.00 - 170 -Table L Age Distribution of Patients in Glen, Grandview and Heather Street Annex Hospitals Total Age Glen Grandview H.S.A. No. Per cent Under 40 6 0 3 9 4.6 AO - A9 A 2 3 9 4.6 50 - 59 8 9 2 19 9.9 60 - 69 12 8 11 31 15.9 70-79 2A 20 21 65 33.3 80-89 17 18 U 49 25.1 90 and over 6 2 0 8 4-0 Unknown 2 1 2 5 2.6 Total 79 60 56 195 100.0 - 171 -Table M Types of Patients i n Glen, Grandview and Heather Street Annex Hospitals C l a s s i f i c a t i o n Glen Grandview H.S.A. Total % Infectious & p a r a s i t i c disease: results including V.D., encephalitis, etc. 5 0 A 9 4.6 Diseases of metabolism & deficiency 5 1 1 7 3.6 Inj u r i e s , fractures etc. 16 7 2 25 12.9 Diseases of the circulatory system 13 18 10 41 21.0 Tumors - benign & malignant 11 2 A 17 8.9 Diseases of the nervous system 11 10 12 . 33 16.9 Diseases of the bones, joints,muscles 13 4 3 20 10.2 Diseases of the gastro-intestinal t r a c t 1 3 1 5 2.5 Diseases of the genito-urinary system 1 3 2 6 3.1 Degenerative diseases associated with old age ( s e n i l i t y ) 1 9 14 24 12.3 Diseases of the skin 2 2 0 A 2.0 Undefined and unclassified 0 1 3 A 2.0 To t a l 79 60 56 195 100.0 - 172 -Appendix C Books and Surveys 1. Boas, Ernst P. M.D., The Care of the Chronically 111. (Reprinted from the Proceedings of the National Conference of Social V'/ork) New York, Columbia University Press 1939. 2. Boas, Ernst P. M.D., The Unseen Plague. Chronic Disease. New York, J. J . Augustin Inc., 194-0. 3. Commission on Hospital Care, Hospital Care i n the United States. New York, The Commonwealth Fund, 194-7. 4-. Chatwin, Mary C , Some Soc i a l Factors Contributing t o the Prolonged  Hospitalization of Chronic Disease Patients i n a General  Hospital. Master's Thesis, Department of Soc i a l Work, U.B.C. October, 194-7. 5. C i t y of Vancouver, Annual Report of the So c i a l Services Committee. January 5> 1949 (mimeographed). 6. Committee on Chronic I l l n e s s , Report f o r Two Years. May. 1937 to May. 1939. Welfare Council of New York City 1939. 7. The Canadian Medical Procurement and Assignment Board, The National Health Survey Report. Ottawa King's Printer 1945. 8. Dominion Bureau of S t a t i s t i c s , I n s t i t u t i o n a l S t a t i s t i c s Branch, Annual Report of Hospitals i n Canada 1946. 9. Dominion Bureau of S t a t i s t i c s , The Canada Year Book 1947. Ottawa, King's Printer. 10. Elledge, Caroline H., The Rehabilitation of the Patient. S o c i a l Casework i n Medicine. Montreal, J . B. Lippencott Co., 1948. 11. Harvey, Isobel, A Study of Chronic Diseases i n B r i t i s h Columbia. A Report Prepared f o r the Minister of Health and Welfare, Province of B r i t i s h Columbia, March, 1946. (typescript).. 12. I n s t i t u t i o n a l Care for the Chronically 111 of Class "C" i n New York. Welfare Council of New York, November, 1939, The Report of the Joint Committee on I n s t i t u t i o n a l Care of the Chronically 111 of Committee on Chronic I l l n e s s and Section on the Care of the aged. - 173 -13. J a r r e t t , Mary C. Chronic I l l n e s s i n Mew York C i t y . Vols. 1 and 2, Welfare Council of New York C i t y , New York, Columbia University Press, 1933. 14-. J a r r e t t , Mary C , Care of the Chronically 111 of Cleveland and Cuyahaga County, Cleveland, The Benjamin Rose I n s t i t u t e , 1944-. 15. J a r r e t t , Mary C , Housekeeping Service For Home Care of Chronic Patients, Report of a W.P.A. Project i n New York Cit y , October, 1935 to July, 1938. New York 1938. 16. J a r r e t t , Mary C , The Care of the Chronically 111, Reprinted from the Hospital Survey for New York. Vol. I I , Chapter XI, United Hospital Fund of New York, 1937. 17. J a r r e t t , Mary C , A Survey of the Care of the Aged of Rochester. New York; Conducted f o r the Survey Committee of the Rochester Community Chest Inc. A p r i l 1940. 18. Jensen, Frade M.D., Weiskotten H., M.D., and Thomas, Margaret A., Medical Care of the Discharged Hospital Patient. New York, 1944-19. Marsh, Edith L., Nursing Care i n Chronic Diseases.Philadelphia. J . B. Lippencott Co., Philadelphia 1946. 20. Public Welfare i n the State of Washington. October 1946 to September 1948, State Department of Public Welfare, Olympia, Washington, 1949. 21. Province of B r i t i s h Columbia, Report on Hospital S t a t i s t i c s and Administration of "the Hospital Act" f o r the year ending Dec. 31. 1947y Department of the P r o v i n c i a l Secretary, V i c t o r i a B.C. King's Pr i n t e r . 22. Province of B r i t i s h Columbia, S t a t i s t i c s and Administration of the "Welfare I n s t i t u t i o n s Licensing Act" f o r the year ending December 31, 1947, Department of the P r o v i n c i a l Secretary, V i c t o r i a , B.C., King's P r i n t e r . 23. Province of Saskatchewan, Care of the Chronically 111 and Aged. Proposed Recommendations, Inter-departmental Co-ordinating Committee, Province of Saskatchewan, September, 1948. 24. Resources Manual, Section I I , S o c i a l Assistance Branch, Department of the Pr o v i n c i a l Secretary, December, 1945. 25. Report of the Vancouver Hospital Survey Commission upon the Hospital Situation of Greater Vancouver. Conducted by Drs. A.K. Haywood, M.T. MacEachern, W. H. Walsh under the auspices of the C i t y Council, The Hospital Board of Directors and the P r o v i n c i a l Government of B.C., Submitted A p r i l 25., 1930. - 174 -26. Special Committee of Montreal Social Workers (Mrs. M.A. Lanthier, chairman) The Care of the Chronically 111 i n Montreal, Metropolitan L i f e Insurance Company, Canadian Head Of f i c e , Ottawa, 1941. 27. Standards of Medical Care i n I n s t i t u t i o n s Providing Custodial Care for the Chronically 111. Welfare Council of New York Cit y , March 31, 1938. The Report of the Joint Committee on I n s t i t u t i o n a l Care of the Chronically 111 of Section of the Aged and Committee on Chronic I l l n e s s . 28. A Vancouver Hospital Clearance Plan, A Report by Dr-. J . Moscovich af t e r one year's operation of the plan, issued through the S o c i a l Service Department, City of Vancouver. (Mimeographed) 29. Vic t o r i a n Order of Nurses (Vancouver Branch) Annual Reports for the Years 1947. 1948. (Mimeographed) 30.. Welfare i n Alberta . A Report of a Study Undertaken by the I.O.D.E. Alberta P r o v i n c i a l Chapter, 1947. Periodicals 31. Bluestone, E.M., "The Chronic Has a Claim to Care and Cure i n the Acute General Hospital", The Modern Hospital. V o l . 6 3 , No. 3, September, 1944. 32. Bluestone, E.M., "The Emergencies of the Chronic Patient" ' Journal of the American Medical Association. Vol. 123, No. 6, October 9, 1943. 33. Boas, Ernst P., M.D., "The Care of the Aged Sick", S o c i a l Service Review. V o l . 4, June, 1930. 34- Boas, Ernst P., M.D., "The Contribution of Medical S o c i a l Work to Medical Care", S o c i a l Service Review. Vol. 13, December 1939. 35. Conant, Richard K., "Chronic Disease and the Public Welfare"., The Commonwealth, Quarterly B u l l e t i n of the Massachussets Department of Public Health, V o l . 16, No. 4., 0ci>-Nov.-Dec. 1929. 36. Durand, John D., "The Trend Toward an Older Population", The Annals of the American Academy of P o l i t i c a l and S o c i a l Science. Vol. 237, January, 1945-37. Dublin, Louis and Lotka, A l f r e d , "Trends i n Longevity", Annals of the American Academy of P o l i t i c a l and Social Service. Vol. 237, January, 1945. - 175 -38. Dowries, Jean, "Illness in the Chronic Disease Family", American Journal of Public Health and the Nation's Health. Vol. 32, No. 6, June 1942. 39. Evens, Louis, "Providing Institutional Care for Recipients of Public Assistance", Public Welfare? Vol. 3, No. 11, November, 194-5. 4.0. Eaves, Lucille, "When Chronic Illness Hits the Wage Earner", The Survey. Vol. 62, No. 8, July 15, 1929. 4.1. Eaves, Lucille, "Children Who are Chronically Sick", The Survey. Vol. 62, No. 4, May 15, 1929. 42. Field, Minna, "Medical Social Work for the Aged", Bulletin'.. The American Association of Medical Social Workers , Vol. 22, No. 1, February 1949. 43. Galpern, Marie and Roncoli, Fannie, Boarding Homes for the Aged in New York City, Public Welfare. Vol. 4, No. 2, February, 1946. 44« Hilliard, Raymond M., "The Development of County Homes for Care of the Chronically 111", Public Welfare. Vol. 3, No. 12, December 1945. 45. "How Much Hospitalization is Really Necessary for the Chronically 111", The Canadian Hospital. Vol. 23, No. 1, January, 1946. 46. Jarrett, Mary C, "Combatting Chronic Illness", Public Welfare. Vol. 3, No. 6, June, 1945. 47. Keith, George M., "Disability Assistance", Public Welfare. Vol. 4, No. 7, July, 1946. 48. Kietschmer, Herman, "The Problem of the Chronically 111 Patient", The Journal of the-American Medical Association. Vol. 127, No. 16, April 21, 1945. 49. Lillauer, David, M.D., "Care of the Long Term Patient Requires Careful Planning", The Modern Hospital. Vol. 69, No. 3, September, 1947. 50. Levine, Harry A., "Recreation and Services for the Aged", Bulletin. The American Association of Medical Social Workers. Vol. 22, No. 1, February, 1 9 4 9 . 51. "Medical Science and the Longer Life! 1, Science. Vol. 107, No. 2778, March 26, 1948. 52. Nicholson, Edna, "To What Extent Can We Prevent and Control Chronic Diseases", The Canadian Hospital. Vol. 25, No. 5, May, 1948. - 176 -53. Perret, F. St. J . , The Problems of Chronic Disease, Psychosomatic  Medicine, V o l . 7, January, 194-5-54.. "Planning f o r the Chronically 111", Public Welfare. V o l . 5, No. 10, October 1947. The work of a Joint Committee composed of representatives of the American Hospital Association, American Medical Association, American Public Health Association and the American Public Welfare Association. 55* Potter, E l l e n C , M.D., "Inspection and Power of License as Tools i n the Care of the Chronically 111", Public Welfare. Vol. 2, No. 4, A p r i l 1944-56. Potter, E l l e n C , M.D., and Howell, Laura, "How Can a Program f o r the Chronically 111 be Integrated", Public Welfare, Part I - Vol. 1, No. 11, November 1943. Part I I - V o l . 1, No. 12, December 1943. 57. Rogers, E.C., "Chronic Disease a Problem That Must Be Faced", American Journal of Public Health. V o l . 36, A p r i l , 194-6. 58. St. Thomas Hospital f o r the Chronically 111, The Canadian Hospital. V o l . 25,'No. 2, February, 1948. 59. "What Do We Mean By Chronic Patients", The Canadian Hospital. Vol. 23, No. 10, 1946. 

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