CONTENTdm
British Columbia Historical Books Collection
Cassidy, Harry M. (Harry Morris), 1900-1951
"Bibliography: p.458-459. Includes a large section on B.C."-- Edwards, M. H., Lort, J. C. R., & Carmichael, W. J. (1975). A bibliography of British Columbia: Years of growth, 1900-1950. Victoria, BC: University of Victoria, p. 67.
xi, 464 pages : charts, tables ; 21 cm
application/pdf
Public Health and Welfare Reorganization Public Health and Welfare Reorganization THE POSTWAR PROBLEM IN THE CANADIAN PROVINCES HARRY M. CASSIDY, Ph.D. Toronto THE RYERSON PRESS To HON. GEORGE M. WEIR AND OTHER FORMER ASSOCIATES IN THE DEPARTMENT OF THE PROVINCIAL SECRETARY, BRITISH COLUMBIA Pioneers in Public Health and Welfare Preface Jlhis is a sequel to Social Security and Reconstruction in Canada, published in February of 1943 by The Ryerson Press. I had set out, in the summer of 1942, to write the present book. But as the work progressed it became clear that the general premises regarding social security policy in the postwar period, which were essential for an inquiry into the reorganization of the provincial and local services, required far more attention than could be given in two or three introductory chapters, as originally contemplated. The result was that the section on major premises emerged as an independent book and that this volume, the main undertaking, has been much delayed. The premises of social security policy on which this study is based are stated briefly in Chapter I, and the reader is referred to the preceding book for more adequate treatment of the subject. In the preface to Social Security and Reconstruction in Canada, I said: Thus far the administration of the Canadian social services has been generally undistinguished and frequently incompetent, yet the subject has been given very little serious thought by expert students, by politicians, or by the general public. Unless heroic efforts are i viii Preface made to build up efficient administrative machinery throughout the country there is small chance of a great national programme of social security in Canada realizing its objective. This statement suggests the purpose of the present book. It is to analyse the problem of reorganizing and developing the provincial and local health and welfare services so as to fit them into a national plan of social security. The major emphasis is placed upon questions of organizational structure, intergovernmental relations, and administrative practice. Since the problems of organization and administration are similar in most provinces it has seemed appropriate to concentrate attention upon one province and to deal with the others much more briefly. The fact that British Columbia is in many respects the most advanced province in the field of the social services and that its experience is particularly worthy of record is an obvious reason for making a case study of it, and for dealing with the other provinces much more briefly. In addition there is the personal reason that I have first-hand knowledge of the background in British Columbia, where I spent the years from 1934 to 1939 as Director of Social Welfare. The book expresses convictions, arising out of this practical experience, that drastic changes in organization and administration are required before the provincial and local social services in Canada can reach high standards. The sections on the provinces east of the Rockies are also derived, to a considerable extent, from personal observation and discussions with public officials and other informed persons over a period of years. Thanks to a grant from the Carnegie Corporation of New York I was enabled, during the summer of 1942, to visit the provincial capitals in six provinces, from Victoria to Quebec City, and to revisit British Columbia in December, 1943. The documentary materials on the Canadian social services are so limited that personal investigation of this sort is particularly necessary to gain an understanding of issues in the field. Unfortunately I was unable to visit the Maritime Provinces, so that Chapter II is based Preface \ ix only on documents supplemented by correspondence. Developments in British Columbia are described up to May, 1944, and in the other provinces up to the end of 1943, except as it is otherwise stated in the text. Copies of the manuscript have been sent to the premiers or other responsible officials of the various provinces for criticism, as well as to informed persons outside of government circles, and their advice has been very helpful in making final revisions. But there has been a great stirring in the fields of health and welfare across Canada during the past year; and I fear that recent events in some of the provinces may not have come to my attention, to be reported here. Inevitably, in a study of the kind, there are adverse criticisms of existing arrangements. But if there is criticism there is also no lack of appreciation on my part of the devoted service being rendered by my former colleagues of British Columbia and by officials in the other provinces. I hope that they will accept my criticisms as constructive, designed to point the way to better arrangements which will give them a fuller opportunity of getting on with the job to which the great majority are earnestly committed, the improvement of the health and the welfare of the Canadian people. I have to thank the Carnegie Corporation of New York and my University for research grants; many public officials and others throughout Canada, too numerous to be mentioned here, for their courtesy in granting interviews, giving out documents, and replying to letters; friends in Canada and the United States for criticizing the manuscript and offering helpful suggestions; my former associates in British Columbia, including Hon. George M. Weir, Hon. George S. Pearson, Mr. P. W. Walker, the late Dr. H. E. Young, Dr. George F. Davidson, Mr. E. W. Griffith, Dr. Allon Peebles, Dr. G. F. Amyot, Dr. W. H. Hatfield, Dr. Donald Williams, Dr. Claude Dolman, Mr. J. T. Marshall, Dr. A. L. Crease, Mr. F. C. JBoyes, Mr. George Ross, Mr. J. H. Creighton, Miss Laura Holland, Miss Isabel Harvey, and Mr. Percy Ward, for their manifold con- Contents CHAPTER PAGE Preface . vii PART I—INTRODUCTION I. Premises for Provincial Planning 1 PART II—BRITISH COLUMBIA II. The British Columbia Background to 1933 . . 35 III. A Decade of Progress—Health and Other Services 66 IV. A Decade of Progress—Public Assistance . .104 V. Transition to Social Security 144 VI. Provincial-Municipal Relations 188 VII. Administrative Machinery and Personnel . . 235 PART III—EAST OF THE ROCKIES VIII. The Prairie Provinces 283 IX. Ontario 335 X. Quebec 364 XL The Maritimes 392 PART IV—CONCLUSION XII. The Road Forward 443 Appendix—Note on Sources 458 Index xi PART I Introduction Premises for Provincial Planning Social security became a real issue in Canada in 1943. Spokesmen for all three of the leading political parties, Liberals, Conservatives, and the Co-operative Commonwealth Federation, reiterated and amplified earlier state-' ments in favour of broad measures of social security after the war. In principle there was agreement on the political front, however differently the various parties might propose to implement the principle. Still more important, glittering generalities -were translated into definite proposals on policy. Enthusiasm aroused by Britain's Beveridge report at the end of 1942 was stimulated further by the Marsh report on Social Security for Canada, an official Dominion document which was released on March 16, 1943, and which was hailed immediately throughout the country as the Canadian Beveridge plan. On the same day there appeared a bulky report on health insurance and public health, prepared by the Dominion Advisory Committee on Health Insurance (the Heagerty Committee) which had been appointed in February, 1942. Early in the autumn there followed a critique of the Marsh and Heagerty reports, with an alternative plan of social security, which 1 2 Public Health & Welfare Reorganization was written by Miss Charlotte Whitton under the auspices of the Progressive-Conservative Party. In February, just before publication of the official reports, the writer had offered his ideas on national policy in his book, Social Security and Reconstruction in Canada. Throughout the year these major reports were supplemented by many articles and memoranda and by hundreds of newspaper stories and editorials. More fully and more clearly than ever before the leading issues of social security were presented to the Canadian people. At the beginning of 1944 the Dominion government made further commitments on social security policy. In the Speech from the Throne at the opening of parliament in January the government promised "a comprehensive national scheme of social insurance—which will constitute a charter of social security for the whole of Canada/'1 Contributory old age pensions, health insurance, and children's allowances were mentioned as desirable elements in the programme. Subsequently the government undertook to establish a new federal department of social welfare to take 'charge of the prospective new measures. A special committee of the House of Commons on social security was appointed to consider and report upon specific proposals for action. Early in February the Prime Minister announced that a Dominion-provincial conference would be summoned in the course of the year to discuss, among other things, the division of responsibilities between the Dominion and the provinces for the proposed social security programme. Thus the way has been cleared for another stage of discussion and planning. In this next stage the merits of alternative methods and tools of policy should be weighed carefully and attention should be directed towards the more important questions of detail Wancouver Sun, January 28, 1944. *Since this was written and set in type parliament enacted, in the summer of 1944, legislation to authorize a national system of family allowances and the establishment of a federal department of health and welfare. Premises for Provincial Planning 3 that arise as attempts are made to translate principles into concrete measures. There is considerable agreement, among those who have discussed the subject, on the broad outlines of a social security plan for Canada. Among the proposals are economic policies designed to sustain prosperity and employment; a nationally operated social insurance system covering the hazards of old age, death, disability, and unemployment; a supporting system of public assistance; the extension of public health services; the provision of a public system of prepaid medical care; Dominion financial aid to the provinces and the local authorities to enable them to build up to acceptable national standards certain services they will administer; and Dominion leadership and co-ordination of the whole programme. So far so good. But in the reports and articles and memoranda that have been published thus far only slight attention has been given to a number of problems of "ways and means." Among these are the feasibility of including the agricultural population under social insurance; the stamp plan versus the wage- or income-deduction method of social insurance collections; cash allowances versus services-in-kind for children; the nature of Dominion grants to the provinces; administrative organization at the Dominion level; the relation of social services for veterans to the civilian social security programme; and the finances of an adequate national scheme. Another urgent question for study is that of the adjustment of the existing provincial and local social services to the new national plan and the possible utilization of their administrative machinery for broader obligations. There is already, in every province, a network of health and welfare services upon which there was being spent some $250,000,000 of tax funds annually in the years just preceding the war. By general agreement similar services will be required as part of the national plan of social security. ItWould be folly not to use what already exists for the new structure. But it may not be easy to fit into an over-all national scheme the provincial programmes, diverse as they are, which were constructed to meet 4 Public Health & Welfare Reorganization regional and local needs and ideas of adequacy and which have been cut according to the limited financial cloth of the provincial and local governments. This process of adjustment will certainly demand considerable development and reorganization of present systems. Therefore it is essential that they be examined carefully, province by province, to see what there is to build upon and the nature and the extent of the changes that may be necessary. It is the purpose of this book to make such an inquiry, placing major emphasis upon such questions as the distribution of operating functions and financial responsibilities between the provinces and the local governments, administrative machinery, and administrative practice. There are other important questions about the content of the various programmes operated by the provincial and local governments which will also be discussed to a limited extent. Thus this study deals with only one segment of the total problem of social security, and even with that only partially. But it is a segment that presents peculiar difficulties, because it is conditioned by the complexities of historical background and of Dominion- provincial-local relationships, political and financial. It is particularly important because it is likely to be one of the most difficult parts of the problem to solve. The Health and Welfare Services The programmes of provincial and local government which are the central concern of this study may be described as the health and welfare services. The main branches of this closely related group of governmental activities are public health, mental hygiene, public medical care, public assistance, child welfare, and corrections (or the delinquency services). Since the dividing lines between these categories are not at all clear and since these terms are not used uniformly even by professional health and welfare workers, it will be desirable to make brief working definitions for purposes of this Premises for Provincial Planning 5 study, and to do the same for the broader terms public welfare, the social services, and social security. Public health commonly has a narrower connotation than the words suggest, for it has been concerned primarily with measures of preventive medicine and the conservation of health, notably sanitation, vital statistics, the control of communicable diseases (including tuberculosis and venereal disease), and health education. Mental hygiene includes the work of mental hospitals, institutions for the feeble-minded, psychiatric and child guidance clinics, and preventive work in mental health. Public medical care includes those medical services, mainly curative, which have been provided at public expense for persons unable to pay for or to arrange their own medical care. Provincial hospital programmes, typically providing grants to hospitals to cover the costs of care for the needy, are included in this category. As and when medical service is made available through public agencies to persons who are financially independent, with or without payments by them, it should also be included. The term "health insurance," even when there are no cash benefits, is commonly used to refer to such programmes. Historically public medical care has been part of poor relief—for medical relief is a necessary form of assistance to the needy—and administratively it has been commonly associated with public assistance in Canada and the United States. But according to the views of some public health authorities both medical care and mental hygiene should be considered within the field of public health, and this is a viewpoint readily accepted by laymen. However, the narrower concept of public health given above is more in accord with professional usage at present in Canada and will be followed in these pages. Public assistance refers to grants made to needy persons in cash or in kind and is usually varied in amount according to their needs. This is the leading characteristic of the schemes of old age pensions, mothers' allowances, unemployment relief, and general assistance (more commonly called indigent relief or poor relief) which have 6 Public Health & Welfare Reorganization emerged in Canada. Work relief programmes, which provide work only for the needy unemployed, belong also to this category. Child welfare services cover those measures of child care and protection which are necessary because of the failure of the family to perform its normal protective functions, and include the care of orphans and neglected children in institutions or foster-homes, assistance to unmarried mothers and their children, the administration of adoption laws, and. protective work in behalf of the children of incompetent parents. The field of corrections (or the delinquency services) embraces care and training for delinquents, adult and juvenile, in penal institutions and training schools, along with programmes of probation and parole for those not in detention. From this it will be seen that these various services are not easy to distinguish one from another. It is still more difficult to give an acceptable definition of public welfare. This term has been used in the United States, notably by the American Public Welfare Association, to include public assistance (including public medical care), child welfare, mental hygiene, and corrections. But as we have seen public health makes some claims over public medical care and mental hygiene, and there is something to be said for this. The core of public welfare is clearly public assistance and child welfare, and there are also strong arguments for including corrections. In the following pages the term "public welfare" will be used to cover these three fields except when the context shows otherwise. Obviously use of the term "health and welfare services " avoids the controversy between public welfare and public health regarding jurisdiction over public medical care and mental hygiene. The social services is a still broader term, covering those organized activities of government that are primarily and directly concerned with the conservation, the protection, and the improvement of human resources. Along with the programmes already mentioned it includes social insurance; and some closely related programmes, notably vocational rehabilitation, recreation, labour protection, housing, and education are often classified as social services. Premises for Provincial Planning 7 Social security is a newer term to Canadians than any of the others. It refers, first, to certain measures of income maintenance, notably social insurance and public assistance; but it also covers, although not very definitely, the provision of a social environment and of community services that will permit and assist the citizen to utilize his economic resources wisely and well. In this second aspect it includes virtually all of the health and welfare programmes. Thus it is synonymous with the social services in the sense of social insurance plus health and welfare. It will be sufficient for our purposes (although questionable for others) if we use the term in this way. One further explanation of the scope of this study remains to be made. There will be little reference to the problem of social insurance (which is represented in the provinces only by workmen's compensation), except for some reference to the health insurance movement in British Columbia and to the problems of provincial organization and administration likely to be posed by a Dominion health insurance act. The workmen's compensation agencies are relatively well organized and administered at present, they are quite separate and distinct from the health and welfare services, and under a national plan of social security it will probably be wise to leave them as independent agencies, much in their present form, so that they pose no difficult problems of assimilation into the national system. The Present System The present Canadian system of health and welfare services is the product of a haphazard development extending over many years. In the early years after Confederation public welfare, under the provisions of poor law or municipal statutes, was almost wholly the responsibility of the municipalities. Following British poor law precedent, they were charged with the obligation of making provision for all classes of the poor, while the provincial governments did little except operate jails or insane asylums. 8 Public Health & Welfare Reorganization Public health was also a local responsibility, under the terms of elementary public health legislation. But by the end of the nineteenth century it had become apparent that additional specialized services were needed, and the provinces enacted legislation to provide for institutions for the feeble-minded, homes for the aged and infirm, child welfare services, hospitalization for the indigent, and other programmes, to be operated directly or by the municipalities and private agencies, sometimes with provincial financial support. After the war of 1914-1918 there came provincial schemes of mothers' pensions, a Dominion-provincial system of old age pensions, and extensions and improvements in public health. The 1930's brought the need for a great programme of unemployment relief, administered mainly by the municipalities but financed in large part by Dominion and provincial grants-in-aid. At the same time there was provincial and even Dominion administration of certain relief activities, such as land settlement schemes and work projects for single men. Thus there has taken place a significant transfer of health and welfare responsibilities, administrative and financial, from the local authorities to the provincial governments. By the outbreak of the war in 1939 circumstances had forced the provinces to enter the business of health and welfare on a large scale. Similar forces affected the Dominion, which under the British North America Act was charged with very little direct responsibility for the social services. After the last war federal public health services, to deal with international or interprovincial health problems, were expanded under a division of the Department of Pensions and National Health. The Old Age Pensions Act of 1927, providing for federal grants equal to half the costs of old age pensions (75 per cent, after 1931) to be awarded under provincial legislation, marked the serious entrance of the Dominion into the field of public assistance. From 1930 to 1941 the Dominion spent nearly $400,000,000 on unemployment relief, mainly in grants to the provinces. In 1940, after constitutional authorization was obtained by amendment of Premises for Provincial Planning 9 the British North America Act, a national system of unemployment insurance was adopted. Penitentiaries have always been operated by the Dominion and since the last war the federal government has provided various social services for war veterans over and above the usual military pensions. By 1940 the Dominion was carrying 36.2 per cent, of the costs of public health and welfare (not including corrections or services to war veterans) while the provincial and municipal shares were Respectively 41.5 per cent, and 22.3 per cent. In 1913, on the other hand, the municipal share had been 53.9 per cent., the provincial 28.7 per cent., and the Dominion 17.4 per cent.2 The roles of the three levels of government in the financing of the social services had been changed drastically between the two great wars. Responsibility for administration had also shifted upwards, although not to so great an extent. Together the provinces and the local governments operated practically all of the health and welfare services except the penitentiaries, the federal public health activities, and specialized federal programmes for war veterans and Indians. Notwithstanding the division of responsibilities contemplated in the British North America Act, which in effect classified the social services with "all matters of a merely local . . . nature" which were to be left to the provinces and their creatures, the municipalities, there had emerged by the beginning of the war a loose and imperfect partnership between the three levels of government. The extent to which the Dominion should assume responsibility for health and welfare was a central problem of the depression period. During the 1930's the costliness of the social services, particularly unemployment relief, and the obvious inability of most of the provinces and municipalities to finance them from their limited tax resources led to a substantial demand that the Dominion should take them over entirely. A less extreme view was that at least the Dominion should assume full responsibility, financial and 2See Social Security and Reconstruction in Canada, p. 37, for a detailed table on this point. 10 Public Health & Welfare Reorganization administrative, for the maintenance of the unemployed and their dependents. On the other hand, it was pointed out that constitutionally this sort of thing was none of the Dominion's business. In 1935 a harassed federal government referred the vexed question of unemployment relief to the National Employment Commission for study and advice, and a year later appointed the Royal Commission on Dominion-Provincial Relations (the Rowell-Sirois Commission) to consider the manifold difficulties of intergovernmental relations which depression and unemployment and the high costs of the social services had brought to a head. Thus there was constant wrangling during the depression decade between the Dominion and the provinces regarding their social service obligations, culminating in a great constitutional debate that probed to the very foundations of the Canadian nation. This controversy was a major barrier to significant reforms in the social services. Uncertain about long-run national policy, preoccupied with financial grievances against the Dominion, and handicapped by unbalanced budgets, the provincial authorities had but little disposition to build up their programmes constructively. The emergency problem of unemployment relief was dominant and discussion and administrative effort were centred on this. Policies were determined by considerations of finance much more than of human welfare. Between the provinces and the municipalities there was also continuous dispute over their respective roles in administration and finance. Pending solution of the Dominion- provincial controversy the provinces tried to avoid making permanent commitments about the extent of the responsibilities that they would assume, and this left the local authorities without appropriate premises for policy formation. Thus temporary expedients, stopgap solutions, and delays in dealing with fundamental issues were common. As the decade wore on and as public finances recovered from the worst effects of economic depression, some provinces and communities extended and improved their Premises for Provincial Planning 11 social services substantially and made certain administrative reforms. But these efforts were generally sporadic and fragmentary rather than systematic and comprehensive. In no province (with the possible exceptions of British Columbia and Ontario), was there a really bold attempt made to attack fundamental issues and to build up a first-rate system of public health and welfare. There was no "revolution in the social services" such as occurred in the United States as a result of the Social Security Act of 1935 and related national measures, leading to great advances and drastic reorganizations in most of the states. Canada, which had been abreast of the United States in public health and welfare at the beginning of the decade, and in some respects ahead, lagged seriously behind after 1935. In 1933 the Civic Division of the British Political and Economic Planning group explained the "confusion and lack of guiding principle in the British social services" by pointing out that "for thirty years there has been a haphazard piling up of measures, the form and precise objectives of which have been indicated by temporary circumstances, financial and political considerations, and passing fashions of administrative method.3 There has been a similar "haphazard piling up of measures" in Canada, leading to final results that are worse because (unlike the situation in Britain) there has been little or no leadership from the central government to bring about uniformity and consistency. Instead, each of the nine provinces has its own system or lack of system. The result of this unplanned development and of a virtual moratorium on constructive achievement during much of the 1930's was that Canada entered the war period with a set of provincial and local social services that were disorganized and weak in many respects. In British Columbia and some other provinces there has been considerable progress during the war years, but not enough to overcome the major defects of the system. sThe British Social Services (London: 1937), p. 9. 12 Public Health 8c Welfare Reorganization \ National Plans for Social Security To discover premises of national policy for planning at the provincial level it will be appropriate to turn now to a review of the main proposals for social security that have been made recently. Four national plans will be discussed, those prepared by Dr. L. C. Marsh, the Heagerty Committee on Health Insurance, Miss Charlotte Whitton, and the writer. The Marsh Plan The Marsh report4 is the Canadian counterpart of the Beveridge report on social security for Great Britain and the National Resources Planning Board report for the United States. It is somewhat unusual in that it is essentially the work of one person, a civil servant. However, it was prepared for an official body, the Advisory Committee on Reconstruction of the Dominion government, and it has been endorsed by that committee. Although the government is not committed to follow its recommendations in any way, the report is important as the first attempt, within official circles, to outline a comprehensive national plan of social security for Canada. Dr. Marsh says in his preface that he has attempted to set out "the principles . . . of a comprehensive social security system . . . suited to Canadian conditions." His main proposals (or preferences, for many points are advanced very tentatively) may be outlined under the six headings which follow, the last five representing the social security programme proper. 1. A national employment programme. This is needed as the "first positive measure in providing social security ... in the widest sense we must have a policy for economic security as well as for welfare security, which is what 'social security' usually 4L. C. Marsh, Report on Social Security for Canada, prepared for th» Advisory Committee on Reconstruction, House of Commons Special Committee on Social Security, Sess. 1943. Premises for Provincial Planning 13 implies."5 Immediately following the war a federally sponsored programme of public works and other public investment projects at the rate of a billion dollars a year may be necessary to hold up employment. 2. Supplementary occupational and training schemes. These would be needed for semi-employable persons and others not provided with work at standard wages under the national employment programme or not cared for adequately or appropriately by unemployment insurance benefits. Employment on the work projects would be an alternative to unemployment assistance for certain workers and this part of the work scheme would be closely related, administratively and otherwise, to unemployment assistance, which would be operated by the Dominion government through the national employment offices. However, proposals on the administration of the work projects are not very clear, and it is suggested that there may be Dominion, provincial, and local collaboration in their operation. Vocational training and guidance facilities would be provided largely by the provincial and local authorities, with Dominion support and direction. 3. Social insurance. In the narrow sense of cash benefit schemes of income maintenance, social insurance measures are proposed to meet the major risks to the incomes of the gainfully occupied. The first group of insurance schemes, covering wage-earners only, would provide cash benefits in respect of unemployment, sickness, maternity, and industrial disability or death. This group of schemes, to protect against "employment risks," would be financed by employers' contributions, would offer benefits graduated in accordance with wages as at present under the Dominion unemployment insurance scheme, and would be operated by the Dominion— except for workmen's compensation, which would continue to be provincially administered. A second group of schemes, to cover all gainfully occupied persons, would provide flat-rate benefits in 5Ibid., pp. 37-40. 14 Public Health & Welfare Reorganization respect of old age retirement, permanent disability, the death of insured persons, and funerals. These plans, to be operated by the Dominion government, would be financed by joint contributions from insured persons and the government. Insurance benefits would be designed to meet the needs only of single persons or of man and wife, child dependents being cared for through a separate system of children's allowances. 4. Medical care. A comprehensive system of public medical care for the whole population is proposed, to be financed by contributions from the gainfully employed and from the Dominion and provincial governments. Administration would be (probably) in the hands of the provincial authorities, and would be closely related to the existing public health services. 5. Children9s allowances. These, according to Dr. Marsh, represent the "key to consistency" in a social security system. It is proposed that they should be payable in cash to all families with children, whether the breadwinners are earning or not, at rates varying with the ages of the children. The Dominion would operate this scheme and would meet the costs entirely from tax funds. 6. Public assistance. A nationally operated and financed scheme of unemployment assistance is proposed, offering maintenance grants on a means-test basis for persons who have exhausted their unemployment insurance benefit rights and for other employable persons. The existing Dominion-provincial system of non- contributory old age pensions should be liberalized and continued, to supplement the old age insurance system; and for similar reasons the provincial mothers' allowances systems would have to be continued, on a modified basis, providing grants for mothers but not for children, until the progressive development of survivors' insurance would make it unnecessary. No close attempt is made to estimate the costs of this large project. But it is suggested that, not including the employment programme, it may cost some $900,000,000, or 12J^ per cent, of Premises for Provincial Planning 15 national income. About half of this amount would be met by the Dominion from tax funds. Presumably the provinces and the local authorities would bear a good part of the costs of those services, notably public health and public assistance, which they would administer; but Dr. Marsh does not estimate how great this burden would be nor how they would raise the necessary funds. There is in the report only incidental reference to the provincial and local health and welfare services, but it is explained in the preface that this subject calls for separate examination, in a supplementary study to be prepared later. The Heagerty Report More limited in scope, but more specific in its proposals, is the Heagerty report on health insurance and public health.6 This report was prepared at the request of the government by a committee of civil servants appointed early in 1942 and contains detailed proposals on health insurance and public health in the form of draft bills requiring enactment by the Dominion parliament and provincial legislatures. "The fundamental and primary object" of the recommendations, says the report, "is the integration of public health and medical care for the purpose of raising and- maintaining the standard of health of the people of Canada. "7 It is proposed that both the medical care and the public health portions of the scheme be administered by the provinces, with the Dominion offering encouragement, support, and direction through substantial grants-in-aid and the setting of standards to be maintained throughout the country. Emphasis upon preventive medicine is to be guaranteed by the provision that no province shall be eligible for health insurance grants unless it accepts aid to build up its general public health services. 6House of Commons Special Committee on Social Security, Sess. 1943, Report of the Advisory Committee on Health Insurance. 7Ibid., p. 5. 16 Public Health & Welfare Reorganization The draft bills have been revised considerably since they were first prepared. A brief summary of the seventh draft, presented to the House of Commons Committee on Social Security on March 1, 1944, follows. The whole population, rural and urban, rich and poor, normally resident within any province, is to be covered. Insured persons are to be eligible for a full range of benefits in kind, including medical, dental, pharmaceutical, hospital, and nursing services, these to be provided by the medical professions and institutions in a manner and at prices to be arranged by the provincial health insurance commissions. These are to be established as the administrative authorities, and are to consist of persons representative of the health professions and socio-economic groups such as organized labour, industry, and agriculture, with the provincial health officers serving ex officio. In each case the chairman, the chief administrative officer, is to be a doctor. It is proposed that operations be decentralized through the formation in each province of administrative districts, which are to be the same for purposes of health insurance and public health and in which the two services are to be closely co-ordinated. The finances of the proposed system are to be drawn from three sources—contributions by the Dominion, the provinces, and insured persons. Every person sixteen years of age and over is to pay (or to have paid for him by the head of his family) a registration fee of $12 per year. This will make him and his dependents eligible for service under the scheme. In the case of those persons who cannot pay this fee each provincial health insurance authority may work out provisions to exempt them wholly or partially from it, the deficits to be made up by the provincial treasuries. Thus the provinces, in effect, are to pay registration fees in behalf of the indigent group. In addition to the registration fees, all income taxpayers will be called upon to pay a health insurance tax at the rate of three per cent., up to a maximum of $30 in the case of single persons, and at five per cent., up to $50, in the case of married persons. It has been estimated that about $100,000,000 per Premises for Provincial Planning 17 annum will be raised from registration fees and another $50,000,000 from the health insurance taxes. The balance required to operate the scheme on a nation-wide basis, about $100,000,000, is to be contributed by the Dominion out of general revenues. There has been much debate about the financial provisions before the House of Commons Committee on Social Security, and the proposals outlined above, which differ materially from the first recommendations of the Heagerty committee, may be changed further before the legislation which the government has promised is adopted. The scheme provides further for Dominion aid towards general public health and a number of other health services. Grants for seven specific purposes are proposed, including tuberculosis treatment (on condition that a general programme of free treatment is in effect); treatment of the mentally ill (with the same condition regarding free treatment); general public health; venereal disease control; professional training; investigation; and the treatment of crippled children. Miss Whitton9 s Proposals A third significant contribution to social security planning has been made by Miss Charlotte Whitton, formerly Executive Director of the Canadian Welfare Council, in an extensive memorandum which she has prepared at the invitation of Hon. John Bracken, leader of the Progressive-Conservative party.8 While this is an independent report by a leading Canadian student of the question, it obviously has considerable political significance because of the auspices under which it appears. Miss Whitton criticizes seriously both the Marsh and the Heagerty reports and emerges with her own set of proposals, which, she submits, are more in keeping with the peculiar economic, constitutional, racial, and historical factors of the Canadian scene than those of the other two reports, which draw too heavily upon English thinking and experience. 8The Dawn of Ampler Life (Toronto: MacMillan, 1943). 18 Public Health & Welfare Reorganization Miss Whitton's positive recommendations follow upon two premises of economic policy—first, that vigorous measures should be taken to keep the national income as high as possible after the war; and second, that there should be a living-wage policy which would guarantee for every male adult a wage sufficient to support him and a family with two or three children. She does not develop specifically how these very important policies would be put into effect, but makes it clear that the Dominion government would be expected to implement them. Assuming these premises, she suggests that the social security programme should be built along the following lines: 1. Expansion of "social utilities." By these Miss Whitton means direct community services to protect and advance well- being, such as those concerned with education, health, child care and protection, vocational training, and housing. The existing network of these services throughout the country, under the jurisdiction of the provincial and local governments, should be improved and expanded, entirely out of tax funds. The social needs of children might be met not only by expansion of existing child welfare services, but also by adoption of the living-wage policy, by low-cost housing for families with children, and by extension of income-tax deductions in respect of children. These policies, she thinks, will make unnecessary a system of cash allowances for children, as proposed by Dr. Marsh, which are open to many objections. In addition, and most striking, she proposes the radical plan of a complete state system of medical care for the whole population, to be integrated with the provincial and local public health systems and to be financed entirely from taxation. This system would be administered by the provinces and the costs would be shared between them and the Dominion. 2. Improvement and extension of the present system of public assistance. This Miss Whitton calls the "second priority " for postwar planning on social security. She claims that the country must Premises for Provincial Planning 19 rely mainly on public assistance to meet problems of economic need in the immediate future because adequate protection through social insurance cannot possibly be worked out except over a considerable period of time. Federal grants to the provinces, and through them to the local governments, should be used to build up locally administered schemes of aid for the unemployed, the aged, mothers with dependent children, the handicapped, and other needy groups. 3. "Social or income insurance.99 In Miss Whitton's view this is "logically the last stone to be set in the basic structure of social security." She proposes a Dominion system of "income insurance," differing from traditional social insurance in that it would cover all persons with incomes above the minimum income-tax level (specifically, farmers and the self-employed as well as wage-earners), that it would protect insured persons against income loss for a wide variety of reasons, and that it would be supported by an income-tax levy on the prospective beneficiaries without any contribution from employers, although possibly with some assistance from general tax funds. She calls this system "practically a compulsory savings or reserves plan." 4. Organization and administration. The Dominion should take the lead in setting up the new system, but in general administrative responsibilities should be assumed by the provincial and local governments except in the case of income insurance. This division of administrative jurisdiction would be made possible by Dominion provision of large grants-in-aid to the provinces, to be distributed in accordance with their needs, on the recommendation of a Dominion Social Assistance Board made up of representatives of provincial and local governments and private health and welfare agencies. This agency would not supervise or interfere with the provincial and local programmes so long as they complied with certain minimum conditions. The income insurance scheme would be operated by a Dominion Insurance Board, independent of Parliament, which would be something like "a great crown corporation. 1 20 Public Health & Welfare Reorganization The Writers Plan Social Security and Reconstruction in Canada presents the writer's suggestions on social security policy. There are two major premises for this plan\: first, that there should be a Dominion economic policy designed to support full employment and agricultural prosperity; and second, that sufficient money can be raised and distributed among the co-operating governments, federal, provincial, and local, to finance the necessary measures. "A total programme of social security for Canada," it was stated, "calls for the complete overhaul, rebuilding, and extension of the present system of social services, together with the addition of a number of new schemes. . . . Since Canada is a vast federal country administrative and financial responsibilities should be divided between the Dominion and the provinces."9 The main points in the plan are as follows: 1. A comprehensive system of social insurance. This would cover the great bulk of the population, including farmers and other self-employed persons, and would offer them partial protection, through cash benefits, against losses of earnings incidental to unemployment, sickness, disability from industrial accident or other cause, maternity, superannuation, and death of the breadwinner. It would be financed by contributions from insured persons, the federal government, and employers. The system would be nationally administered, except that workmen's compensation schemes might remain much as at present, under provincial management, subject only to the transfer of their medical care activities to the new health insurance agencies. 2 Family allowances. A national system of family (or children's) allowances should be established to bridge the chronic gap between the chief breadwinner's earnings and the needs of many families with children, These might be payable in cash or in kind <>P. 138. Premises for Provincial Planning (food, shelter, medical care, educational service, etc.), or partly in cash and partly in kind. Other important questions of how the principle should be applied were left open for further consideration. With a family allowances system in operation social insurance benefits would only cover the needs of insured persons and their adult dependents. The system would be administered and financed entirely by the Dominion. 3. Work and maintenance programmes. Two schemes were proposed under this heading, a "supplementary work programme" and a "farm security programme." The former, somewhat akin to the WPA, NYA, and CCC schemes of the 1930's In the United States, would provide useful occupation and reasonable earnings for "those who will not be placed easily in regular employment, including ordinary public works,"10 when there is a surplus of labour at certain times and places. This plan, to be operated and financed entirely by the Dominion (with the possible exception of some financial contribution from provincial and local governments in recognition of the value to them of completed work projects), would be designed, along with social insurance, to provide maintenance incomes for all of the "unemployed"—those without gainful occupation who are capable of and available for some kind of work. The farm security programme, similar to the American FSA scheme, would be the rural counterpart of the supplementary work programme. It, too, would be administered and financed by the Dominion, and it would am to develop a capacity for self-support on the land by "marginal" farm families. 4. Public assistance. In addition there must be a system of public assistance, built upon present foundations. There will be need in the immediate future for at least three "categorical aids," old age pensions, disability allowances, and mothers' allowances, as well as for general assistance for those not covered by the three categories. These schemes should be operated by the provincial ™Ibid., p. 152. 22 Public Health & Welfare Reorganization and local governments, as at present, with financial aid and with some supervision from the Dominion. 5. Medical care. What is needed is "a public medical service for the nation, to provide the essentials of medical care for all." ! This might be made available for those insured under the general insurance plan, that is, the great bulk of the population. Part of their social insurance contributions might be earmarked for medical care, with the Dominion government and employers also contributing in the same proportions as for social insurance. Indigent persons would have the costs of service to them met by governmental contributions. Administration would be handled, preferably, by the provinces, which would bear part of the total costs but would obtain revenues mainly from funds collected or contributed by the Dominion. There would be federal standards to be met by the separate provincial systems and some degree of federal supervision. Such arrangements would be favourable to the integration of curative medical care with the provincial and local public health programmes. Cash benefits would be provided by the Dominion social insurance authorities, so that these would be quite separate from the medical care system. - 6. Public health, mental hygiene, child welfare, and delinquency services. These programmes should remain under the operating jurisdiction of the provincial and local authorities, as at present, but they should be built up to good standards quantitatively and qualitatively, with the assistance of federal grants-in-aid and technical service. The recommendation of the Royal Commission on the Penal System of 1938 that the provincial prisons be transferred to the Dominion has great merit, but it does not seem essential that this be done if the Dominion undertakes to support and encourage good standards in the provincial institutions. 7. National leadership and financial assistance. "The development of a nationally co-ordinated system of social security demands i1 Ibid., 157. Premises for Provincial Planning 23 federal leadership with respect to all parts of the system. . . . This point cannot be emphasized too strongly. It is the very kernel of the proposals put forth in this book."12 The principle of national leadership would be implemented by federal operation and financing of some parts of the programme, as indicated above, and by technical service, the setting of standards, supervision, and financial aid with respect to all other branches operated by the provinces and the local authorities. Adequate financial aid to the provinces, and through them to the local governments, might be provided by an over-all system of Dominion grants, varied according to their needs, as was proposed by the Rowell-Sirois Commission in 1940, supplemented by relatively small conditional grants-in-aid for specific social services. Premises for Provincial Planning While there are important differences on major questions of policy and many diijerences on points of detail between the four reports, their agreement on the distribution of administrative and financial responsibilities between the Dominion, on the one hand, and the provincial and local authorities, on the other hand, is striking. They support two conclusions of great importance, which will be taken as major premises for this study. These are that, if and when a full-fledged national system of social security is established: 1. The provincial and local governments will be expected to participate by operating substantially the same range of health and welfare services as those to be found now in the more advanced provinces, along with workmen's compensation and broadened schemes of medical care; while the administrative role of the Dominion will be to operate new services, such as work programmes, social insurance, and family allowances, to stimulate provincial programmes, and to co-ordinate the whole system. 2. The Dominion will have to provide financial aid to the 12Ibid., p. 170. 24 Public Health & Welfare Reorganization provincial and local governments in such amount and in such manner as to encourage and enable them to discharge their social security obligations satisfactorily. There are a few comments to be made on these two premises. Dr. Marsh differs from Miss Whitton and the writer in suggesting a Dominion-operated system of unemployment assistance. This same recommendation was made by the National Employment Commission in 1938 and by the Rowell-Sirois Commission in 1940. The writer13 and Miss Whitton,14 as well as others, have criticized this idea seriously, and there will certainly be considerable opposition to its adoption. But even if it should be accepted there would still be need for a general assistance service similar to that now offered by municipal welfare departments. For Dr. Marsh's plan would leave the unemployables in need, who in periods of good employment make up the greater part of the clientele of the welfare office, to the provincial and local authorities. The effect of his plan, therefore, would be to protect them against the danger of large general assistance caseloads, such as they had in the 1930's, rather than to enable them to dispense with an existing service. The proposals made by the writer for work and maintenance programmes supplementing social insurance would also do this, in a different way, although perhaps not so fully. Miss Whitton, on the other hand, is more prepared to contemplate public assistance for the unemployed, as well as the unemployables, as a primary line of defence. Perhaps more realistically than either Dr. Marsh or the writer, she argues that a large volume of public assistance is to be anticipated in the immediate postwar period because there will not be time enough to develop adequately social insurance and other defences against want. Thus the differences between the three reports, at this point, have to do with the volume of work which the general assistance service is likely to face rather than with the need for its continuance. ™Ibid., pp. 100-104. l*0p. cit., pp. 48-51. Premises for Provincial Planning 25 So far as the categorical aids of old age pensions, disability allowances, and mothers' allowance are concerned there is complete agreement in the reports that these should be administered by the provincial and local governments. But again there are questions about the volume of work to be contemplated under each scheme. Miss Whitton's approach would lead to very heavy case loads under each category. She is almost certainly right in suggesting that there will have to be great reliance on these schemes in the immediate postwar period because it will take some time to build up alternative methods of protection by means of social insurance. However, their burdens should decrease progressively and sharply if broad and generous social insurance measures are brought into effect. On the subject of medical care the Heagerty report and Miss Whitton are very definite in favouring provincial administration, the writer expresses a preference for this, and Dr. Marsh leans the same way. There is complete agreement that the public health I and mental hygiene services and workmen's compensation should remain under provincial jurisdiction and Dr. Marsh appears to agree with the writer and Miss Whitton, implicitly if not explicitly, that the same policy should apply to child welfare. The writer's report is the only one to refer directly to the delinquency services, giving limited approval to the idea that an important part of these, the provincial jails, should be transferred to the Dominion. The second premise, on the need of Dominion financial aid to the provinces and the local authorities, requires but little elaboration. The four reports agree on the principle of Dominion aid, but there are differences on the methods of implementing it. It is very significant that in three of the reports, those by the Heagerty committee, Miss Whitton, and the writer, there is clear support for conditional grants for specific services, which were condemned seriously by the Rowell-Sirois Commission.15 Careful consideration of the problem of working out a national system of social 15The Commission's position on this point is criticized in some detail in Social Security and Reconstruction, pp. 107-110. 26 Public Health & Welfare Reorganization security leads to a return to the idea of the conditional grant which is "an indispensable device for organizing effectively the relationships between two levels of government."16 It may appear to the reader that the four reports which have been summarized, three of them professing only to present the personal views of the writers, are scarcely important enough to provide major premises for social security planning at the provincial level. This would be true but for the fact that they express, on the central issue of Dominion-provincial relations, conclusions which have been widely accepted thoughout Canada. This is a result of the great constitutional debate of the 1930's. Three important national commissions of inquiry, the National Employment Commission (1936-1938), the Royal Commission on the Penal System (1936-1938), and the Rowell-Sirois Commission (1937-1940), then studied the problems of the social services. In spite of the pressures of the period in favour of the wholesale shifting of social service responsibilities from the provinces to the Dominion, these responsible commissions did not go beyond advocating the transfer upwards of services for the unemployed and of provincial jails. The remaining health and welfare programmes, according to the Rowell-Sirois report, should continue to be operated by the provincial and local authorities, subject to reasonable financial aid from the Dominion to make this possible. Although the Rowell-Sirois recommendations on many points have been severely criticized, the findings on the distribution of social security operating functions and on the need for Dominion financial aid have met with general approval. Thus the constitutional debate has greatly cleared the way for those who strive to draft social security plans appropriate to the Canadian system of federalism. Further evidence in support of the premises for provincial planning comes from the lack of opposition to them in recent public discussions. The findings of the Marsh and the Heagerty reports ™Ibid., p. 110. Premises for Provincial Planning 27 were under review by the Committee on Reconstruction and Re- establishment of the House of Commons and the committees on social security of the House and the Senate during the parliamentary session of 1943, but practically no objections were made to their recommendations on Dominion-provincial distribution of functions and on federal grants by the committee members or the witnesses who appeared. Nor has there been much question raised about these proposals in the press or in the utterances of leaders of public opinion. It will be assumed, for purposes of this book, that there are no insuperable constitutional obstacles to be overcome in working out the division of functions between the Dominion and the provinces which has been outlined. A number of the major proposals appear to be consistent with the present provisions of the British North America Act. Dominion grants-in-aid to the provinces for social services are not new or unconstitutional. Legal officers of the Dominion government believe the health insurance scheme prepared by the Heagerty committee to be constitutional.17 There is ample precedent for the direct operation of work programme and farm security measures by the Dominion. On the other hand, there are serious questions about the right of the Dominion to set up a full-fledged system of social insurance and family allowance. The Privy Council's decision in 1937, disallowing the Dominion Employment and Social Insurance Act of 1935, and other recent decisions led the Rowell-Sirois Commission to say that "the possibility of framing any contributory social insurance scheme of nation-wide extent which could be validly enacted by the Dominion is open to the gravest doubt."18 Perhaps a changed 17Mr. W. G. Gunn, Solicitor for the Department of Pensions and National Health, who had drafted the bill, assured the House of Commons Special Committee on Social Security on June 29,1943, that he believed it to be constitutional. (Minutes of Proceedings, No. 25, p. 679.) He said further, "The draft bill is at present before the Department of Justice for study, and apart from three or four clauses ... no major fault has been found with it." 180p. cit., Book I, p. 249. 28 Public Health & Welfare Reorganization climate of opinion on social issues in consequence of the war, which may affect even the judiciary, will lead to a different reading of the Canadian constitution by the lords of Privy Council. But the possibility, or even the probability, that it may be necessary to amend the British North America Act to give the Dominion adequate authority over social insurance, as was done in 1940 to clear the way for national unemployment insurance, is a very real issue. Fortunately the strong body of opinion in favour of contributory social insurance on a national basis suggests that some such amendment will prove to be politically feasible, There are various other problems of constitutional law to be faced in drafting a national social security plan. But it is not necessary to inquire into them here, since there is no reason to believe that they represent insurmountable barriers to parliamentary action. Thus there are substantial reasons for accepting the conclusions of the four reports on Dominion-provincial relations in the field of the social services as the consensus of informed opinion—and indeed of political thinking also. There is no longer, as there was in the 1930's, valid excuse for provincial delay in making social service reforms because of complete uncertainty regarding Dominion policy. While the details of Dominion policy must remain unknown until they are officially announced, the main outlines on the central point of Dominion-provincial relations-can now be forecast with sufficient assurance to justify and indeed to demand intensive planning as well as some action by the provinces. This is particularly true with respect to administrative reform, as will be explained later. The Rowell-Sirois Commission expressed the hope that the various provinces would take up the work of examining problems of the social services where it left off, stating that "its researches and main recommendations have laid the ground-work for every government in Canada to institute inquiries into its own policies."19 The argument for such action is enormously greater ™Ibid., Book II, p. 165. Premises for Provincial Planning 29 now, with a victorious conclusion to the war in early prospect, than it was in 1940 when the Commission made its report. Adjustments in the Provincial Systems The adjustments in the present health and welfare services that will be necessary to comply with the requirements of a national system of social security are of two kinds, which may be termed "content" and "administration." The adjustments of content will be concerned with such matters as bringing public assistance grants up to standards of adequacy, extending psychiatric-clinic, probation, child-welfare and other programmes so that they are available in all parts of every province, developing physical facilities to a point where all reasonable demands for service can be met, revising rules and regulations so that no persons or groups are excluded from services which they need, and establishing new programmes in some provinces. This will call for much rewriting of legislation and regulations, for larger appropriations, and for increased staff. The adjustments of an administrative nature may seem more prosaic but they are certainly not less important. They have to do with such questions as the provincial-municipal distribution of operating functions, the allocation of financial responsibilities, the structure and the relationships of operating agencies, and the development of competent personnel. Indeed, the reform of the administrative system is both the more urgent and the more possible of the two types of adjustments that are required. There are several reasons for this. In the first place, the premises for provincial planning which have been stated above are reasonably good for purposes of administrative reform. So long as the type and the probable scope of the programmes to be operated by the provincial and local governments are known it is possible to make sensible decisions regarding the nature of the administrative system that will be required. But the provinces do not yet have enough information about Dominion policy on 30 Public Health & Welfare Reorganization social security to go very far in changing the content of some of their present programmes, notably public assistance and medical care. Nor, until they have definite assurances regarding Dominion financial policies on the social services, will most of them be in a position to make good decisions about the more costly extensions of service which are desirable. Secondly, administrative reform is basic to the improvement and extension of most of the social services. Larger amounts of money may be handed out without much trouble to old age pensioners and recipients of mothers' allowances through the existing machinery; but effective "service" to clients (which they often need as much as money) and adequate protection of the taxpayers' interest will not be guaranteed without great improvements in administration. More money can be allotted for public health; but without the general development of full-time local health units and the employment of properly trained personnel it will not go far to protect the health of the people. Child welfare, probation and parole, and mental hygiene are to a large extent "service" programmes that call first of all for sound organization and specially trained personnel if they are to get anywhere. Coverage of all parts of every province with appropriate services demands that the fundamental problem of provincial-municipal relations in the field of health and welfare be settled. The development of trained personnel is absolutely indispensable to satisfactory operations. Ineffective measures of co-ordination between the different programmes will lead to frustration and disappointment for applicants for help and to great wastes of money. Without strong administrative systems the provincial and local governments will be quite unable to contribute effectively to a national system of social security. Thirdly, there is a great backlog of administrative house- cleaning to be done, the results of neglect in the 1930's. Hence there is now a double need for reorganization—to overcome the confusion and disorder that is the legacy of the depression years and to prepare for the new obligations of the postwar period. The Premises for Provincial Planning 31 job needs badly to be done whether there is to be a great national programme of'social security or not. Administrative reorganization calls, first of all, for thorough surveys of the health and welfare systems of each province. These will provide the factual data indispensable for reorganization plans. During the 1930's there was but little objective study of social service administration. The Ontario Public Welfare Commission (1930) and the Quebec Social Insurance Commission (1930-1933) made broad and useful investigations at the beginning of the decade, but their administrative findings are now largely out-of-date. Much more useful for present purposes, although more limited in scope, are two provincial public health surveys, one made in Nova Scotia by the Rockefeller Foundation in 1935 and the latest in Manitoba by the American Public Health Association in 1941. As this is written there is a stirring in the provinces that promises useful results in the way of information and guidance on policy. Welfare surveys were made early in 1944 for Nova Scotia and Ontario, the results of which have not yet been published. Arrangements have been made for a welfare study of Manitoba by the American Public Welfare Association, and a Quebec Commission has reported on the hospital system and the health problems of that province.20 Other provinces are becoming interested in surveys. These studies should yield an inventory of the assets and the liabilities of the existing services such as has never been available before. The following chapters, particularly those on British Columbia, will give the writer's conception of the ground that ought to be covered by adequate surveys. Suitable reorganization plans will probably vary considerably from province to province on account of the peculiarities, historical, economic, sociological, and administrative, of each situation. No standard scheme can be constructed that will be appropriate everywhere. But past experience in Canada, in Great Britain, and in 20The Quebec Commission of Public Charities and Hospitals presented a report to the legislature in March, 1943, which has not been published*. PART II British Columbia The British Columbia Background to 1933 British Columbians are in- clined to boast about their social services. On those occasions when they compare their province with other domains, as when they make political speeches, write editorials on public affairs, address luncheon clubs, or describe the home setting to a newcomer, they are likely to point with pride to their "advanced social legislation" along with their great natural resources, the moderate climate of the Pacific Coast, the grandeur of the natural setting, and their dominantly Anglo-Saxon population. With all due allowances for provincial patriotism there is some reason for their claim. British Columbia does have a system of social services that is progressive as compared with others, at least in Canada. Before sketching the historical background of the system it will be useful to look briefly at the physical, economic, and social setting and to point out why this has been relatively favourable to the development of social services. Mountains and valleys, rivers and lakes, deep coastal bays and 35 36 Public Health & Welfare Reorganization rocky islands, green forests and bare hilltops—these are the physical characteristics that first impress the visitor to the province. North from the American border for more than 700 miles and west from the continental divide of the Rocky Mountains for 400 or 500 miles lies this great and distinctive area of rugged terrain, 366,255 square miles of land and water. In this huge territory there are only a few broad valleys or plateaus of arable land, notably the Fraser Valley near Vancouver, the Okanagan.Valley in the south-central part of the province, the "Kootenay Valley in the south-eastern part, the Cariboo and the Prince George districts in the north-central region, and the Peace River country (east of the Rockies and an extension of the western prairies) in the north-east. Agricultural land amounts only to 20,700 square miles, or 5.7 per cent, of the total area; and only about a quarter of this has been occupied by settlers.1 The great resources of the province are its forests and minerals rather than its agricultural potentialities. There are some 85,780 square miles of productive forest land (about 23 per cent, of total area) including the huge coastal stands of fir, hemlock, spruce, and pine2; mineral resources of gold, silver, lead, zinc, copper, coal, and low-grade iron are important; and the salmon and other fisheries of the Pacific Coast represent a valuable, if wasting, asset. Dominion Bureau of Statistics reports show that in 1939 the leading industry in value of production was forestry (including lumber manufacturing), while mining was third, and agriculture was fourth. About half of the net value of production was contributed by forestry, mining, and fisheries. Manufacturing, which held second place in 1939 with 21.5 per cent, of the net value of production, has increased greatly during the war period on account of the development of shipbuilding, airplane construction, and the making of munitions, and will no doubt occupy a much more important place in the economy of the province after the war than it did before. In such a land there is naturally not a large population. Accord- 1 Canada Year Book, 1938, p. 60. HUd. The British Columbia Background to 1933 37 ing to the Dominion census of 1941 there were 809,203 people, only 2.25 to the square mile. However, the population is highly concentrated in and around the main cities of Vancouver and Victoria in the south-western corner of the province. In 1941 Vancouver (with 271,597 inhabitants) and ten satellite municipalities made up a metropolitan area with about 368,000 people3; and Victoria (42,907) and the three surrounding districts of Oak Bay, Esquimalt, and Saanich made up an urban community of some 76,000 people.4 Thus the Vancouver district had about 46 per cent, of the total population and the Victoria district nearly 10 per cent. Since a large part of the remainder is to be found in lumbering, mining, and trading towns throughout the province urban concentration is relatively high. In 1941 there were only 106,196 residing on farms. Vast areas in the northern and central portions of the province are virtually uninhabited. The people are predominantly of Anglo- Saxon stock and many are English and Scottish immigrants who came to Canada in the great wave of migration that preceded World War I. However, there are two important alien elements in an otherwise homogeneous population, Orientals and Indians. The Oriental group (which has since been reduced considerably by the transfer of Japanese eastward as a wartime security measure) numbered 42,160 in 1941 and there were 24,882 Indians. Since the beginnings of settlement by white men, little over a hundred years ago, the province has had a history of booms and depressions arising out of the exploitation of natural resources. The-early fur trading at Victoria and on the Fraser River, the 3The cities of New Westminster, North Vancouver, Port Coquitlam, and Port Moody, and the districts of Burnaby, Fraser Mills, Coquitlam, North Vancouver, Richmond, and West Vancouver. There are also some portions of "unorganized territory" within the metropolitan area, the addition of whose population would bring the total to about 375,000. 4There has been a sharp increase in population in the coastal cities on account of wartime conditions. According to reports in the Vancouver Sun for November 23 and 24, 1943, ration book distribution figures for the month of August gave the Greater Vancouver area a population of 415,388, the Greater Victoria area, 82,390, and the province, 859,729. 38 Public Health & Welfare Reorganization Cariboo gold rush of 1858, the completion of the Canadian Pacific Railroad in 1885, the building of the Canadian Northern and the Grand Trunk Pacific transcontinental lines in the first decade of the present century, land settlement and land speculation just before World War I, shipbuilding and munitions making during the war years, the development of foreign markets for forestry and mineral products in the 1920's, and now another great expansion of war industry—these have been high points in the economic history of the province, each followed by recessions, some of which were very serious and prolonged. When the struggling colony joined the Canadian federation in 1871 as a province, in the hope of overcoming the economic stagnation of the day, the population was only 36,000. After the completion of the C.P.R. in 1885, linking the Pacific Coast with the East, early hopes for rapid development began to be realized. Population rose from 98,000 in 1891 to nearly 700,000 in 1931, the basic industries of the province emerged, towns and cities grew up, and schools and other amenities of civilized life appeared. The more enterprising or lucky of the new settlers made fortunes, and a relatively high standard of living for most people was achieved. This boom experience, checked only by relatively brief periods of depression for thirty years after 1900, generated in the people attitudes of exuberant optimism regarding material affairs and great confidence in the future of their province. If you were a British Columbian you were "progressive," by contrast with the "conservatives" from the East. The long and acute depression of the 1930's put a severe strain upon this pioneer "boom psychol- ology," but there is still much of it in the air, at least among the older people who built a new society out of a wilderness. Pioneer communities stand very much in need of vigorous and extensive service from their central government. Transportation must be provided to open up new areas and to link settled districts together, hospitals, education, and other community services are in demand, and impatient pioneers have no desire to wait for the gradual provision of these necessities and amenities by municipalities The British Columbia Background to 1933 39 and private organizations. Hence the provincial government has played a very important part in the physical development of British Columbia and has gone farther than the governments of the eastern provinces in assuming responsibility for community services of various kinds. Government finance, both provincial and municipal, has been dominated by the apparent need, in the days of rapid growth, for expensive roads, streets, bridges, and other public works, which led to heavy borrowing and a burden of debt charges that proved impossible or most difficult to meet during the long depression of the 1930's. j^ The importance of the provincial government in public affairs is further to be explained by the incomplete coverage and relative weakness of the municipal system.// Only one-half of 1 per cent, of the land area is within municipal boundaries, and some 204,000 people, or 24 per cent, of the population, lived in "unorganized territory" in 1941. Through its "government agents" the province operates the usual local government services for these people, with the exception of education, which, as in the municipalities, is generally administered by and through local school boards. The first legislation authorizing municipalities was passed in 1872, but their growth was slow. By 1941 there were sixty-one of them, consisting of the city of Vancouver, incorporated under a special act, and thirty-two city and twenty-eight district (or rural) municipalities incorporated under the provisions of the general municipal act. In addition there were nineteen village municipalities, a new category authorized by legislation adopted in 1920, which have only limited functions of local government. Most of the municipalities are small in population. In 1941 only 22 out of the 61 cities and districts had more than 5,000 inhabitants; and of these, 10 were the cities of Vancouver and Victoria and their satellite municipalities. Radical political ideas have played a significant part in the life of the province for the last forty years. Trade unionism, developed in large part by sturdy British immigrants who had been well schooled in unionism and socialism in the "Old Country," is 40 Public Health & Welfare Reorganization relatively strong. Since the turn of the century there have been Labour or Socialist members in the provincial legislature, supported by active Socialist groups in Vancouver and such working-class towns as Nanaimo and Fernie. Thus there were important roots for the emergence of the socialist Co-operative Commonwealth Federation, in 1933, as a political party on a par with the Liberals and the Conservatives, which for years had alternated in controlling provincial affairs. The influence of the labour and radical groups did something to bring questions of social reform to the fore even in periods of the most rapid growth, so that for many years there has been an undercurrent of social politics to which the older parties have had to give some attention in spite of their preoccupation with the development of natural resources and the central political business of being "in" rather than "out." v Such an environment has been fairly good soil for the growth of public social services/ Social problems early came to the fore in a society where urban communities developed rapidly, where booms were followed by slumps and good fortune for many was succeeded by economic ruin for others, and where the conditions for settled family life were not very favourable. Radical or progressive pressure and political groups were at hand to call for state action to cope with these problems.5 An optimistic and "progressive" public opinion was inclined to support public measures to meet the more urgent needs and to look with some approval upon advanced social policies. The great wealth of the province and its favourable economic prospects seemed to justify relatively generous expenditures on social services. The absence of private social agencies with vested interests and the relatively slow and weak development of municipal government left the field free for leadership by the province. / The thin spread of population over the interior and the consequent difficulty of delegating financial and 5In 1925, for example, a small group of Labour and independent members held virtually the balance of power in the provincial legislature, and it was on their initiative that the radical Male Minimum Wage Act was passed. The British Columbia Background to 1933 41 administrative responsibilities to municipal units further encouraged central control over policy and practice. How these forces affected the growth of the social services up to the 1930's will appear more fully in the historical sketch which follows. The Beginnings of Public Health Apart from a colonial ordinance on public health, incorporated in the statutes of the new province in 1871, which was but slightly used, there was no legislation of importance until 1893. An epidemic of smallpox in the summer of 1892 and a cholera scare brought home the need for more health protection and led to the adoption of a 'public health act. | This established a provincial board of health and designated municipal councils as local boards, and they were directed to concern themselves with sanitary conditions, the control of communicable disease, and other matters affecting health. The first provincial board, made up of physicians, had no permanent staff and was abolished n£ 1899, to be succeeded by a new board consisting of the Lieutenant-Governor-in-Council (the provincial cabinet) with a full-time medical secretary, Dr. J. J. Fagan. This marked the beginning of a real provincial health service. The public health code was extended by amendments and new legislation regarding the control of tuberculosis (1901), sanitary inspection and regulation (1904), inspection of foods (1906), medical examination of school children (1910), sanitary conditions in work camps (1911), and other items. Regulations of general application, to be enforced by the local health boards, were adopted. Elementary health services, under part-time medical officers, emerged in a few municipalities. The Provincial Health Officer played an important part in the formation of the Anti-Tuberculosis Society and the establishment in 1907 of the Tranquille Sanatorium, near the interior town of Kamloops, as a philanthropic institution for tuberculosis patients. From 1908 to 1920 Tranquille was supported in part by provincial grants. A cannery inspector, later to become 42 Public Health & Welfare Reorganization entitled "sanitary inspector," was added to the provincial staff in 1903. After being placed first in the Department of the Attorney- General and then in the Department of Agriculture, the administrative work of the Provincial Board of Health was transferred in 1907 to the Department of the Provincial Secretary, where it has remained ever since, h For the next thirty years the progress of public health in the province was due in large measure to the enterprise and the devotion of Dr. Henry Esson Young, a pioneer physician from the Atlin mining district of the far north, who entered the legislature early in the century, became Minister of Education and Provincial Secretary in 1907, and was appointed Provincial Health Officer in 1916, on his retirement from politics. Dr. Young, as minister and civil servant, laid the foundations of the present system. The collection of vital statistics, which had previously been under the Registrar-General of Titles, was taken over by the Provincial Board of Health in 1911.\ To combat tuberculosis more effectively the province purchased Tranquille Sanatorium in 1921 and began a travelling diagnostic clinic in 1923. Stimulated by an assurance of grants-in-aid from the Dominion the legislature passed a venereal disease control act in 1919 and set up free treatment clinics in Vancouver and Victoria. During the 1920's arrangements were made with several hospitals to carry on public health laboratory work in return for payments from the province, and in 1931, to cope with the growing volume of work, a provincial laboratory was opened in Vancouver, with operating expenses to be shared by the province and the city. In 1929 an epidemiologist joined the provincial staff. Dr. Young devoted much of his time and effort to the strengthening of local health services and the development of trained personnel. "Previous to the War [of 1914-1918]," he wrote, "health activities were confined in the public mind to sanitation, and to sanitation alone. When epidemics occurred they were considered as a The British Columbia Background to 1933 43 visitation from Providence, and every effort was devoted to checking the epidemic. When the epidemic was over the same neglect recurred. "6 There must be public education, trained public health doctors and nurses, and full-time personnel in the local health districts^ \\Largely on the initiative of Dr. Young a public health nursing course, the first of its kind in the British Empire, was established at the University of British Columbia in 1919./ The School Act was amended to authorize grants towards the salaries of public health nurses working with school children and Provincial Board of Health funds were appropriated for the same purpose. This inducement led some local authorities to appoint public health nurses, first at Saanich in 1917 and then in jother communities. ^The development of full-time local health units followed. The first of these, established at Saanich in 1921, was supported in part by grants from the Provincial Board of Health and the International Health Board of the Rockefeller Foundation, each of which met 25 per cent, of the costs. Two other units were organized later at Kelowna (1929) and at North Vancouver (1930), both stimulated by joint grants from the province and the Rockefeller Foundation. The foundation also helped greatly to develop personnel for the expanding work by providing fellowships for young doctors who were sent to Eastern Canada or the United States for postgraduate training in public health. By 1929 there were fifty public health nurses in the field doing generalized and school work and there were four municipalities and the three health units with full-time medical health officers, several of whom had taken specialized training for their work. Dr. Young's aspirations for an effective local system of public health were beginning to be realized.7 6"Full-Time Health Units in British Columbia," Canadian Public Health Journal (March, 1929), p. 133. 7See J. T. Marshall, "Public Health in British Columbia," Canadian Public Health Association, The Development of Public Health in Canada (Toronto: 1940), for a fuller historical sketch. 44 Public Health & Welfare Reorganization Public Assistance and Medical Care British Columbia, unlike Nova Scotia and New Brunswick and nearly all the American states, has never had a poor law./ However, there has been the equivalent of this in the simple provision of the % Municipal Act that "it shall be the duty of every city and district municipality ... to make suitable provision for its poor and destitute,"8 one of the earliest obligations imposed upon the municipalities. The obligation did not mean much in the early days of municipal history, partly because demands for relief were small and partly because there was no provincial machinery to guarantee that the local authorities would take it seriously. However, the city of Victoria found it expedient to establish the "Old Men's Home" by 1900 and to contribute towards the care of destitute old women9; while in Vancouver a municipal institution for the care of the aged was established some years later. The severe slump after the collapse of the railroad and land settlement boom of the first decade of the century led to much unemployment and destitution, particularly in the winter months, and Vancouver organized a relief department in 1914. After World War I there was heavy unemployment for a couple of years and winter unemployment was considerable for most of the 1920's. For the first ^ time, in the years 1920 to 1926, the Dominion granted aid to the provinces to assist them in providing unemployment relief, and during this period Dominion-provincial grants were made to Vancouver and a few other British Columbia municipalities in support of relief works or direct relief. Provincial expenditures on this programme were about $500,000 in total.10 But Vancouver /remained, until the 1930's, the only municipality with a per- V manently organized relief department. In Victoria, as late as 1932, the administration of civic relief was handled mainly by a private 8R.S.B.C, 1936, chap. 199, sec. 501. 9S. D. Clark, The Social Development of Canada (Toronto: 1942), p. 405. 10British Columbia, British Columbia in the Canadian Confederation, Submission to the Royal Commission on Dominion-Provincial Relations (1938), p. 108. The British Columbia Background to 1933 45 agency, the Friendly Help Association, with large subsidies from public funds. Since 1911 the secretary of this organization had also held the post of city relief officer. The province, on account of its administrative jurisdiction over unorganized territory, was compelled early to make some provision for the care of the destitute, particularly for the aged and the sick whose claims could not easily be brushed aside. As early as 1886 appropriations were made "in aid of the destitute, poor, and sick" and for the "burial of indigents,"11 and these increased in amount through the years until annual expenditures were about $100,000 by the end of the 1920's. To care for the old and the infirm without suitable homes, particularly the pioneer miners, trappers, lumbermen, and others who had opened up the new country and were worn out in the struggle with nature,\ the province established the Provincial Home at Kamloops in 1893. Municipal residents, as well as those from unorganized territory, might be admitted on condition that their municipality assumed 75 per cent, of the costs of maintenance. In 1922 another infirmary, with the uninviting name "The Provincial Home for Incurables," was established at Vancouver to serve both provincial and municipal cases, the latter at the expense of their home communities. Grants to resident physicians in outlying districts, to compensate them in some measure for service to the poor and to encourage them to remain in remote communities, began before 1886 and have continued on^ a small scale.12 Subsidies were also given to various private < charitable agencies practically from the beginning of the provinces- More important was the provision made for the hospitalization of indigent persons. As early as 1886 the sum of $19,000 was paid out to hospitals which made special claims for help,13 and in succeeding years the grants increased. To put order into the system! legislation was adopted in 1902 authorizing aid on a patienl;- llIbid., p. 169. 12Ibid., p. 91. ^Ibid., Table 82. 46 Public Health & Welfare Reorganization day basis for all hospitals complying with simple conditions, the most important of which was that they should freely admit and treat indigent patients needing care./ At the same time the municipalities were required to contribute in respect of each day of hospitalization given to their residents. Six years later a new system of "special" grants to hospitals was authorized, these to be made according to needs, mainly (although not exclusively) for the purpose of meeting capital charges. Thus there began a programme of^ provincial and municipal aid to hospitals, most of which were private (but not profit-making) institutions which has proven to be one of the most expensive social services in the province. By 1929 provincial grants, statutory and special, amounted to $898,748 and municipal aid to $459,451, a total of $1,358,199.14 Following the examples set by Manitoba (1916), Saskatchewan (1917), and Alberta (1919). British Columbia. p^HI th<> Mothpry Pensions Ac± in 1920. If it was not the first in Canada, it was the most generous. Mothers in need with one or more children under sixteen years of age, whose husbands were dead, disabled, or detained in prisons or mental institutions, were declared eligible to receive allowances amounting to $42.50 monthly for a woman with one child and $7.50 for each additional child under sixteen. The province was to meet all costs, thus relieving the municipalities of a large burden of responsibility to which they were technically liable under the indigent provisions of the Municipal Act. Administration of the new scheme was delegated first to the Department of the Attorney-General and then to the Workmen's Compensation Board, which had been established in 1916 and which had gained public confidence as a competent agency. There was a great rush of applications for this new type of public aid, and within a year and a half expenditures mounted far beyond expectations, to the rate of about $500,000 annually. By the fiscal year ending March 31, 1932, expenditures were $843,000 and there was serious concern about the size of the financial burden. Miss Charlotte Whitton uibid., .90. The British Columbia Background to 1933 47 of the Canadian Council on Child and Family Welfare, called in to survey the situation, reported in Decerriber, 1931, that the British Columbia scheme was "the most generous of its kind on the continent" by a wide margin, but attributed the heavy costs not so much to this as to the acceptance of a mistaken "pension" theory of mothers' aid and to serious laxity in administration.15 The "pension" theory was that mothers should be pensioned to stay at home and look after their children even if they were capable of making their own arrangements, by taking jobs or otherwise, to maintain their families. Miss Whitton's reccmmendations for administrative improvement included the appointment of a supervisor of mothers' pensions, specially trained and equipped for this responsible position, under the Superintendent of Welfare of the Provincial Secretary's Department, and the virtual doubling of the existing field staff of six persons and their distribution throughout the province in appropriate districts. Her proposals were partly implemented in 1932 by the appointment as supervisor of Miss Elizabeth King, a trained and experienced social worker from the East, and by transferring administration from the Workmen's Compensation Board to the Provincial Secretary. The next major item to be added to the public assistance system was the Old A^p p^ncirmq /\ rf Mf ] pfl 7 British Columbia was the first province in Canada to take advantage of the Dominion legislation of that year which offered 50 per cent, of costs as a subsidy to provinces passing enabling acts to authorize pensions up to $20 per month to needy old people over seventy years of age,// As in the case of mothers' pensions, administrative responsibility for the new programme was delegated to the Workmen's Compensation Board, on the theory that this agency, successful in its own field and trusted by the public, could do a better job of distributing large sums of money to individuals than any department of the government under direct ministerial control. Again the munici- 15"Report on the Administration of Mothers' Pensions in British Columbia," Supplement to Child and Family Welfare (May, 1932), p. 10 ff. 48 Public Health & Welfare Reorganization palities were relieved of a large part of their technical liability for poor relief, for the province undertook to assume all costs over and above the Dominion grant, and again expenditures mounted rapidly, until by 1930 they were running at the rate of more than $1,000,000 a year in total/ Other Welfare Services Well before the public assistance system took form mental hygiene had emerged as a distinct field of provincial administration. Even in colonial days the need for an institution for the insane had been felt. Some patients were sent to California for care in the 1850's and others were kept in jail in Victoria. The British Colonist, of Victoria, complained in 1860 of "poor Scotty" that "this miserable lunatic perambulates our streets day and night, reciting his insane gibberish to all who will lend an ear. What a pity we have not an Asylum where all such might be properly cared for"; and Matthew MacFie, in a book entitled Vancouver Island and Victoria which was published in 1865, pointed out that "lunatics were placed under the same roof with felons" in the Police Barracks, adding that he hoped "that this reproach will soon be wiped out and a suitable asylum provided for these unhappy creatures. "16 First steps to meet the problem were taken in 1872, with the opening of a small mental institution at Victoria, and in 1873, with j the adoption of the Insane Asylums Act. By 1876 the average number of patients under care was thirty-six and every year the number grew. Indeed, the patient group increased much faster than the population of the province, until in 1931 the average number was about 2,500 and annual expenditures on their maintenance exceeded $1,000,000.17 The New Westminster Asylum, red-brick, Victorian in architecture and facilities, and much too ugly for its lovely setting high above the Fraser River, was opened ^Quoted in S. D. Clark, op. cit., p. 328. 17British Columbia in the Canadian Confederation, op. cit., pp. 91, 92 The British Columbia Background to 1933 49 in 1878, but soon became overcrowded and additions were necessary from time to time. In 1913 the first unit of a fine new mental hospital was opened a few miles up the Fraser at Essondale (named after Dr. Henry Esson Young, then the Provincial Secretary in charge of mental hospitals) and this became the main institution for psycho tics. Progressively New Westminster was turned into an institution for mental defectives, mainly children. A third hospital, for the criminally insane, was established at Colquitz, near Victoria, in 1919. New units were opened at Essondale in 1930 and 1935. The first social worker was added to the mental hospital staff in 1930, and in 1932 a psychiatric clinic for children was begun in Vancouver. Child welfare problems called for the attention of the government early in the history of the province. At first grants were made to orphanages and other private societies. But as time passed it became clear that a more positive programme was necessary and in 1901 the Tnf^nts Art^ ^yp.s passed, providing for the appointment of a provincial Superintendent of Neglected Children and for the formation of children's aid societies. These provisions were modelled upon the distinctively Canadian pattern of public child care and protection which had emerged first in Ontario with the adoption of the Children's Protection acts of 1893 and 1897 and which soon spread to other provinces. The Infants Act, as amended later, defined the circumstances under which a "neglected child" might be removed from his parents or guardian by court order and transferred to the care of a children's aid society or the superintendent, and laid an obligation upon his municipality of residence, or, alternatively, upon the provincial government, to contribute to his maintenance by order of the court. Another important piece of legislation, the Adoptions Act, was added in 1920. The first children's aid society was organized in Vancouver in 1901 as a private agency under a board, to be supported from private funds with respect to its administration and its services to non-wards and from public funds with respect to the maintenance 50 Public Health & Welfare Reorganization of wards, subject to compliance with certain conditions specified in the Infants Act and to the general oversight and supervision of the Superintendent of Neglected Children. The Victoria Children's Aid Society, to provide service in the city of Victoria and nearby communities, was organized in 1901, and in 1905 there was established the Catholic Children's Aid Society of the Vancouver Archdiocese to care for Catholic children throughout an undefined area, in practice the whole province. Actually all three of these agencies have been used to serve wards from all parts of the province, for the provincial superintendent generally turned over to them children committed to his charge by the courts until recent years, and to some extent this practice still continues. A very important development occurred in 1927, when the Canadian Council on Child and Family Welfare made a survey of child welfare problems in Vancouver and the work of the Vancouver society. This led to the appointment in the same year of Miss Laura Holland, an able and experienced professional social worker from Toronto, as director of the agency, and to a reorganization which stressed the employment of trained personnel and the introduction of modern methods of child welfare work. By 1931 Miss Holland moved to the provincial service as Deputy Superintendent of Neglected Children, in charge of the child welfare work of the province under the Superintendent of Welfare (and of Neglected Children) who was appointed at the same time in the Department of the Provincial Secretary. Miss Holland's appointment marked the beginning of a professional approach in the welfare programme of the province, in place of the amateur (if useful and well intentioned) efforts which had been made previously by untrained personnel. The detention and the punishment, if not the reformation, of delinquents, required the attention of the provincial government from the beginning, for it inherited from the rough colonial days a bad crime situation. According to one account of Victoria in 1862 "the public Journal ... is literally teeming with records of the lawlessness of the people of these unhappy colonies. In a single The British Columbia Background to 1933 51 copy of the paper referred to, the following unparalleled black list is given . . . one murder, two attempts at murder, four of theft, one of stabbing, one of indecency, and numerous other minor offences."1 The province early established several "county gaols" to which prisoners sentenced either by the municipal magistrates or the provincial judges might be committed. In 1910 thp Ofl%j|ftt Prison Farm near Vancouver was nppnPf] fl« fhf TPfl1'n prifift" *™ tfrp p*r""T^T anc[ in addition smaller institutions at Kamloops, Nelson, and Prince George have been operated for many years. The jails have for long been under the jurisdiction of the Department of the Attorney-General. Separate provision for the detention and training of juvenile delinquents dates from 1890, when a juvenile reformatory for boys was established at Victoria, virtually as an annex to one of the provincial jails. In 1905 this was replaced by the "Provincial Industrial School and Boys' Home" at Point Grey, near Vancouver, and in 1921 the institution was moved to new and commodious buildings at Port Coquitlam, close to the Essondale mental hospital. The present Industrial School for Girls was established at Vancouver in 1914. The juvenile court system began in 1910, when the province adopted legislation to authorize the formation of juvenile courts, in conformity with the provisions of the Dominion Juvenile Delinquents Act of 1908. Courts were established in Vancouver in 1910 and in Victoria soon after, and gradually others were added. The juvenile court judges were authorized to appoint probation officers and the obligation of providing necessary physical facilities and paying the salaries of probation officers and other personnel was placed upon the municipalities within which the new courts were given jurisdiction. Since the concept of the juvenile delinquency services prevailing in the earlier years was one that regarded them as part of the machinery of law enforcement, along with the police, the law courts, and the prisons for adults, it was natural that 18D. F. G. Macdonald, British Columbia and Vancouver Island, quoted in S. D. Clark, op. cit, p. 340. 52 Public Health & Welfare Reorganization the industrial schools, as well as general oversight of the juvenile courts, should be placed under the Department of the Attorney- General. But growing recognition of juvenile delinquency as a welfare problem led to the transfer of the boys' school to the Department of the Provincial Secretary in 1921, and in 1934 the girls' school followed. Related Services, Public and Private British Columbia's reputation as a province with advanced "social legislation ' is probably based more upon its labour code than anything else. The Factories Ac]:, dating from 1908, provides for regulation of working conditions in manufacturing and forbids the employment of children. The eight-hour day was prescribed for workers in metal mines in 1899 and for coal miners in 1905, and in 1921 the ^mim of Wrrlf A"+ effective in 1925, broke new ground in Canada by limiting the workday to eight hours in industrial establishments of all kinds. Along with Manitoba, British Columbia led the way in 1918 by enacting a minimum wage act for women. Regulation of the wages of men in coal mining followed in 1919, and in 1925 came the Male Minimum Wage Act, first of its kind in North America, to provide machinery for setting minimum rates for men in a wide range of industry. This was a very radical innovation, aimed particularly at the employment of low-wage Oriental workers in the lumber industry to the disadvantage, it was thought, of whites, and it attracted a good deal of attention throughout Canada and the United States. Public employment offices were established in 1917 and two years later fee-charging agencies were made illegal. In 1917 t^** rippart- Tnpnt of Lfl.frnnr was organized to administer the growing code of labour legislation.19 British Columbia was the third Canadian province to pass a 19See B. M. Stewart, Canadian Labour Laws and the Treaty (New York; 1926) for a detailed account of early developments, The British Columbia Background to 1933 53 workmen's compensation act, following the lead set by Ontario in 1914 and by'Nova Scotia the following year. The act of 1916 was based largely on the Ontario legislation, which was very advanced for the time. It provided protection for a wide range of industrial workers, with administration being delegated to a board of three full-time, paid members, free from ministerial control. Its provisions were generous at the time and it has remained one of the most liberal measures of the kind in Canada. The Workmen's Compensation Board soon developed an administrative system that operated to the general satisfaction of employees, employers, and the public. This first experiment in social insurance helped to stimulate interest in other forms, and a Royal Commission appointed in 1919 recommended the adoption of health insurance. Another Royal Commission, after much more extensive investigation, reported strongly in favour of health insurance in 1932, and this paved the way for the legislation on the subject which was passed in 1936. Compulsory school attendance for children dates from legislation adopted in 1873 and 1876. Local school districts were established shortly after formation of the province, the organized municipalities (cities and districts) being constituted as school units and rural districts being created in unorganized territory. Under the provisions of the school code as it has grown the affairs of each district are governed by an elected school board, subject to compliance with standards set by the provincial Department of Education. Two provincial normal schools for the training of teachers have been established, the first at Vancouver, in 1901, and the second at Victoria, in 1915. The organization of a provincial university was authorized before World War I, but the opening of the University of British Columbia was deferred until 1916 on account of the war. Previously there had been no comprehensive provision for higher education, although an outpost of McGill University in Vancouver had offered partial college work. Dominion legislation providing grants to aid agricultural instruction in 1910 54 Public Health & Welfare Reorganization and technical education in 1919 stimulated the development of vocational education in these fields in the British Columbia schools. In 1920 a provincial School for the Deaf and Blind was established at Vancouver. With the growth of secondary schools and the diversification of curriculum the costs of education rose steadily. At first all expenses were assumed by the provincial government. But in 1888 part of the costs were transferred to the taxpayers of the local school districts and in 1893 a fundamental change was made, whereby basic responsibility, administrative and financial, was placed upon the school boards, with the financial role of the provincial government being limited to the provision of grants-in-aid except in special cases. By 1907 the local authorities were carrying about half the costs of the school system and by 1929 about two- thirds.20 The evolution of the system was described as follows in 1925 by two educational authorities: Beginning with a highly centralized system in 1871, in practice controlled from Victoria by one man, the school administration has developed in the direction of local control until its cities, district municipalities, and regularly organized rural sections have as much voice in school affairs as the older provinces of Canada and the states of the American Union, the only marked difference being that the Provincial Treasury bears a larger part of the total cost of education than is borne by any other province or state in America.21 Concurrently with the emergence of the equivalent public social services, or even after them (unlike the usual pattern of development in older communities), there was a considerable growth of private health and welfare agencies in Vancouver and Victoria, although not much in other places. By the 1920's a provincial tuberculosis society, tuberculosis clinics at Vancouver and Victoria, visiting nursing societies, missions and hostels for homeless men, homes for the aged and infirm, orphanages, relief societies, YMCA's and 20British Columbia in the Canadian Confederation, op. cit, Table 75. 21J. H. Putnam and G. M. Weir, quoted in Ibid., p. 150. The British Columbia Background to 1933 55 YWCA's, and other organizations had been formed under private auspices. After World War I the Canadian National Institute for the Blind, supported in part by a substantial provincial grant, undertook a fairly comprehensive programme of blind welfare, including the operation of a workshop for the blind. The Canadian Red Cross carried on more extensive health and welfare activities than prior to the war, including the operation of "outpost hospitals" in remote districts. Veterans' organizations entered the welfare field. Many separate appeals for funds by these agencies, including annoying tag days, and the unco-ordinated nature of the private health and welfare work called for better methods of community organization, and in 1930 Vancouver established the Vancouver Welfare Federation as a community chest and council of social agencies. Victoria followed with a council and chest in 1937. The Family Welfare Bureau of Vancouver was organized in 1928 and was placed under the direction of an experienced professional social worker from the East. Victoria followed suit with the formation of a family welfare society in 1932 to be staffed with trained social workers, in place of older relief and service agencies. Several surveys by eastern social workers had pointed to the need for more modern social machinery in the two cities and had paved the way for the action that was taken. The surveys also pointed out the great importance of trained staff and this led to the importation of several Easterners to occupy key positions in the new organizations and the reorganized agencies like the children's aid societies. Thus trained social workers appeared on the scene for the first time in the later 1920's. A demand for additional trained personnel for the more junior positions could not be met by importing people and training at home was the obvious solution. The first step to solve this problem was taken in 1929, when a modest graduate curriculum in social work was established by the university. As we have seen, a curriculum in public health nursing had been set up nearly ten years earlier. There was still no provision 56 Public Health & Welfare Reorganization for the training of physicians within the province, nor has this developed up to the present. Thus there had emerged, by 1930, a fairly comprehensive set of public health and welfare services. From spending little more than $100,000 annually at the beginning of the twentieth century the provincial government's outlay had risen to $3,845,000 for the fiscal year ending March 31,1930, about 15 per cent, of total expenditures for government during th/e year or about 20 per cent, of all current expenditures, not including debt charges.22 Municipal expenditures on health and welfare had also mounted steadily, to nearly $2,000,000 for the calendar year 1930, including $763,000 for the relief of the poor.23 There was concern, in both provincial and municipal circles, about the rapidly mounting burden of costs, but so long as economic prosperity prevailed it could be carried without real difficulty. The system had grown rapidly in response to particular needs and pressures, and far too little attention had been paid to problems of administrative machinery, co-ordination, or qualified staff. Hence it was ill prepared to face the mass problems of human need with which it was presented by the economic storm of the great depression which was at hand. The Impact of the Depression The economy of British Columbia, so largely based upon the primary-product industries, was very susceptible to the effects of world depression beginning in 1929. Export markets for lumber, minerals, fruits, and fish dried up, the new and promising tourist business declined, the vigorous construction industry virtually closet! down, prices fell sharply, winter unemployment rose to 22The totals, derived from the Public Accounts, cover health and welfare services under the jurisdiction of the Provincial Secretary's Department ml 930 and old age pensions, virtually everything except jails. 23British Columbia in the Canadian Confederation, op. cit., p. 166. The British Columbia Background to 1933 57 unprecedented levels, and men remained idle through the summer months. Per capita income, which had been the highest in Canada, declined by 47 per cent., from $594 in 1928-1929 to $314 in 1933, according to the estimates of the Rowell-Sirois Commission.24 This was close to the average decline for Canada (48 per cent.), the three Prairie Provinces having dropped more than British Columbia, and the other provinces less. On June 1, 1931, according to the Dominion census of that year, 27.45 per cent, of male wage-earners in British Columbia were not at work (mainly on account of unemployment), the highest percentage for any province.25 Destitution grew apace, and the unemployed besieged the municipal authorities for relief. The revenues of the provincial government dropped from about $26,000,000 for the fiscal year ending March 31,1930, to little more than $20,000,000 in each of the fiscal years 1933 and 1934 and the province incurred heavy deficits.26 Municipal revenues from taxation also dropped, although hot so sharply, but the government soon withdrew grants derived from liquor profits, motor license fees, and pari-mutuel betting taxes (amounting to nearly $2,000,000 in 1929), which had been made for about ten years. This drop in revenues from taxes and grants at the very time when expenses for relief were mounting sharply caused acute financial difficulties for the municipalities, and within a few years a number of them, including Burnaby, North Vancouver City, North Vancouver District, Fernie, and Prince Rupert defaulted on their debt obligations and their administration was taken over by commissioners appointed by the provincial government. According ^Report, Vol. I, p. 150. > 25Dominion Bureau of Statistics, Census Monograph No. 11, Unemployment, p. 257. 26This, however, was not a new experience. The casual and optimistic financing of the preceding years, when large sums were being borrowed for public works, had led to deficits in every year but two from 1912 to 1930, and this had contributed to the piling.up of debts, and annual debt charges, which on a per capita basis were the highest in Canada. 58 Public Health & Welfare Reorganization to the Rowell-Sirois Commission, "Debts rose rapidly and by 1933 the credit of the province and the municipalities was exhausted. "2 There were two major effects upon the social services—drastic curtailment of expenditures on most of the established programmes and the creation of a new service, unemployment relief, which was to be the most extensive and the most expensive of all. The provincial deficits of 1931 and 1932 led to frantic efforts to balance the budget. In 1932 the Kidd Committee, a group of businessmen appointed by the government to look into provincial finances, attributed the crisis largely to negligent administration and financial mismanagement in the past, stating that "the public purse has been regarded as an inexhaustible booty upon which all may prey."28 The remedy proposed was drastic retrenchment and economy, including discontinuance of all capital expenditures on highways and other public works, reduction in size of the legislature and in the number of government departments, transfer of all provincial police duties to the Royal Canadian Mounted Police, limitation of the age of free education to fourteen years, and abolition of the provincial grant to the university even if this led to the closing of its doors. The total prescription was too much for the people and the government of the day to stomach, but many of the recommendations were followed. Budgets for the various social services were cut sharply, staffs and salaries were reduced, extensions and improvements of all kinds were banned, mothers' pensions grants were cut from a basic figure of $42.50 monthly for a mother and one child to $35, and grants to hospitals were dropped from a basic figure of 70 cents per patient day to 45 cents. Miss Whitton, in her report on mothers' pensions,29 had recommended that the municipalities share in the costs, and the government took up this idea with so much enthusiasm as to go far beyond it. Legislation 27Report, Vol. I, p. 172. 28British Columbia, Report of the Committee British Columbia, p. 54. 290p. cit to investigate the Finances of The British Columbia Background to 1933 59 which became effective in April, 1932, imposed upon the municipal authorities an obligation to contribute 50 per cent, of the pensions granted to mothers resident in their communities and required them also to pay per diem charges for their residents who were patients or inmates of the mental hospitals, the Tranquille Sanatorium, and the boys' or girls' industrial schools. At the same time grants for education were reduced sharply. This policy of provincial economizing at their expense was naturally resented bitterly by the municipalities and it set the stage perfectly for years of controversy, ill-will, and lack of co-operation between the two levels of government. But what the province took away from the social services with the one hand it had to give with the other—and more besides. For the demands of the unemployed and their families for relief could not be denied. Until the fall of 1930 the municipalities and the few private agencies carried the growing load of relief without assistance from the province. Then the Dominion came forward with the first national unemployment relief act of the 1930's to authorize $20,000,000 for aid to the unemployed by means of work projects and direct relief. In October, 1930, the province made its first agreement with the Dominion to participate in this scheme, which provided that the Dominion would share equally with provinces and municipalities in the costs of direct relief to municipal residents and that it would assume half the costs of municipal relief works on condition that the province and the municipal authorities each carry 25 per cent. The Dominion undertook to share equally with the province the costs of works and direct relief for homeless men and transients (essentially, those without settled residence in any community) and for the residents of unorganized territory. Both provincial and municipal work projects were undertaken, supplemented by direct relief for those who did not benefit from emergency employment, and British Columbia was launched upon its largest enterprise in social welfare. The unemployment situation became increasingly worse, and for the winter of 1931-1932 both the province and the municipalities 60 Public Health Sc Welfare Reorganization planned ambitious work programmes, to cost altogether about $12,000,000.30 It was agreed that transients and single men should be moved from the cities to work camps where they might be employed on road construction and other jobs, and the province hastily constructed or acquired 237 camps, with a capacity of some 18,000 men, at a cost of $667,000.31 Work on the proposed projects had scarcely begun when the Dominion decided the plans were too extensive and sliced in half the grants that had been promised. This led to great curtailment in the provincial programme, with the men in camp being given only their maintenance for part of the winter and later an additional nominal wage of $7.50 per month in return for limited work. After this costly fiasco there was a general retreat from the policy of wage employment on public works and the method of direct relief dominated for the next three years. The municipalities continued to receive grants of one-third of their relief costs from both the Dominion and the province up to the summer of 1934, while the Dominion shared the costs equally with the province for the residents of unorganized territory. Early in this period the policy was laid down that Dominion-provincial relief grants were designed only for employable persons and their dependents, and not for "normal cases of indigency or destitution, which are solely the responsibility of the city or municipality concerned.32 Special measures were taken to deal with the problem of transients and homeless men, chronically serious in British Columbia because of the drift to the towns in the winter months and in periods of depression by unemployed workers from the primary industries, including many from the Prairie Provinces who sought the mild climate and other attractions of the Pacific Coast when they were idle. For the year 1932-1933 the Dominion agreed to 30British Columbia, Report of the Select Committee of the Legislative Assembly on Unemployment, 1932, p. 2. 31Ibid., p. 4. 32Minutes of the Unemployment Relief Committee of the Cabinet, Nov. 17,1930. The British Columbia Background to 1933 61 meet all the costs of maintaining men in camps, up to 40 cents per inmate per day, to be administered by an "Honorary Commission." This scheme lasted for only one year, being replaced from 1933 to 1936 by Dominion operation and financing of the camps, under the Department of National Defense. During this period homeless men were offered subsistence in the camps and an allowance of 20 cents per day in return for some work. Since the whole programme was regarded as an emergency undertaking, with Dominion aid to the province and provincial aid to the municipalities being on a year-to-year or (sometimes) a month-to- month basis, and since there was no provincial administrative machinery in existence to handle such an undertaking, improvisation in policy and administration was necessary. The Cabinet Committee on Unemployment Relief was established in October, 1930, to direct the programme, with details of administration being delegated to several government departments. The Public Works Department administered the provincial work projects and operated the work camps of 1932-1933. The office of the Deputy Provincial Secretary dealt with questions of direct relief, including administration in unorganized territory and grants to the municipalities, until May, 1932, when this work was transferred to the Secretary of the Unemployment Relief Committee. In September of 1931 the Provincial Health Officer assumed responsibility for problems of medical and sanitary service in the work camps. Field service of one kind or another was undertaken by the government agents of the Department of Finance, the district engineers of the Public Works Department, the employment office officials of the Department of Labour, and the provincial police of the Department of the Attorney-General. The cabinet committee formulated policies on a day-to-day basis, often with little regard to principle or consistency, there were few clear rules to guide or limit the municipalities in their administration, supervision of the local authorities was very slight, and confusions, uncertainties, and conflicts were common. The municipal councils likewise had to 62 Public Health Sc Welfare Reorganization improvise an administrative machine. Their casual provisions for handing out poor relief were insufficient and the larger places turned progressively to the appointment of "relief officers" and the employment of full-time staff; but in many places the municipal clerk or some other official added relief administration to his other duties, perhaps with the assistance of one or two men recruited from the ranks of the unemployed. For the first three years the relief programme grew steadily in extent. By March of 1933 the number of recipients of relief rose to 128,358. With old age pensioners, poor relief recipients, and other groups added the total number in receipt of public assistance in that month was 151,730, or 22.1 per cent, of the population of the province.33 As it turned out, this was the peak month of the whole depression period, but the relief and other public assistance rolls remained very high for several years, declining only slowly from the high points reached in 1933. For each of the fiscal years ending March 31, 1931, to 1934, total relief expenditures exceeded $8,000,000, with the provincial share over $3,500,000 and the municipal share over $1,000,000.34 This heavy new expense, arising at a time when public revenues were greatly curtailed, created financial problems which were completely baffling to the provincial government of the day and to many municipal councils. Political Repercussions The Conservative government headed by Hon. S. F. Tolmie, which had held office since 1928, was bewildered and overwhelmed by the problems of the depression. Frantically it strove to repair provincial finances at the same time that it did something to meet the most urgent needs of the people for economic maintenance. But almost everything it did, including the muddling over work camps in 1931, its treatment of the municipalities, its curtailment of 33From unpublished statistical records, office of the Director of Social Welfare, Provincial Secretary's Department. s4British Columbia in the Canadian Confederation, op. cit., p. 108. The British Columbia Background to 1933 63 educational grants, its drastic reduction of the university grant, and its turn for advice to the reactionary Kidd Committee, gained ill will rather than popular approval. Progressive British Columbia was shocked. "Sound finance," "belt-tightening," "retrenchment," and "patience until natural economic recovery" were not precepts to satisfy a vigorous and intelligent people. Revolutionary talk was in the air. Radicalism grew apace. The election of Mr. Roosevelt to the presidency of the United States and the emergence of the "New Deal" suggested the need for a similar movement in Canada. Socialist and Labour political forces coalesced to become one of the most important provincial units of the C.C.F., organized in 1931 and 19B2; and under the new banner they attracted great numbers of new members to their ranks. Any political party that hoped to win the next election must offer a radical, or at least a progressive, programme to the electorate. The Conservatives were incapable of changing their colours to this extent, Mr. Tolmie's government literally disintegrated on account of internal quarrels and resignations, and the political choice lay between the Liberals and the rising C.C.F. The Liberals, headed by Hon. T. D. Patullo, a vigorous and optimistic pioneer who had grown up with the country, hammered out a programme that promised "work and wages," economic development, health insurance, educational reform, and expansion of social services, as well as stabilization of provincial and municipal finances. The more respectable and substantial citizens, conservatives as well as progressives who believed that "something ought to be done," turned to the Liberals as the only group which could defeat the revolutionary and politically inexperienced C.C.F. When the smoke of battle cleared away after the provincial election in the fall of 1933 the Liberals had captured a large majority of the forty- eight seats in the legislature, the C.C.F. had won seven seats to become the official opposition, and there was a scattering of independents, most of them former'Conservatives who had disowned their party's label. The C.C.F. had polled nearly one-third of the 64 Public Health & Welfare Reorganization total vote, a very good beginning for a new and inexperienced party. Clearly the time had come for a provincial government to turn from the easy-going frontier politics of roads and bridges and construction contracts and patronage and the spoils of office to the politics of social welfare in order to retain the confidence of the people. To the three cabinet posts most concerned with the social services, those of Labour, Education, and the Provincial Secretary, Premier Patullo appointed his two most liberal supporters, Hon. George S. Pearson and Hon. George M. Weir. Mr. Pearson, a self- made man who had built up a successful business in the mining town of Nanaimo and who had been a prominent member of the Royal Commission on Health Insurance of 1929-1932, took over the portfolio of Labour and the responsibility for unemployment relief administration. Dr. Weir had been professor of education at the University of British Columbia and was well known throughout western Canada as an able teacher and educational leader who held progressive views not only on his own subject but also on social questions in general. The fact that a man of such standing was attracted to the Liberal camp was one of the chief guarantees offered to the electorate that the party was really committed to a policy of reform. Dr. Weir was given the two portfolios of Education and Provincial Secretary, carrying with them jurisdiction over the two largest departments of provincial government. Other ministers were not so noted for their progressive views—and indeed one, Hon. John Hart, the Minister of Finance, was frankly conservative. Mr. Hart was a partner in a successful financial house in Victoria whose ability and genial personality had led to a successful career in politics extending over many years. It was his business, in the new government, to clean up the tangled financial affairs of the province and to find the money for the bold and brave schemes of the Weirs and the Pearsons. Obviously he stood in a strategic position—for without his collaboration social reform could not go very far. And since he was a "sound money" man who The British Columbia Background to 1933 65 would not agree to anything that would interfere seriously with the balancing of the budget and the re-establishment of provincial credit with the financial houses of Montreal and New York he. represented a most important barrier to the costly extension of public services. Politically, the stage was set for something of a New Deal—but a very modest New Deal, compatible with Mr. Hart's financial policies. " Work and wages " was the first casualty. The Dominion wouldn't provide the money, Mr. Hart couldn't, or wouldn't, go in for deficit financing, and there was little money to be obtained through orthodox methods of finance. So the New Deal was destined to be confined mainly to developments in the fields of labour, education, and the social services, under the jurisdiction of Mr. Pearson and Dr. Weir, which, with the exception of the very necessary unemployment relief, were not very costly. But some of these, as we shall see in the next chapter, were of considerable importance. A Decade of Progress—Health and Other Services F JL OR THE REASONS OUTLINED IN the last chapter problems of the social services were grave and numerous when the new government took office in November of 1933. Among the critical situations were the following: 1. The Department of the Provincial Secretary, in which most of the health and welfare services were grouped, was a poorly organized mixture of more or less autonomous agencies, lacking qualified personnel in key positions and essential staff to perform field duties. 2. Restriction of public health budgets for several years, during a period of economic distress when needs for service were greater than before, had led to a situation in which the health agencies were overwhelmed with demands which they could not meet. 3. There were urgent needs for medical care for the relief population and for many above the relief level. The hospitals were overwhelmed with demands for free service and were pressing the government for more financial aid. 4. The mental hospitals were overcrowded and public demands for preventive work in mental hygiene were not being met. 66 A Decade of Progress—Health and Other Services 67 5. There were bad internal situations, verging on the scandalous, at several institutions, notably the Tranquille Sanatorium and the Boys' Industrial School. 6. The municipalities, impoverished and indignant over the financial treatment to which they had been subjected by the province, were taking it out on the destitute in many cases by granting only pittances of relief and by ignoring or evading the social welfare obligations for which they were technically responsible. 7. Provincial machinery for the administration of unemployment relief was relatively undeveloped and was unsatisfactory, relations with the municipalities were bad, and relief provisions varied greatly from place to place. Problems of relief for the homeless, particularly physically handicapped men excluded from the Dominion National Defense camps, were acute. The two ministers chiefly concerned with the social services, Dr. Weir and Mr. Pearson, proceeded vigorously to undertake internal housecleaning and to improve the programmes underJ:heir jurisdiction. Fortunately there was a gradual, if slow,^improve- ment in the economic situation and in provincial finances, and they ! obtained increased appropriations for their departments. In consequence they were able to make a number of significant reforms during the next four years, touching practically every branch under ' their control. In June, 1937, there was a new election and the government was returned to office, although with a reduced majority. The financial situation continued to improve, but the j movement of social reform had spent its strength and there were not many new developments until after the beginning of the war.4 Then another election in October, 1941, led to an indecisive result, with the C.C.F. and the Conservatives gaining at the expense of the Liberals and no party having a clear majority. This was followed by the establishment of a coalition government of Liberals and Conservatives under the Hon. John Hart. Dr. Weir, in spite of outstanding services, was not re-elected to the legislature and Mr. Pearson became Provincial Secretary. Since then, under Mr. Pearson's leadership, there have been important administrative 68 Public Health & Welfare Reorganization reforms and advances in extent and quality of service. This chapter will sketch the major developments in public health and a number of other fields since 1933 and the succeeding chapter will outline the record in public assistance and wartime reorganization. The Provincial Secretary's Department The concentration of most of the health and welfare services under the Provincial Secretary had been the result of drift rather . than of long-range plan. The name of this cabinet officer suggests that his functions were not originally intended to be those of a minister of social services. The fact that his early duties were relatively light and that there was no other department into which • the gradually emerging health and welfare services would logically fit explains their progressive grouping under his direction. There they were brigaded along with administration of the Elections- Act and the Superannuation Act, the Civil Service Commission,, the Provincial Library, the Provincial Museum, the King's Printer, • and other odds and ends with which they had no close connection. Within this overgrown department, where the tail had become much bigger than the dog, the several main branches that had emerged,» notably the Board of Health, the mental hospitals, and the Welfare • Branch, were virtually autonomous, several small institutions • were operating pretty much as they chose, and much business that- called for branch organization was being handled by the central offices of the Deputy Provincial Secretary and the Provincial1 Health Officer. Tnese two officials, overloaded with the details, of their centralized administration and with little or no help from responsible assistants, were unable to supervise properly the pro-' grammes under their jurisdiction or to give adequate attention to problems of policy and co-ordination. None of the institutions and' agencies in the department except the Welfare Branch had any field" staff, intradepartmental co-ordination was poor, and administrative. methods and procedures were commonly casual and inefficient. A Decade of Progress—Health and Other Services 69 The chart on the next page, a modified version of one prepared in 1933, wil! show the organization at that time and will illustrate graphically the points that have been made above. After dealing with emergency problems, such as internal difficulties at the Boys' Industrial School and the Tranquille Sanatorium, the new Provincial Secretary turned his attention to clearing up the tangled affairs of his department. Since there was neither time nor facilities for making specific plans prior to the session of the legislature in the spring of 1934 nothing of importance requiring legislative action was proposed except the appropriation of $100,000 for."Special Health and Welfare Services" without any commitments being made as to how it should be spent. This fund proved to be a godsend in that it made possible prompt action on several matters of importance without waiting for specific legis- . lative appropriations, and it was renewed, in lesser amounts, at later sessions of the legislature for a number of years. In July of 1934 the first important reorganization step occurred, when the position of Director of Social Welfare was created, to which the writer was> appointed. The new official was to share general jurisdiction with the Deputy Provincial Secretary over the health and welfare services j of the department, dealing specifically with problems of reorganization, planning, and co-ordination, while the flow of ordinary j administrative work continued to go through the deputy's office.. Those who were immediately concerned recognized from the beginning that this dual arrangement, whereby the normal functions of the deputy minister were divided between two officials of equal | status, was dubious in principle, but at the time there were reasons of expediency for it and it worked reasonably well for a number of years. Shortly afterwards a conference of the senior officers of the department met in Vancouver to review outstanding problems and out of this arose many suggestions for action, sufficient in the way of agenda for several years of work. M 1 8 JSE |> tion ol Act, ontrol ;Act, quirie >usGr dministra Elections Liquor C Plebiscite Public In Act, et [iscellanec fficial Ent en O > w eft as /C _ — 11 .|| 1 S"| ■'5 i £ *J<- p suL5 «£i r3° y |j cS' 1 ■* 1 1 i i ........J 1 .... I l__l I.,.,.,,, » 1 8 spitals ai ispection Municip ice Char &*>» as1-1 O.® (Be *ofe £ ■3* £ nts to nts to ssociaf nts to hysicia >cial S. e- ©en u o o o u co 00 G> < ■s 1 1 •{• ->> H o u c3< > * e "2 H 3s 1 ^ £ 2; O ll §H EC g. 1 1 1 » X P 1J u o < £" HW |i2 as S3 \ | O 2 O Q I I I I I Q as eft 3 Cd W cfl a q o o ^ w cc < 'i £j §5 fc u I 8 as Q ssondal ew Wes hild Gu S w z u u Ed das oas g Vital Statistics Medical Inspection of Schools Grants to Public Heal Nursing and Health Units Tuberculosis Clinics Provincial Laboratory Sanitary Inspection Venereal Disease Clin Unemployment Relief Medical Service A Decade of Progress—Health and Other Servi Central Services 71 One of the most urgent needs was for a staff of social workers to undertake field work throughout the province for the different branches and institutions. At the end of 1934 only the Welfare Branch, with a supervisor and nine visitors stationed at Vancouver and four other points, had such a staff. These visitors were mainly engaged in mothers' pensions work, although they dealt also with child welfare and provincial poor relief cases. In addition there were two specialized child welfare workers in a Vancouver office, two social workers on the staff of the mental hospitals, and one' attached to the Boys' Industrial School. Only a few of the group had had formal training in social work. A departmental memorandum of December 20,1934, summarized the situation as follows: In consequence of the lack of field staff outside of the Vancouver district, our branches and institutions have to rely upon assistance from provincial police, government agents, municipal officials, and « others who are not equipped to do specialized work for us and who of course have other main duties in which they are naturally very much more interested. The Welfare Field Service was established in April, 1935, to solve this problem. Since it was obviously uneconomical and impossible for each division of the department to engage enough social workers to cover the province effectively, the new unit was charged with the responsibility of providing, through district offices, a generalized service for all branches. In addition it was to allocate social workers to specialized duty with the different i branches insofar as this was necessary. Fortunately an outstanding social worker, Miss Laura Holland, was at hand to undertake the direction of this new and essential piece of central machinery, which was set up under the office of the Director of Social Welfare. The existing field staff of the Welfare Branch, consisting of nine visitors, made up the nucleus of the new unit and six new positions werev authorized. Social work supervisors, as they came to be appointed, 72 Public Health & Welfare Reorganization were attached directly to the respective branches which they served, but all rank and file workers were appointed to the Welfare Field Service, except in the case of the mental hospital and industrial school workers who remained outside of the scheme. A council of supervisors was organized, under the director of the field service, to work out problems of policy and co-ordination. Centralized control of social work personnel made possible uniformity of policy regarding recruiting and staff development,j which was particularly important because of a chronic shortage of trained and experienced personnel. At the outset personnel standards were adopted which called for graduate training in social ■ work or the equivalent and all possible efforts were made to recruit trained personnel. Most of the recruits were young graduates from the social service course of the provincial university. Provincial funds were appropriated to provide scholarships for the training, at the University of British Columbia or elsewhere, of likely persons already on the departmental staff or outside of it who would agree to accept positions on completion of their studies. During the next ^ve years the field service grew steadily, with more (and smaller) districts being set up progressively throughout the province and staff and duties being expanded. By March 31, 1940, it consisted of a director and thirty-six visitors, performing- generalized service in fifteen districts (including Vancouver and Victoria) or doing specialized work for five different branches of the department. Out of the group of thirty-six, twenty-eight were professionally trained for social work.1 The generalized visitors were then serving ten different units of the department, the Welfare Branch, the Child Welfare Branch, the Division of Tuberculosis Control, the Division of Venereal Disease Control, the mental hospitals, the industrial schools, the Division of Vital Statistics, the office of the Inspector of Hospitals, the Provincial Infirmary, 1 Annual Report of the Welfare Field Service, 1939-1940, mimeographed, p. 2. The staff remained the same in size the following year and was increased slightly in 1942. A Decade of Progress—Health and Other Services 73 and the Collections Office. "In addition," the director wrote in a report in 1939, "the municipalities frequently call upon them in problem situations. They give as well an appreciable amount of service to private agencies of the two large cities and of cities outside the province—and even outside the country—the latter through the Inter-Agency Service of which we are a member." Their duties were further increased in the war period by undertaking investigations and reports for the federal Dependents' Allowances Board and Board of Dependents Trustees. With demands growing steadily as the value of the service became better known, volume of work increased faster than qualified staff and the visitors were* always overloaded. But the work was interesting, the new project was exciting, morale was high, and the young social workers plunged bravely into difficult situations. By their works they proved the great usefulness of the new scheme and they obtained widespread acceptance and support. Some of the early difficulties and achievements of the visitors have been vividly described by Miss Isobel Harvey, Superintendent of Neglected Children, as follows: There is so much variety . . . that the visitors are willing to put up with a good deal. You don't get bored when you start the day with a mothers' pension visit, look in on a neglect case, take the information for a social history on a patient just admitted to mental hospital, and finish up with an argument with the municipal clerk or the government agent over the proper amount of relief to be paid to a T.B. convalescent just out of hospital—you just don't get a chance to get in a rut. . . . The visits must be made, no matter how hard the road. I wonder how many of us would come back cheerfully at the end of a day after having driven one hundred miles over a bad road, walked ten miles, three of them down a railway track and the rest in the bush—walked a boom of logs and crossed the Fraser River twice in a dugout canoe with half a foot of water in it. Our youngest visitor did just that in her second week in the field. . . . This does give her an excellent chance for publicizing her services, the only disadvantage being that when she does sell the idea of social work, she is almost overwhelmed, for the powers-that-be 74 Public Health & Welfare Reorganization refer everything to her, from Johnny's temper tantrum to where Mary is to get a new wooden leg. . . . Gradually it grows upon the mind of the community that this work is not as simple as it looks. The visitor's plan is diametrically opposed in a certain case to community opinion, yet strangely enough it works out better for the individual and saves community funds, so they start to ask questions. . . . Her community is becoming social-work conscious, and from various points in the province we are now getting results.2 Since government finances were in very poor condition in 1933 it was particularly important that every possible effort be made to improve departmental revenues. One possible means of doing this was to increase collections from patients in the mental hospitals and other institutions or from their responsible relatives who, according to the regulations, were required to pay for care or treatment in accordance with their means. Collecting the fees had been -the responsibility of the bursars of the respective institutions, but they lacked the machinery for doing an effective job and revenues from this source were very low. Another central office, that of the Collector of Institutional Revenue, was set up in Vancouver in j March, 1935, to handle collections for all branches of the department and to prepare claims for payments against the estates of deceased patients. In order to bring order and uniformity into the system of charging according to means, uniform policies on this subject were established for all institutions and an assessment committee, composed of a number of departmental officials, along with the collector, was appointed to pass upon all agreements with patients or relatives for service at less than full fees. The Welfare Field Service undertook the field work necessary to obtain reports < on the capacity of patients or relatives to meet charges and to negotiate agreements with them. The new system led to a prompt and a substantial increase in collections and, generally speaking, to s 2"The Generalized Social Worker in Public Welfare," Proceedings of the Fifth Canadian Conference on Social Work, 1937, pp. 32-34. A Decade of Progress—Health and Other Services 75 good-will on the part of those who were assessed, for they were not pressed to Commit themselves to payments beyond their capacity. As time went on the Collector of Institutional Revenue came to act - informally as a personnel officer for the department in Vancouver in the case of clerical and other junior employees, thus relieving various branches as well as the head office at Victoria of a good deal of detail. Public Health The first step that was necessary in 1934 to improve the provincial public health service was to relieve the Provincial Health officer and his'small office of the crushing load of work incidental ■ to administration of the unemployment relief medical service. This was achieved by transferring this programme in March, 1935, to the newly established Medical Services Branch of the * Provincial Secretary's Department. A major problem was the inadequacy of local health services, particularly in rural districts. Dr. Young returned with enthusiasm to his campaign for health units. Two new ones were established in 1935, in the Peace River district and in the Matsqui-Sumas- Abbotsford district of the Fraser Valley, with the aid, as before, of grants from the provincial government and the Rockefeller Foundation. The way was cleared for these developments by a programme of reform initiated at this time by the Department of Education which included, among other things, the formation of larger school units in rural districts. In 1935 some sixty-five small school districts in the Peace River area were combined into one administrative unit and there was a similar consolidation in the Matsqui-Sumas-Abbotsford area. In both cases the Department of Education co-operated eagerly in the formation of the health units, which took over the school medical work and consolidated it with the generalized public health service, thus eliminating the previous overlapping of these similar programmes. The functions 76 Public Health & Welfare Reorganization of the health units and their advantages are simply described by the Provincial Board of Health as follows: A Health Unit is merely a modern full-time health department staffed by full-time trained public health personnel. In British Columbia, Health Units are responsible for all the generalized public- health services made available locally for the areas they serve. These services include the school health programme . . . and are the media through which the specialized Provincial health services are translated into action for the people. Many parts of the province do not benefit from these specialized services because they have no adequate [local programme]. ... It is impossible for small cities, towns, and rural areas to independently employ sufficient full-time health personnel to meet their needs, but by combining their resources with those of adjacent communities it is possible to develop and support a Health Unit.3 There was also need for the consolidation of the local health services in the Greater Vancouver area, partly for the reasons given above which applied particularly to a number of small municipalities in the metropolitan district, and partly for other reasons. One of the most compelling arguments for amalgamation was that the metropolitan community was a unit from the standpoint of the control of communicable disease. Measles, whooping-cough, and other communicables moved freely across local boundaries, and poor measures of control in one municipality made it practically impossible for others to do a good job. Moreover, it appeared that certain common overhead costs might be avoided and other economies effected if the separate municipal health services were merged or brought under common direction. For some ten years the idea of a metropolitan health service had been discussed, but it was not until the Provincial Board of Health took vigorous action \ to work out detailed plans and reconcile differences of opinion among the local groups that results were achieved. In 1936 the Metropolitan Health Board was established, with - the aid of provincial and Rockefeller grants, to provide a unified ^Annual Report, 1942, p. 27. A Decade of Progress—Health and Other Services 77 health service for the municipalities of Vancouver, North Vancouver City, North Vancouver District, Richmond, and Burnaby, and for the University of British Columbia area. Provision was made for the later entrance of other municipalities. The formula for union did not provide for a totally integrated department, but only for the pooling of existing general and school services under a central; Metropolitan Health Committee and the administrative control of the Senior Medical Officer of Vancouver, who was also made . health officer for each of the other municipalities. Thus each constituent unit might keep its own identity and have its own budget. However, this represented a long step towards complete amalgamation. 'The scheme was particularly significant because it was the first of the kind in North America, and it has attracted much favourable comment from public health authorities throughout the United States as well as Canada. The Provincial Board of Health continued with its missionary work regarding the virtues of health units, but local appreciation of the policy grew slowly and it was the beginning of 1942 before another one was established—this time in the Okanagan Valley, including the former Kelowna unit. Later in the year the Prince Rupert unit was formed and in November of 1943 the Central Vancouver Island health unit followed. These new schemes were aided by two government grants, one from the Provincial Board of Health in respect of the. work in general and another from the Department of Education in respect of each nurse employed. In the case of the earlier units, which had been aided in part by grants from the Rockefeller Foundation for a limited number of years, the province increased its assistance to make up for the loss of * Rockefeller funds. By 1943 there were five units in full operation outside of the Vancouver district (the Matsqui-Sumas-Abbotsford unit having been curtailed in its activities because of the wartime shortage of public health physicians) and these, with the Vancouver metropolitan board and the health departments of Victoria and a few other municipalities, gave full-time service to the great majority 78 Public Health & Welfare Reorganization of the population. In most communities which were not ready for health units public health nurses had been placed progressively, . with the assistance of Board of Health and Department of Education grants; so that about 80 per cent, of the population had the advantage of public health nursing service by the end of 1943.4 The development of the local health programmes called for consistent support, guidance, and technical assistance from the Board of Health, much more than the Provincial Health Officer or * any of the heads of his operating divisions could give. In particular, the local agencies needed supervision and assistance from . three well-qualified specialists, a public health physician, a public health nurse, and a sanitary engineer, the counterparts of the technical team of three required for the chief posts in the local units. The first important step towards solution of this problem was the creation, in 1936, of the position of Assistant Provincial. Health Officer, to whom was delegated special responsibility for the local services. In 1940 a director of public health nursing was ■ added to the provincial staff. This was a particularly valuable addition, for the public health nurses in small communities had been working for years without proper supervision or technical - assistance, and they agreed, as did the health officers, that professional leadership for this phase of the total programme was much to be desired. In the same year the post of chief sanitary engineer - was vacated by the veteran who had filled it for thirty years and it was replaced by a new position, that of public health engineer, to which a graduate engineer with post-graduate training in public health was appointed. Another new appointee was a dentist, who was given charge of a programme of preventive dentistry which had been conducted for some years in small towns and rural communities with the aid of modest grants from the province.5 Dr. Provincial Board of Health, Report, 1943, p. 39. 5The Provincial Secretary, arguing for funds for this project, said, "There are more holes in the teeth of the school children than there are in the roads of British Columbia"—and nobody could deny that, if the statement was true, it was an appalling indictment! A Decade of Progress—Health and Other Services 79 H. E. Young had died in 1939, after many years of honorable service, and the new Provincial Health Officer, Dr. G. F. Amyot, ■ who had already played a leading role in the reforms accomplished since 1934, set up the Bureau of Local Health Services within the * Board of Health to channel the technical services of the specialists to the local units and to take general charge of relations with them. This was placed under the direction of the Assistant Provincial Health Officer. The appointment of a nutritionist to the central staff, in 1942, rounded it out still further. Tuberculosis Control In 1933 the death rate from tuberculosis in British Columbia was 76.5 per 100,000 of population, far higher than the rates of other provinces except Quebec and the Maritimes. Tuberculosis caused about six times as many deaths in Vancouver as all other - infectious diseases combined. Tranquille Sanatorium and the tuberculosis wards of the general hospitals were crowded, homeless men with tuberculosis were lying virtually untended in primitive hospital camps set up by the relief authorities, and newly diagnosed cases could not gain admittance to sanatoria. Citizens held public meetings to complain about this scandalous situation and to demand the immediate construction of a two-hundred-bed tuberculosis institution in the Vancouver district. It was clear that the machinery of tuberculosis control in the province was far from adequate. Analysis of the problem showed that the resources of control Were not only insufficient but were also badly dispersed and unco-' ordinated. The chief resources were about 585 tuberculosis beds, more than half of them at Tranquille Sanatorium and the remainder in several general hospitals; a stationary clinic at the Vancouver General Hospital, maintained jointly by the hospital and the city of Vancouver; one travelling diagnostic clinic under the Provincial i Board of Health to cover the province outside of Vancouver; and 80 Public Health & Welfare Reorganization certain other limited services operated by a few municipalities and - private organizations. Thus responsibility for the programme was divided between the province, the municipalities, and private organizations. Even the provincial activities were not integrated and co-ordinated, for the superintendent of Tranquille ran his institution practically as he pleased, the Deputy Provincial Secretary's office administered grants to general hospitals in respect of tuberculosis patients as well as others, and the travelling clinic was under the Provincial Health Officer. The provincial pro- gramme was headless and under the circumstances no concerted attack upon the problem could be expected. Central control and direction of the whole system was obviously the indispensable condition of reform. To achieve this objective - the Division of Tuberculosis Control was established in the Provincial Board of Health in July, 1935, and Dr. W. H. Hatfield, an able young medical man with excellent organizing ability and a fine reputation as a chest specialist,, was appointed director. Under Dr. Hatfield's energetic leadership a new co-ordinated programme rapidly took shape. The division soon took over control of Tranquille Sanatorium and of tuberculosis beds from the general hos-. pitals, until virtually all tuberculosis beds in the province were under its jurisdiction. There was little money for new construction, but enough was provided for a building on the grounds of the Vancouver General Hospital, opened in November of 1936, to provide central offices, clinic space, and about seventy new beds. This gave the division approximately 650 beds and the number has remained about the same since then. Stationary clinics were set up at Victoria and Tranquille to supplement the one at Vancouver that | was taken over from the Vancouver General Hospital. By 1937 four travelling clinics for case-finding and treatment were in operation to serve people in small towns and rural districts and in addition a number of special treatment centres (modified versions of the stationary clinics) were organized at various places. Under the central office a uniform record system and a comprehensive A Decade of Progress—Health and Other Services 81 scheme of statistical reporting were instituted, with the assistance of the Division of Vital Statistics of the Board of Health. Provision ! was made for all admissions to institutions to be handled through the central office and for central control of discharges. A public health nurse was appointed to act as liaison officer with the local - public health nurses on tuberculosis problems and a medical social service division was established, to be staffed with social workers - from the Welfare Field Service. One of the important functions of the medical social workers was to arrange discharge to their homes or to boarding homes in the case of patients no longer in serious need of institutional care and thus to free beds for others who ought to be in hospital. The list of new and progressive steps undertaken by the division is much too long to be described here in detail. Besides the items mentioned it includes the negotiation of arrangements with the Dominion government for improved care of the Indians who- contribute greatly to the high tuberculosis rate in British Columbia and who infect the rest of the population6; the development of a vigorous educational programme; the great extension of case-* finding; the promotion of a private agency (Vancouver Occupational and Vocational Industries) for the rehabilitation of recovered patients; the recruiting of a vigorous staff of young physicians and other technical workers; the improvement of surgery and other techniques; the installation of the most modern mechanical equip-1 ment; and the encouragement of research. During the war period it has been necessary to modify the programme considerably on account of the withdrawal of physicians and others for war service, notably by leaving the travelling clinic work to be done by nurse- X-ray-technicians, with the doctors visiting small centres only occasionally to examine and advise patients who have been diagnosed as tubercular after examination of the X-ray films obtained by the nurse-technicians. In spite of depletion of staff on account 6The Dominion government, not the province, is responsible for the affairs of Indians domiciled on reservations. 82 Public Health & Welfare Reorganization of the war the division undertook, in 1943, greatly to expand its case-finding programme by means of a mass X-ray scheme which is . designed eventually to reach everyone in the province. This has been made possible because of the acquisition of new equipment for the taking of miniature X-ray films. This vigorous and imaginative programme has led to good results. By December of 1936 the number of known tuberculosis cases in the province was more than twice as great as two years earlier; and by the end of 1943 the number of known cases was 10,918,7 nearly six times as large as at the end of 1934. The ratio of known cases to deaths was 16 to 1, an exceedingly high ratio that shows outstanding work in case-finding. The length of stay of patients in institutions has been greatly reduced, so that faster . bed turnover has gone far to make up for a shortage of beds. Good case-finding has led to early treatment for a much higher proportion of patients than in the past and therefore to greater success in treatment. The death rate has dropped from 78.5 per 100,000 in 1934 to 63.5 in 1942 and about the same in 1943.8 Clearly Dr. Hatfield and his associates have done an outstanding job. But they do not have nearly enough beds for treatment purposes and this is a deficiency which the best of organization and of technical skill cannot wholly overcome. Venereal Disease Control In organization, the venereal disease programme suffered from the same defect as tuberculosis control in 1933—lack of central direction. Theoretically there was provision for this, for it was wholly under the jurisdiction of the Provincial Health Officer.- But as we have seen this official was overloaded with central office duties and there was no specialist in charge of the venereal disease 1 Annual Report of the Division of Tuberculosis Control, 1943 (unpublished). 8The rate for the non-Indian population was very much lower. It was only 46.4 in 1941, as compared with an Indian rate of 638.2, about 14 times as much. A Decade of Progress—Health and Other Services 83 work. Part-time doctors ran treatment clinics at Vancouver and Victoria which were drab and repulsive and badly equipped, there were no facilities for case-finding, case-holding, or social service, and there was no public health programme in this field outside the two main cities except as private physicians gave treatments free, or at low fees in response to the incentive of free drugs supplied on request by the Provincial Health Officer. The annual budget (about $20,000 per year in the early l930's) was inadequate, the programme had an evil reputation, and complaints about it from the medical profession and from health and social agencies were legion. A survey of the problem in the summer of 1936 led to reorganization along the lines of the tuberculosis pattern—establishment of the Division of Venereal Disease Control under a responsible director to integrate and co-ordinate all venereal disease work. At the same time the budget was sharply increased, so that annual expenditures rose to about $80,000 in 1938 and succeeding years, the dilapidated clinic building in Vancouver was reconstructed and cleaned up, a social service division was established to be staffed by social workers from the Welfare Field Service, and new physicians , and nurses were appointed. There was difficulty at the outset in finding a competent director, but this problem was solved early in 1938 by the appointment of Dr. D. H. Williams, a highly trained * and aggressive young venerealogist. Under his energetic leadership the new programme greatly improved. A system of clinics outside of the Vancouver area which had been set up was modified some-- what, leading to regular clinics at Victoria, New Westminster, Trail, and Oakalla Prison Farm, with the services of private physicians, assisted by the donation of free drug supplies, being utilized in other places. In 1943, to serve more effectively the growing needs of the north country, whose population, both military and civil, had greatly expanded on account of war conditions, full- fledged clinics were added at Prince Rupert and Dawson Creek. A vigorous educational programme was instituted, involving the 84 Public Health & Welfare Reorganization distribution of thousands of pieces of literature, radio and speaking programmes, and the preparation of an educational film entitled "Nine Cents per Capita." A special consultation service offered, valuable information and aid to physicians in private practice, a new record system provided essential facts and statistics, and. research showed what must be done to stamp out sources of infection. The most dramatic incidents in the history of the new division have centred about its attempts to eliminate prostitution. Data on sources of infection showed clearly that brothels and professional prostitutes were responsible for a very high proportion of all male infections, so that for reasons of public health, quite apart from moral issues, it was desirable to suppress them. The police departments were -relatively ineffective in the suppression of commercialized vice, although this was forbidden under the law. Dr. Williams and his associates rolled up their sleeves and tackled this problem with determination. Official inertia, the opposition of powerful vested interests, and the common scepticism that so old I an institution as prostitution either could or should be abolished, stood in their way. But their incontrovertible evidence about sources of infection and their persistence gained them the support of the law enforcement authorities and by 1939 practically all the brothels in Vancouver were closed down. The campaign extended to other communities in the province, with similar success except in staid and respectable Victoria, where there was more resistance to it than anywhere. The first attack against organized houses of prostitution was followed by campaigns against dancehalls, beer-parlours, hotels, rooming houses and other places where professional or amateur prostitutes commonly met men. The revealing statistics of the division showed clearly that, next to the brothel, such were the chief agencies of "facilitation" to bring the prostitute and her customer together. By means of education, persuasion, or the A Decade of Progress—Health and Other Services 85 invoking of legal penalties Dr. Williams and his colleagues managed to control the facilitation centres so that casual contacts between men and women were made more difficult. There has not been complete success. The report of the division for 1943 states that "there has been observable a tendency towards relaxing supervision in beer-parlours and a number of small hotels"; and that, apropos of dancehalls, "these resorts, and one or two in particular, continue to offer a problem which has thus far proved insoluble.9 But there has certainly been great improvement in the Vancouver situation, and the division has broken new ground in North America by its clear statistical demonstrations that the facilitation process must- be thoroughly controlled if the venereal diseases are to be eradicated.10 The results of the new programme have been striking. Monthly admissions of new male cases to the Vancouver clinic dropped by one-third, from a median figure of 292.5 patients for a period of 13 months prior to suppression of brothels to 193 patients monthly over a period of 15 months after suppression.11 By 1941 new notifications of syphilis (in spite of a much improved reporting system) were 38 per cent, lower than in 1938 and of gonorrhea 20 per cent, less;12 and the Provincial Health Officer was able to claim in his annual report for 1942 that "British Columbia has a venereal disease rate lower than any other province in the Dominion."13 During the war period the division has co-operated effectively with the military authorities in the control of venereal disease among service men, so that rates of infection among them have been much the lowest in Canada. For the first six months of Provincial Board of Health, Report, 1943, pp. 70-71. 10For an excellent description of the problem and the Vancouver programme, see Donald H. Williams, "The Facilitation Process and Venereal Disease Control," U.S. Public Health Service, Venereal Disease Information (Vol. 24, Sept., 1943), Reprint 208. J1Donald H. Williams, "Commercialized Prostitution and Venereal Disease Control," Canadian Public Health Journal (October, 1940), p. 469. 12Annual Report of the Division of Venereal Disease Control, 1941, p. 4. Ill 26. 86 Public Health & Welfare Reorganization 1943, 13 out of every 1,000 soldiers in British Columbia were infected, while the national ratio was 32.u Without question this programme has been a brilliant success. It has attracted attention from all parts of the continent, notably from the United States Public Health Service and from the Division of Social Protection of the U.S. Office of Community War Services, which has modelled its nation-wide attack on prostitution partially on the British Columbia 'experience. Recognition of his outstanding achievement came to Dr. Williams in 1942 when he was made national director, with the army rank of Lieutenant-Colonel, of a joint military and civil campaign against venereal disease initiated by the Dominion government. Other Public Health Services Two branches of a health department that are essential, although their own contribution to the protection of health is indirect rather than direct, are those concerned with laboratory service and vital, statistics. Laboratory tests are a major guide for the physician in the diagnosis of disease and for the public health officer in the analysis of water, milk, foods, and other potential hazards to health; while good vital statistics are the indices of success or failure in his work which the alert health officer must watch constantly. As we have seen these basic services had been developed in the Provincial, Board of Health by 1933. But both of them were understaffed and underequipped and neither had clear-cut status as a branch of the I agency, so that they were unable to meet adequately the demands being made upon them. In 1937 both were set up as divisions of the Board of Health, n under responsible and competent directors. Early in 1935 the Vital Statistics office acquired modern statistical and tabulating * machinery which enabled it not only to carry on its routine work more efficiently but also to undertake extensive statistical jobs for 14"This is What VD Costs," MacLean's Magazine (March 1, 1944), p. 7. A Decade of Progress—Health and Other Services 87 other branches of the department and for outside government offices. Increasingly the division, under the direction of Mr. J. T. Marshall, became a statistical workshop for other departmental units, to which it rendered invaluable technical service on such matters as the preparation of basic forms and the keeping of records. The excellent statistical reports which a number of the branches have issued in recent years have been made possible in large part by the collaboration of the Division of Vital Statistics. In 1935, by virtue of a three-way arrangement between the Board of Health, the University of British Columbia, and the Connaught Laboratories of the University of Toronto, an able and highly trained bacteriologist, Dr. C. E. Dolman, was brought to Vancouver from Toronto to become Professor of Preventive Medicine at the university and Director of the Provincial Laboratory in Vancouver. When the Division of Laboratories was established in 1937 the several branch laboratories, of which there are now six throughout the province, were brought under the director's jurisdiction and uniform policies and procedures for all were worked out. The branch laboratories are operated by various hospitals or persons, with the support of provincial grants, to provide public health service for surrounding districts. The great expansion of the tuberculosis and venereal disease programmes, as well as of the local health services, has made for constantly growing demands for laboratory service. Between 1937 and 1943 the number of laboratory tests performed at the main and branch offices more than doubled, rising from 111,953 to 259,381.15 Technical staff has been considerably enlarged and facilities in Vancouver have been extended by acquiring and remodelling several old houses adjacent to the one in which the laboratory was opened in 1931. But these are inadequate and makeshift quarters, and new facilities are long overdue. Various pieces of public health legislation have been recast and 15As reported in annual reports of the Provincial Board of Health, 1938 and 1943. 88 Public Health & Welfare Reorganization improved during the last ten years, some new items have been added to the health code, and regulations have been strengthened. Within each of the new divisions of the Board of Health there has been a great deal of patient and effective work on detailed matters of programme and procedure, leading to marked improvements in quality of service. Every section of the programme has grown vigorously, and the volume of work handled is far greater than it was ten years ago. The total budget authorized for the fiscal year ending March 31, 1944, was approximately $1,250,000,16 about twice the amount spent on equivalent services for the fiscal year 1934; and there has been a growth of four or five times in expenditures on public health work proper (that is, excluding the institutional care of tuberculosis patients which the preceding figures cover). The activities and the expenditures of the local health agencies have also grown substantially. In organization and personnel the provincial health services are very much stronger than they were ten years ago. Formation of the new divisions under responsible directors has cleared away most of the detail of administration from the Provincial Health Officer, has given him both more freedom and more expert advice and assistance for his functions of planning, promotion, and coordination, and has provided indispensable machinery for the proper conduct of the major branches of the programme. The chart on the next page, showing the internal organization of the Board of Health at the end of 1943, is neat and clean, in marked contrast to the highly centralized yet confused picture that the chartmaker would have drawn ten years ago. As a result of a consistent policy of recruiting competent personnel there was a remarkable improvement in staff, both quantitatively and qualitatively, until resignations and leaves of absence for war service during the last two or three years halted the upward trend. Sincere efforts have been made, since 1934, to appoint only 16Based on figures in the provincial Estimates for the Fiscal Year Ending 1944. I^-J \<ai\ > CJ oo Si fc (X cr 2°K M - "3 H \>r6 O cfi 55 5 23 w CO > « PS S V 2 '*- 552 2^ 22# || >o gm 11 >"« M?2 1 -3 8 < w •2 "2 £ to '£ fe w O co ^liJQ j ffi p a S | W>J lliil Us Oh W CO Oh W CO 55«i co-<Z w Central Office Vancouver Clinic Other Clinics and Treatment Centres ^ J 1 I is Central Office Tranquille Sanatorium Other Hospital Units Stationary Clinics Travelling Clinics O 1 N ^ <\ «w J 90 Public Health & Welfare Reorganization well qualified doctors, nurses, and other technical workers, preferably from other parts of Canada. Encouragement and assistance (notably through Rockefeller grants obtained at the instance of the provincial authorities) have been offered to technical workers to obtain advanced training that would fit them for new positions. Most important of all is the fact that the developing programme has had excellent technical leadership from young men of outstanding ability, vision, and enthusiasm for public service. The team that held the leading positions at the outbreak of the war, consisting of Dr. G. F. Amyot, the Provincial Health Officer, and the four division chiefs, Dr. W. H. Hatfield (tuberculosis), Dr. D. H. Williams (venereal disease), Dr. C. E. Dolman (laboratories), and Mr. J. T. Marshall (vital statistics), is one that was probably unsurpassed in Canada and that would be distinguished in most states of the American union. The Reform that Failed If the story of public health since 1933 is a bright one of progressive achievement, the very reverse is true of health insurance, which was the major reform promised by the Patullo government. As we saw in the preceding chapter, there was a considerable background of discussion of the subject and public opinion seemed ripe for the adoption in British Columbia of the first state health insurance scheme in North America. Some influential physicians were thoroughly in favour of the idea and the majority of the medical profession was prepared to accept it "in principle." If a plan could be worked out which would not cost the government much money and which would satisfy the doctors on medical questions prospects for favourable action looked bright. After preliminary planning in 1934 the Provincial Secretary presented a draft health insurance scheme to the legislature and the public in the spring of 1935. The government then appointed the "Hearings Committee" of officials and representative citizens to A Decade of Progress—Health and Other Services 91 obtain public reactions to the scheme and to suggest modifications. Although the great majority of those who appeared before the committee favoured the principle of health insurance it soon became clear that they disagreed sharply as to how the principle should be implemented. The physicians objected that various provisions of the draft bill failed to recognize their interests adequately and that it would not give them fair remuneration for their services. The result of this public discussion and criticism was a considerably modified plan, much more modest in scope, which, as it turned out, failed to satisfy the conservative critics (principally the doctors) and disappointed many of the more progressive advocates. Opposition of the medical profession crystallized by the time the bill came before the legislature in the spring of 1936, and it passed only after a bitter debate. The act provided for the compulsory coverage of wage-earners earning less than $150 per month, with certain exemptions. Insured persons and their dependents were to receive medical benefits only, to consist of the services of doctors and hospitals, part of the cost of drugs, and necessary X-ray and diagnostic services. Costs were to be met by contributions from wage-earners and employers at basic rates respectively of two per cent, and one per cent, of wages, with no governmental aid except an advance of funds for organization purposes. Administration was to be under a commission of not more than five members, of whom two, the chairman and vice- chairman, were to give their full time to the work. The commission was empowered to work out arrangements with physicians, hospitals, and other persons and agencies regarding rates and conditions of service, which were not specified precisely in the act. The commission was soon appointed, under the chairmanship of Dr. Allon Peebles, who had played a leading role in the preparation of the plan, and organized its staff. By the spring of 1937 it was ready to begin collections and to put the scheme into operation. But protracted negotiations with the medical profession had failed to bring about agreement on the terms of practice and remuneration 92 Public Health & Welfare Reorganization for doctors. The physicians stated that they would not serve insured persons on the terms proposed by the commission and the commission was forced to report the impasse to the government. The government, using powers granted to it under the law, decided to defer application of the scheme until the people could be consulted by means of a plebiscite vote at the forthcoming provincial election on the first of June. The government was returned to office (although with a much reduced majority and although Dr. Weir, the chief architect of health insurance, narrowly escaped defeat) and about 60 per cent, of the vote cast in the vaguely worded plebiscite favoured health insurance. Nothing was really settled by this reference to public opinion except that support of vigorous governmental action against the position taken by the medical profession was not so great as had been anticipated. Counsels of caution prevailed in official circles, the premier stated that the health insurance act must be amended, the commission disbanded a staff of about 100 persons, and only the members with a clerk or two remained. And so the situation has stood ever since, except that Dr. Peebles, the chairman, resigned in 1941 to become executive officer of the new Dominion Unemployment Insurance Commission and was not replaced. Each year the legislature has voted a small sum to pay the salaries of the commissioners and to keep an office open, on the plea that this was necessary for continued study of the problems of health insurance, pending decisions on policy. The government has been unwilling to go forward and obviously afraid to retreat. Hospitals and Infirmaries Health insurance had been designed, among other things, to solve the problems of medical care and hospitalization for the recipients of public assistance and for .other indigent persons, which bristled with difficult issues both medical and financial. Pending the anticipated introduction of the health insurance system various A Decade of Progress—Health and Other Services 93 measures were taken to cope with these problems and the new policies have been continued and extended up to the present. As we saw in the last chapter the Tolmie government had reduced grants to hospitals in 1933, as an economy measure, from a basic figure of 70 cents per patient day to 45 cents. This reduction, combined with the sharp decline in revenues from paying patients which followed in the wake of the depression, placed most of the hospitals in severe financial difficulties. The new government listened sympathetically to their pleas for help and restored the grant to the 70 cents level in 1934, where it has remained since. But it was not sufficient merely to hand out more money to the hospitals. They were receiving government grants annually ranging up to $1,000,000 and municipal per capita grants amounting to $500,000 or more, with practically no governmental supervision of their operation. The provincial grants were disbursed loosely, through the office of the Deputy Provincial Secretary, on the presentation of monthly statements by the hospitals setting forth the number of their patient-days, claims which the small clerical staff of the deputy's office had neither the time nor the capacity to check properly. The single tuberculosis control officer on the staff of the Provincial Board of Health also held the post of Inspector of Hospitals, to which he could give no more than perfunctory and routine attention, and he had nothing to do with the distribution of grants. The provincial and municipal authorities were subsidizing hospitals, on a per-capita-of-population basis, much more heavily than in any other Canadian province. At the same time hospitalization rates were the highest in the country; there was a serious shortage of bed accommodation in Vancouver; beds were not utilized nearly to capacity in many other places; some hospitals showed heavy annual deficits while others reported operating surpluses; policies, rates, and procedures varied sharply from institution to institution; the hospitals were chronically unable to obtain capital funds for construction and new equipment; and 94 Public Health & Welfare Reorganization statistical and other data were inadequate to provide clear information on the nature of the problem. Surveys of the situation, notably by Dr. G. F. Amyot, who was appointed as Advisor on Hospital Services at the beginning of 1936, pointed the way towards new policies. More careful government supervision of the hospitals was clearly needed, and provision for this was made by appointing a full-time Inspector of Hospitals, Mr. Percy Ward, early in 1937. He assumed full charge of the distribution of hospital grants and his office became, in effect, a branch of the department. The legislature amended the Hospital Act in 1937 to plug loopholes in the grant system and the government issued regulations with which grant-aided hospitals were required to comply. The new rules included revised procedures regarding the admission and discharge of patients, required each hospital to organize a medical staff to advise the hospital management on all technical medical questions, prescribed that each hospital should appoint a chief executive and should establish satisfactory systems of records and accounts, and specified procedures to facilitate the removal of patients no longer in need of hospital care. The following year, to strike further at the problem of unnecessary hospitalization, an amended regulation provided that grants would not be paid in respect of patients with a length of stay exceeding 300 days. More than new rules was required to cope with the problem of over-hospitalization. Dr. Amyot's study had shown that indigent, or nonpaying, patients spent more than twice as long in hospital as paying patients. Several factors combined to influence physicians and hospital administrators to delay recommending the discharge of indigent patients who were partially recovered and who no longer required the care of the acute hospital. Among these factors were the low relief allowances the patients would receive on discharge, the lack of alternative infirmary or boarding- home facilities for their care, the absence of good provision for their medical treatment in the community, and the poor co-ordination A Decade of Progress—Health and Other Services 95 between the work of the hospitals and the local welfare authorities. To solve the problem there was need both to build up the local social services and to set up new machinery to facilitate hospital clearance. The second step was easier to take than the first. In 1937 the Provincial Secretary's Department made a special grant of $3,000 to the city of Vancouver to assist in the organization of a hospital clearance programme and in the following year a similar grant was made to Vancouver along with one to Victoria. In addition the province loaned social workers to the two cities to take part in the work. The Vancouver scheme, operating through the city Social Service Department, included the finding of suitable boarding homes for patients who could not be returned to their own homes, the provision of medical and nursing care for patients in their homes, the services of social workers and public health nurses in making placements, and provision by the city of adequate payment for all services. During the year ending April 30, 1938, %55 long-stay patients were removed from hospital as a result of the scheme and it lessened appreciably the problem of overcrowding in the Vancouver General Hospital.17 In the smaller communities formal schemes of hospital clearance were not so feasible. But the government undertook to assist the smaller hospitals in clearing their beds through appointing a social worker to the staff of the Inspector of Hospitals in 1937 to work on problem cases, through requesting the hospitals to report long-stay cases and to ask the assistance of the inspector's office in arranging clearance, and through instructing the staff of the Welfare Field Service to cooperate. The hospitals have used this machinery to a considerable extent, the number of cases handled by the inspector's office in 1942 having been 236.18 17 J. Moscovich, "A Hospital Clearance Plan," Proceedings of the Sixth Canadian Conference on Social Work, 1938, p. 131. This paper gives a valuable detailed report upon the plan. 18Department of the Provincial Secretary, Report on Hospital Statistics and the Administration of the Hospital Act, 1942, p. 5. 96 Public Health & Welfare Reorganization One of the most important of the new policies was the establishment of a uniform system of accounting, with which the hospitals were required progressively to comply after 1938. The inspector and his assistants personally assisted most of the smaller institutions to set up the new system and incidentally helped them to improve their internal organization and their business practices. In this way, and in many other ways, the inspector has offered a positive service of advice and assistance to the hospitals which has gone far to improve their operations and to bring out problems of common concern, upon which they have been able to act constructively in co-operation with the government. Closely related to the problem of general hospitals is that of infirmaries which deal with the chronically ill or handicapped who do not need the services of an acute hospital but who do require routine care under medical direction. The Provincial Infirmaries Act was passed in 1937 to govern the operations of the one provincial institution of the kind (the Provincial Home for Incurables, at Marpole, which now was given a less forbidding name, "The Provincial Infirmary, Marpole") and to authorize the establishment, without special legislation, of other institutions. The Allco Camp Hospital in the Fraser Valley, which had been an unemployment relief camp for the physically unfit, was rebuilt and was used as an infirmary, although it did not come under the new act until August, 1943. In 1941 a new institution, operated by an order of nuns under contract with the provincial government, was established as the Mount St. Mary's Infirmary in Victoria. Personnel changes and internal reforms were made at Marpole and at Allco, and an advisory committee, headed by the Inspector of Hospitals, was set up in 1938. But these steps, useful as they were, did not suffice either to integrate the infirmaries sufficiently into the medical care programme of the department or to overcome the basic problem, the shortage of beds.19 19The number of patients which can be accommodated is approximately 400, 170 at Marpole, 130 at Allco, and 100 at Mount St. Mary's. A Decade of Progress—Health and Other Services Mental Hygiene 97 There is much less progress to be reported in the next two fields to be discussed, mental hygiene and the delinquency services. The mental hospitals were grossly overcrowded at the beginning of the 1930's, there has been only a small amount of new building and reconstruction during the past ten years, and the steady growth in patient population has constantly outstripped the provision of new facilities, so that overcrowding is now worse than ever. With this problem overshadowing the whole situation positive achievements have been limited, on the whole, to minor items. Perhaps the most significant advance has been the development of the provincial child guidance clinic, established in Vancouver in 1932 on a part-time basis. By 1937 it was operated as a full-time service in Vancouver, while in 1934 part-time service was extended to Victoria and in 1935 to Chilliwack and Nanaimo. In 1936 Dr. A. L. Crease, who had been superintendent of the Essondale Mental Hospital as well as in general charge of the other institutions, became General Superintendent of Mental Hospitals and Provincial Psychiatrist, and was freed from specific institutional duties in order to devote himself particularly to clinic practice and extra-institutional affairs. For the fiscal year ending March 31, 1944, there was provision for a staff of two psychiatrists, two psychiatric social workers, two psychologists, a nurse, and clerical assistants. The social workers, along with two others attached to the mental hospitals staff, divide their time between hospital and clinic work. Both adults and children are now served, with referrals being made from a wide range of agencies, public and private, and the service has become increasingly popular. As it was pointed out in the last chapter the municipalities were required, in 1932, to pay a per diem charge of 50 cents for their residents who were patients in the mental hospitals. The government removed this charge in 1937, thereby again assuming full 98 Public Health & Welfare Reorganization responsibility for mental hospital finances. The annual budgets of the hospitals were gradually increased and this permitted some extensions and improvements of service. Modern methods of shock therapy were introduced during the 1930's, with encouraging results. Young doctors were given leave of absence and financial assistance for postgraduate study. The nursing school at the Essondale institution was improved and two new residences were built for the nurses, to relieve them from intolerable living conditions in hospital rooms intended originally for patients. Chinese patients were repatriated to China by virtue of a special arrangement in 1935. Revenues were improved by bringing to light a musty agreement with the Dominion government, dating back to 1899, which provided for provincial service to Dominion wards (Indians, war veterans, convicts, and others) at a rate of one dollar per patient-day and by negotiating a new rate more in accord with costs in the 1930's. The legislature passed a new Mental Hospitals Act in 1940, containing modern provisions regarding admission and discharge of patients, voluntary admissions, release of patients on parole, responsibility of relatives for maintenance charges, reciprocal agreements with other provinces regarding the care of mental patients, and other progressive items. The Delinquency Services Early in 1934 a Commission of Inquiry reported on the internal management of the Boys' Industrial School, recommending a number of changes to correct very unsatisfactory conditions. A new principal, Mr. F. C. Boyes, took charge in July, 1934, and under his direction an overextended vocational training programme was curtailed, small boys who should never have been admitted to the institution were released on parole, more competent staff members were recruited, and a more humane and scientific programme of dealing with the boys was inaugurated. The new principal was also made supervising principal of the girls' school, A Decade of Progress—Health and Other Services 99 to give the two institutions common direction, and a follow-up (or parole) officer was appointed to serve both institutions. Some reconstruction of buildings at the boys' school in 1936 improved physical facilities, but these were far from satisfactory until 1942, when a new wing to a main building was added. In 1938 the Provincial Secretary appointed an advisory committee to the industrial schools consisting of interested citizens. The committee has helped the principal much with problems of internal management and outside relations, notably by pressing upon the government the need for more and better buildings at the boys' school. Charges imposed on the municipalities in 1932 in respect of maintenance of boys and girls in the two schools were removed in 1937. Departmental officials recognized that improved management of the industrial schools represented only a minor contribution towards the control of juvenile delinquency and on their suggestion the Advisory Committee on Juvenile Delinquency, composed of officials and representative citizens, was appointed in 1936 to survey and report upon the whole problem. The committee reported that there were serious weaknesses in the juvenile court system of the province, that probation service was inadequate and unsatisfactory, that essential social services such as child guidance and recreation were underdeveloped, and that there was no suitable provision for the care and training of young adults too old for the industrial schools. The report contained fifteen specific recommendations for action. A few of these were implemented, notably by new industrial school acts in 1937 to straighten out some legislative difficulties and by setting up a "Borstal" institution, but nothing was done about the most important recommendation of all, which had proposed transfer of full responsibility for juvenile courts and probation to the provincial government from the municipalities. New Haven, a small institution for about forty delinquent boys and young men which was modelled on the English Borstal institutions, was established in 1937 under a prison officer from the 100 Public Health & Welfare Reorganization Oakalla Prison Farm who had taken a special interest in young prisoners for a number of years. A strong advisory committee, consisting largely of persons who had proposed the scheme, actively assisted the superintendent in working out policies and procedures, the John Howard Society of Vancouver (a prisoners' aid organization) and other agencies gave valuable assistance, and a parole officer worked with boys who were released. Despite the handicaps of very limited and unsatisfactory quarters and relatively unskilled staff the record of the institution was distinctly creditable as an agency for the training and reformation of young men. However, it was closed in 1942 on the ground that the number of prisoners suitable for Borstal-type care was too small to justify the expense of a separate institution, and it has been replaced, temporarily at least, by a special programme for young offenders within the Oakalla Prison walls. Friends of the enterprise feel.that this represents a backward step, although enough is being done to keep the Borstal idea alive. Provision for follow-up work in behalf of young offenders has been made by appointing one of the former members of the New Haven staff to the Attorney-General's Department as social service officer. Besides performing this parole work he also acts as adult probation officer for the cou pty courts and police courts of the Vancouver district. This represents the first formal provision by the provincial government for adult probation work. A statute to outline and authorize a full programme of the kind was drafted early in the war period but the government has taken no action to put it into effect. Child Welfare As we saw in the last chapter, the child welfare work of the provincial government was reorganized at the end of the 1920's, when professionally qualified personnel were brought into the picture. Thus there were sound foundations' for expansion and development during the 1930's. In 1935 the children's work was takenBout of the Welfare Branch of the Department of the Provincial A Decade of Progress—Health and Other Services 101 Secretary to become the Child Welfare Branch. Trained social workers were progressively added to the staff of the Superintendent of Neglected Children until by the end of 1943 there were seven assisting her at the head office in Vancouver. With these resources of staff, and with the invaluable and essential assistance of the departmental field service, the branch has been able to supervise effectively the activities of the three children's aid societies (Vancouver, Catholic, and Victoria), to render useful service in those parts of the province not served directly by the societies, to perform certain province-wide functions such as administration of the Unmarried Parents' Act, and to co-operate constructively with other branches of the department, such as the industrial schools, and with other agencies. Child welfare legislation has been thoroughly revised and improved by the passage of a new Adoptions Act in 1935 and the repeal of the old Infants Act in 1943 and its replacement by the Children's Protection Act which, among other things, changed the title of the leading administrative officer to "Superintendent of Child Welfare." In 1940 the branch organized very successfully a programme for the reception and placement of some 200 children assigned to British Columbia under a joint British-Canadian plan for the evacuation of children from war-torn Britain. Commenting on this experience, the superintendent has stated that "it cannot be too much emphasized that had there not been the set-up in British Columbia of foster-home care for our own children, it would have been very difficult to give adequate service to our Overseas guests. In making our plans we did not have to start something new. "20 Another interesting example of extension of service is that the courts are relying increasingly upon the advice and assistance of the Superintendent of Child Welfare in cases involving the custody of children, under the Divorce Act and the Equal Guardianship of Infants Act. For some years the Supreme Court has asked the superintendent for reports on such cases, and 20Annual Report of the Superintendent of Neglected Children, 1941, p. 44. 102 Public Health & Welfare Reorganization these are obtained through the provincial field service or the children's aid societies. Thus there has been steady improvement rather than dramatic change in the provincial child welfare programme. The work of the three children's aid societies has also expanded steadily and their standards have improved, particularly on account of the addition of better equipped personnel. Virtually all child welfare workers now in service have had professional training for social work. The work of the Child Welfare Branch brought to light the fact that standards of service were very poor in some private institutions and boarding homes for children and adults—and indeed that in some instances there was gross exploitation of children, unmarried mothers, and old people in commercial establishments. The lack of legislative authority to control such institutions was corrected by adoption of the Welfare Institutions.^ipepsing A^ ^ ifl£& It authorized provincial inspection, licensing, and supervision of private institutions and boarding homes offering care for children, expectant mothers, the aged, and other handicapped groups. The powers of the act are exercised by a board of civil servants and an inspector, a position which is now held by the Inspector of Hospitals. Much has been done under this scheme to improve the standards of private institutions of various kinds. Other Developments Problems of the blind have continued to be met largely through the Canadian National Institute for the Blind, supported in part by a provincial grant of $25,000 per annum. However, in 1937 the Advisory Committee on Blind Welfare was established, consisting mainly of interested citizens, to keep in touch with problems of the blind and to advise the government on policy and administration. Nothing in particular was done to deal with the special problems of crippled children beyond the making of regular hospital grants to institutions dealing with them; but surveys of needs in the field provided useful data for later action. A Decade of Progress—Health and Other Services 103 Other developments of the 1930's in the Provincial Secretary's Department (apart from those in the field of public assistance, which will be discussed in the next chapter) call only for brief mention. The raising of social work standards within the department, notably through the Welfare Field Service, set a good example which influenced some of the municipal welfare agencies. Departmental officials assisted materially in the introduction of a few trained social workers to the Vancouver and the Victoria welfare departments. They devoted much time and effort to the improvement of relationships with other departments of government, with the municipalities, with Dominion government agencies, and with private organizations and achieved some success. Their suggestions and their pressure played a large part in the adoption by the Dominion, in 1939, of interprovincial reciprocal provisions regarding relief for transients, which were mentioned in Chapter I. At their instance provisions for reciprocal agreements with other provinces regarding mothers' allowances, hospitalization, and other social services were written into statutes, so as to make possible interprovincial arrangements that would guarantee equality of access to social services for interprovincial migrants as well as for provincial residents. But their efforts in this direction did not lead to much result, and it is pretty clear that the interprovincial problem can only be solved by Dominion action.21 There was a good deal of planning within the department which did not lead to definite results during the 1930's, but which has exercised some influence upon the public assistance developments of the war period and which is valuable for future consideration. 21See Social Security and Reconstruction in Canada, pp. 77-78. 4 A Decade of Progress-Public Assistance JLhe relief of the unemployed was the outstanding problem of the social services to be faced by Mr. Patullo's new government in 1933. The relief programme was distinguished from the other welfare services by its magnitude, its depressing effects upon public finances and therefore upon budgets for more permanent schemes, its political importance, and its independent administration. Inevitably it dominated the welfare scene during the depression decade. It was not until 1942 that it was merged with related public assistance programmes, and its influence is still powerful, as we shall see from the following pages. The Unemployment Relief Branch A first step to build up effective machinery for relief administration and to give more consistent provincial leadership had been taken in August, 1933, some three months before the new government took office, when direction of the programme was transferred from the Unemployment Relief Committee of the cabinet to the Minister of Labour. The small staff of the committee became the 104 A Decade of Progress—Public Assistance 105 nucleus of the Unemployment Relief Branch of the Department of Labour. *Mr. E. W. Griffith, one of the Public Works men who had been active in the relief programme from the beginning, was appointed administrator and other key personnel were also drawn from the same group. However, the divorce from Public Works was not complete, for accounting continued to be handled by that department. As the new branch expanded additional personnel was recruited from the ranks of the unemployed professional, clerical, or other white-collar workers. Men of diverse backgrounds were chosen rather than women social workers. For men (including many who had been successful in their former occupations) were plentiful, the job to be done looked more like a "labour" than a "welfare" undertaking and therefore more fit for men than women, those in authority did not recognize that administrative personnel required special welfare training, and anyhow there were no qualified relief workers available, men or women. Although the Unemployment Relief Branch was set up in the Department of^ Labour it really was an autonomous agency under the minister, to whom the administrator reported directly instead of going through the deputy minister, and its activities were co-ordinated but little with those of the other branches of the department with the exception of the Employment Service. The programme which the branch operated fell into four divisions as follows: 1. Distribution of grants to the municipalities, to assist them with programmes of work and direct relief, and the supervision of their activities. 2. Direct administration of work and home relief and camps for "provincial cases" (the residents of unorganized territory, families and single persons without established residence in any community, and during certain periods single men who were municipal residents). .3. -Operation or oversight of special projects of work and rehabilitation, including farm placement, youth training, and forestry camps. 106 Public Health & Welfare Reorganization 4. A medical care programme involving direct administration for provincial cases and grants to the municipalities for service to their residents. The nature of the relief programme was determined largely by the arrangements for financial aid which were made from year to year by the Dominion. There were frequent changes in Dominion policies regarding grants and the conditions with which the provinces must comply and always there was uncertainty as to how much and how long the Dominion would help. In consequence the provincial authorities had very uncertain premises for their planning and this goes far to explain the many changes in their policies, particularly during the earlier years. However, as time went on policies and procedures were stabilized to a considerable extent. In August of 1934 the Dominion made a major change in its grant policy, substituting monthly lump-sum payments for direct relief, varied in amount from time to time in accord with estimates of provincial need, in place of the earlier percentage system whereby the federal, provincial, and local governments had each assumed one-third of the costs of municipal relief. Under the new scheme, the province and the municipalities were expected to carry all costs in excess of the Dominion subsidy and they were more free to make their own relief policies. From the beginning of 1938 the percentage system was restored,' with the Dominion contributing 30 per cent, of costs, up to a specified monthly limit, until April, 1939, and then 40 per cent., until the cessation of grants at the end of March, 1941. Special arrangements supplemented the main agreements regarding direct relief. As we saw in the last chapter the Dominion maintained work camps for physically fit homeless men, under the Department of National Defence, from 1933 to 1936. In the winter months of 1936-1937 to 1939-1940 the province operated 1 work camps for single men with the aid of a Dominion grant of 50 per cent, of costs. The farm employment plan, providing for A Decade of Progress—Public Assistance 107, the placement of single men on farms during the winter to work for their board and lodging and a nominal wage of $5, was in operation from 1937 to 1941, with the costs being shared equally between the Dominion and the province. The provincial authorities began youth training projects in forestry and placer mining in 1935, and from 1937 until 1941 these were aided by Dominion grants of 50 per cent, of costs. Beginning in 1932 and continuing through 1935, a land settlement scheme was in effect whereby families were given assistance to go on the land, with the costs being shared equally between the Dominion, the province, and the responsible municipalities. The province began a special project of assisting and rehabilitating needy settlers in 1935, which was aided by a Dominion grant after 1937. A grant-aided scheme for the rehabilitation of older workers was begun in 1938. From 1939 to 1941 the Dominion made provision to encourage work projects in the municipalities by meeting 50 per cent, of labour costs of approved undertakings. Thus at the very end of the depression period there was a small return to the policy of local work relief, after seven years of reliance mainly upon a dole method of direct relief which, as we shall see later, had certain work obligations associated with it. After the Dominion changed its direct relief grants from a percentage-of-cost to a lump-sum basis, in 1934, the province revised arrangements for the aid of the municipalities. From December, 1934, to December, 1935, the government contributed from federal grants and its own funds 60 per cent, of municipal costs and then the grant was raised to 80 per cent., at which point it remained. This scheme was designed only to cover aid to employable persons and their dependents, so that the municipalities were wholly responsible for "indigent relief" or "poor relief" until 1938, when the province extended aid to this service.1 Administration of aid to "provincial cases" living in unorganized 1However, the definition of "employable" for purposes of provincial reimbursement was very broad until 1938 so that the number of "unemployables" or "indigents" carried by the municipalities was quite small up to this time. 108 Public Health & Welfare Reorganization territory, which had been carried on by government agents, provincial police, and other permanent officials during the early 1930's, was taken over progressively by the Unemployment Relief Branch after it was established in 1934. The branch stationed its own officers throughout the province to perform this work, to operate special schemes, and to oversee the municipalities. It was also their responsibility to provide relief or other service for provincial cases living within municipal boundaries. In Vancouver this was a large undertaking, mainly because of the concentration there of considerable numbers of single men who were not municipal residents and who for one reason or another were not cared for by means of work camps or other special schemes. Early in the depression period a provincial relief office for single men was opened at Hamilton Hall in Vancouver, which continued to operate until 1937. This office was also used to,assign men to work camps and to other special projects. It worked closely, as did the other provincial relief offices, with the Employment Service of Canada, particularly for purposes of determining the employability of applicants and of arranging work placements. The Transient Problem "Transients" in general, and particularly the single men among the group, posed the most difficult of relief problems. The transients (or more properly, non-residents) fell into two main categories—those who were technically residents of some municipality or of unorganized territory within the province but who were living in some other jurisdiction; and those with no claim at all to residence in British Columbia. Definition of responsibility for the first group was greatly clarified by regulations of the Unemployment Relief Branch in 1935 and 1936 to provide that the province would give assistance to those residents of British Columbia who did not, under existing residence rules, belong to any municipality; and the situation was still further improved by adoption of the Residence A Decade of Progress—Public Assistance 109 and Responsibility Act of 1936, which was designed, among other things, to guarantee that residents of British Columbia would not be denied relief merely because of absence from their home communities.2 The problem was more difficult in the case of the non-provincial group. The municipalities, of course, disclaimed responsibility and refused them assistance; and the provincial government fought consistently against assuming any obligation for their care, claiming that this should be done by the Dominion. As we have seen the federal authorities did accept this responsibility, in part at least, by means of the national defence camps and grants towards the costs of special projects for single men. But always there were some men who were not covered by these schemes and there were family groups and single women for whom the Dominion agreements made no provision. Provincial policy regarding relief for such people was predominantly negative and severe. The government stated repeatedly, as in advertisements placed in Prairie newspapers in 1936 and 1937, that no aid would be given to transient single men from other provinces. But in practice relief was granted to many of them, particularly in the winter months, because the demands of hungry men could not be wholly denied. Serious riots in Vancouver in 1938 and a "march" of unemployed on Victoria made it clear that a wholly negative policy was not possible and after these events relief provisions became more liberal. In the case of married persons and single women the official policy was one of no assistance except to meet emergency needs, followed by repatriation to homes in other provinces or countries. Actually relief was extended to this group with comparative liberality. The dilemma of the British Columbia authorities lay in the fact that during the depression years there was a constant flow of newcomers to the province, both persons who planned to remain permanently and floaters who were attracted by the mild climate of 2See pp. 118-121. 110 Public Health & Welfare Reorganization the Pacific Coast or other inducements. If relief were given freely and generously to such persons, it was argued, this would increase greatly the inward drift of destitute migrants, thereby piling up costs and social problems for the people of British Columbia.3 Clearly Dominion action was necessary to guarantee that nonresidents of the province be given aid as freely as residents. In 1939 the Dominion took a most important step towards this end by incorporating in agreements with the provinces a uniform definition of provincial residence (two years in a province on a self-supporting basis) and by agreeing to assume 50 per cent, of the costs of aid to nonresidents whether it was authorized by the province to which they had migrated or the province which they had left. There were also other provisions to require reciprocal collaboration among the provinces so as to make the scheme uniform in application. The effect of this was that British Columbia might grant assistance to a resident of Alberta or some other province with assurance that it would be reimbursed for all of its expenditure, half from the Dominion and half from the other province. Unfortunately this most important constructive contribution to the solution of the transient problem did not come until the great relief programme of the 1930's was almost over. Most of the special projects undertaken by the Unemployment Relief Branch were for the benefit of both municipal residents and nonresidents, especially single men. The youth training projects in forestry and placer mining were constructive and successful undertakings which gave several thousand young men healthy work at modest wages and valuable training over a period of six years. The Forest Branch of the Department of Lands and the Department of Mines operated these projects by arrangement with the Unemployment Relief Branch. After 1937 various other youth training 3The problem of transient policy, illustrated in some detail by an account of British Columbia experience, is discussed by the writer in L. Richter (ed.), Canada's Unemployment Problem (Toronto: 1939), chap. IV, "Relief and Other Social Services for Transients." A Decade of Progress—Public Assistance 111 activities were undertaken, largely with the assistance of the Department of Education, and these were merged during the war period into the "War Emergency Training Programme" under the Department of Education. The special projects flowered in the later years of the depression period, when economic conditions were improving and there seemed to be some hope of relief recipients finding jobs and self-support if they were helped by means of training and other rehabilitation measures. Medical Care Although the Dominion made no specific provision for medical service to the unemployed the province found it necessary to do so. Beginning in 1931, payments were made to physicians for the care of relief recipients in unorganized territory and a medical care programme was organized for men in provincial camps. In April, 1935, the administration of the medical aid work, which had been handled by the Provincial Health Officer, was transferred to the Medical Services Branch of the Provincial Secretary's Department and policies were stabilized.4 The ( Medical Services Branch continued to pay physicians, on a limited fee schedule, for their services to provincial cases and provided drugs and a few extras; operated a clinic and dispensary for single men in Vancouver; and made nominal payments to general hospitals, on a per-patient-day basis, in respect of provincial relief recipients who were hospitalized. In addition the branch operated several camp hospitals (later reduced to one, the Allco Camp Hospital in the Fraser Valley) for the care of single men, mainly chronic and convalescent patients. From 1931 special grants were made to Vancouver for medical relief and later the system was extended to other municipalities. By 1936 nine of the larger municipalities, including Vancouver, Vic- 4This was a reorganization scheme that did not work. The branch was almost altogether financed by unemployment relief funds, and with money went control—so that for all practical purposes it was really a division of the Unemployment Relief Branch. 112 Public Health & Welfare Reorganization toria, New Westminster, and Burnaby were receiving grants to cover 50 per cent, of the costs of general practitioner service and drugs. Provincial grants towards doctor's services were limited to half of total costs not exceeding 33 cents per relief recipient per month. Under this plan the local governments were left free to make their own arrangements regarding payment of physicians and other matters of administration. In Vancouver, Victoria, and some other places the authorities made agreements with the medical profession for the payment of a lump sum ($5,000 per month for several years in Vancouver) out of which physicians attending relief clients were paid in the proportion that their approved accounts bore to the total sum. By the end of the 1930's the system had spread to most of the municipalities with many relief recipients and in April, 1941, it was operating in thirty places. Thus there developed a programme of medical care for the unemployment relief group which, if it was limited to the most essential services and if it varied in detail from place to place, covered the great majority of those on the relief rolls. The provincial grants were met entirely from unemployment relief funds. Relief Administration After the formation of the Unemployment Relief Branch in 1934 there came from Victoria a steady stream of circular letters setting forth policies and procedures in relief administration to be observed both in unorganized territory and in the municipalities. These were mandatory for the municipal authorities only in the sense that they prescribed the nature of expenditures to which the province would contribute. In effect, therefore, the provincial regulations set maximum standards of assistance to claimants and fixed limits beyond which the local governments might not go without assuming the costs themselves. If they desired they might do less for their unemployed than the provincial regulations allowed, and many of them followed this policy. However, the general A Decade of Progress—Public Assistance 113 effect of the growing body of regulations was very much in the direction of uniformity and in the latter part of the depression period there was a distinct tendency, at least in the larger communities, to make relief allowances and conditions as generous as the provincial rules permitted. Provincial supervision was exercised through careful scrutiny at Victoria of municipal claims for reimbursement and occasional visits by representatives of the Unemployment Relief Branch to the local offices to examine their records and accounts; and in the case of Vancouver a provincial inspector was stationed permanently at the city Social Service Department to check on its activities. The object of the supervision was essentially financial, to protect the province and the Dominion against unreasonable local claims for aid. A few of the leading items of policy in the period of relative stabilization, from about 1935, may be mentioned briefly. Able- bodied men, both provincial and municipal cases, were generally required to "work out relief"—that is to say, to perform some sort of work on sewer, park, or road construction, or on other public jobs at the rate of 40 cents per hour or some such figure until their earnings equalled the amount of their allowances. Thus the system of "direct relief" was transformed partially into one of "work relief." In communities where there was an office of the Employment Service of Canada employable recipients were required to report frequently, usually every two weeks, to see if any jobs were available. Relief was usually issued in cash rather than scrip, at least for food and fuel, but rent was commonly paid direct to the landlord and in a number of places clothing was issued. Provincial rules set the maximum amounts of aid for family units of different sizes. By 1935 the provincial scale for rural municipalities and unorganized territory permitted a monthly food budget of $25 for a family of five, while the Vancouver allowance at this time was $26.99. According to one estimate by Dr. L. C. Marsh and two collaborators the cost of a minimum standard budget to guarantee adequate nutrition for short periods was $24.33 in 114 Public Health & Welfare Reorganization Vancouver, so that the British Columbia allowances were a little above this level.5 But they were not sufficient for longer periods of time. Provision for other items in the family budget was limited to shelter, fuel, and clothing, and by 1938 a provincial rule was in effect limiting the total grant for any one family group to $50 monthly in rural districts and to $60 in cities. As it has been suggested, the provincial food maxima were by no means always granted in the smaller places and some communities made no provision for items other than food. Thus it is evident, although detailed and accurate information on actual grants and minimum necessary budgets is not available, that relief allowances for the majority of the recipients must have been well below the minimum levels necessary to protect health and vitality. This was particularly true of families with several children, which were squeezed by the uniform maximum grant rule. Yet British Columbia standards were, by and large, the best in Canada, and they improved as time went by. One interesting example of the efforts of the provincial authorities to make provision for special needs was the adoption, in 1935, of a rule that pregnant women might be granted an additional allowance of $5 monthly for four months preceding childbirth in recognition of their needs for special diets and other extras at this time.6 A few summary figures on the number of recipients and on costs will show further the great extent and importance of the unemploy- 6L. C. Marsh, et al., Health and Unemployment (Toronto: 1938), p. 169. 6Detail in this section on unemployment relief is derived mainly from the annual reports of the Dominion Commissioner of Unemployment Relief and of the British Columbia Unemployment Relief Branch, from the circular letters of the branch, and from data specially provided. The annual reports are very limited in scope, and no surveys of the whole experience have been prepared, apart from a brief but useful mimeographed report by the Unemployment Relief Branch, Narrative History of Unemployment Relief, 1931-1937, and a confused and inadequate section (mainly concerned with finances) in the provincial brief to the Rowell-Sirois Commission in 1938, British Columbia in the Canadian Confederation. The record is as complicated as it is significant and it ought to be put together clearly for the information of the public and for the guidance of future policy. A Decade of Progress—Public Assistance 115 ment relief programme. Table I shows the average number of persons in receipt of public assistance each month by years from 1932 to 1943. The table brings out the dominance of unemployment relief in the public assistance programmes of the 1930's. In 1933, the peak year, when the average number of all assistance recipients made up 19.2 per cent, of the non-Indian population, the unemployment group (unemployment relief and war veterans' unemployment assistance) contributed 85.4 per cent, of the total. By 1938, the position of the unemployment group was still dominant, for it then made up 60.1 per cent, of the total public aid load, which amounted in total to 13.9 per cent, of the non-Indian population. War conditions led to a rapid decline in the need for relief by employables and to its virtual disappearance by 1941. But, as the table shows, a very substantial number of public assistance recipients of other categories remained. The total costs of the unemployment relief programme, not including expenditures on National Defence camps, were $91,131,437 over a period of twelve years, from the fall of 1930 to September 30, 1941, according to a recent statement by Premier John Hart to the legislature.7 Of this amount $31,341,641 was contributed by the Dominion, $48,515,570 by the province, and $11,274,227 by the municipalities. The provincial obligation, which amounted to $7,575,000 in 1935-1936, the peak year,8 when revenues from all sources other than Dominion relief grants were less than $26,000,000, represented a major financial problem for the government; and the municipalities also found it most difficult to raise their contribution, which was nearly $1,500,000 in some years. Declin'ng costs and improving revenues in the latter part of the 1930's and in the war period led to the gradual disappearance of the financial emergency and cleared the way for other social services to receive more in the way of appropriations and attention than they were able to ^Budget Speech to the Legislative Assembly, Jan. 23, 1942, p. 16. ^British Columbia in the Canadian Confederation, op. cit., p. 108. 116 Public Health & Welfare Reorganization HH & Sfl co ' ^rHrHrH A S § M«5^W«JOHHOJM©W "c3 ^MMrtOOOOOOSOOMH Ci05C©TjHT?CS©«5»Oi>©© 1 r-i i-1 © i> i—l CO i> Q* CO © O ^P OMNHHOsaoooco^^l War ierans employment sistance »-ioocN005»or>o<3ooi>i> 00l0^05O«5©0<0505at» COCJOJQ<G0Ci©O^0000©< 00 OO OO"■ ■*" ^" SO OO ®f rH £&&'•-■* 1 6 1 1 1 ©©©©©©CO©*O0©<©cO hhhoo^ooowcoohm © -^ oo oo •xf a o e< a <* j> co ©?c>o^^co^©^^©coco <» °o ©O0©i>00rH©CO©C>*©« ^ill r-H©*©©*co©*©*©00G0©i-U CO CO GO 00 ©* i—iOO00^M> 2^1 »r>ooaoHe(o5co^f* ^ s ■S § o *- ^ 2 HOooj>»oi>Tfia)»oooHa 0<TfiCD^»0.00©»0S»,*(NO -•^|H«5«5»0«0i>CX)0iOOOO! 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C3 Qi <^go,,**oc©*>o6<35©i-h©*g6 >s OOOOOOOOOOOOOOOO'*'*^'* Oi Qi d- os o* Oi a a a o* a Oi \\ > f Cfl "- fl w c8 „f Q 11 . &s fl^ || O .-£ i ^ t: m " o c i.Sr2 d >> d -E ' su es 8 CD <S O CD ,■>-; -rt » .£ I IS I ^ |1 a co cp «*-« .3 ro *s6 0J«H M Jirri ^ fl -H A S g t ^ CD £ °n •-< « fc* CD ,<u O &C g CD CO ^ «d «0 H n d ^ *£ «» s h d d d^-rl^-'^cp ,d«P 3l%2 .SZHt '3 » o o S 2 S S 5c ,5 Ph Dh^3 cd r> A Decade of Progress—Public Assistance 117 claim in the early or the middle years of the period. The change in the public finance scene has also made possible the great liberalization of public assistance provisions wh'ch, as we shall see later, has occurred recently. '*% Other Public Assistance It is necessary to turn back now to the record of the Provincial Secretary's Department, :n order to sketch developments in the public assistance services other than unemployment relief and local poor relief. It will be remembered that these were mothers' allowances and provincial poor relief, both administered by the Welfare Branch under the Provincial Secretary, and old age pensions, administered by the Workmen's Compensation Board. There were no changes of any significance in this latter programme during the 1930's, except that Domin'on grants were increased in 1931 from 50 per cent, to 75 per cent, of costs and that in 1937 blind persons over forty years of age were brought within the scheme. When the new government entered office in 1933 the administration of mothers' pensions was under severe criticism from the municipalities which had been forced to contribute towards the costs of the programme in 1932 and from women's organizations and other groups which felt that the Tolmie government had gone much too far in curtailing grants and denying applications. Governmental reassumption of all charges as from April 1, 1937, mollified the municipalities, if it did not satisfy them entirely—for they had grievances about many things. Provision for more efficient and more considerate administration was made in July, 1934, through the appointment of a new Superintendent of Welfare, Dr. George F. Davidson,9 through transferring the office of the Supervisor of Mothers' Pensions from Victoria to Vancouver shortly afterwards, 9Dr. Davidson's outstanding ability has been recognized by a rapid series of promotions—to become Executive Director of the Vancouver Welfare Federation in 1936, Director of Social Welfare in 1939, and Executive Director of the Canadian Welfare Council, the leading welfare post in Canada, in 1942. 118 Public Health & Welfare Reorganization and through the development of the Welfare Field Service. Under the direction of the new superintendent cases were reviewed and grants were increased where the need was clearly indicated. In 1936 the legislature liberalized the Mothers' Pensions Act by providing, among other things, for an allowance of $7.50 monthly for disabled husbands in families eligible for aid. A year later new and improved legislation, the Mothers' Allowances Act, was passed. The 1936 amendment authorized an advisory board of representative citizens, which has since then rendered valuable help in administration and in public relations. These various changes, together with detailed improvements in administration, met the more serious criticisms which had been common at the beginning of the period, without leading to runaway expenditures such as had alarmed Miss Whitton when she made her report in 1932.10 The other public assistance scheme under the jurisdiction of the Welfare Branch, known as the Destitute, Poor, and Sick Fund (an ancient title for poor relief for the residents of unorganized territory), had long been handled casually and informally. For the first time the Welfare Field Service offered reasonable facilities for the administration of this programme throughout the province. New regulations adopted at the beginning of 1937 provided orderly rules regarding eligibility and nature and extent of assistance. Shortly afterwards an experienced social worker was promoted from the ranks of the field service to supervise the work. The Medical Services Branch of the department took over the administration of medical aid to recipients, following the same policies and procedures as in the case of the unemployment relief group. The Residence Problem A move of the greatest importance to clarify and improve the administration of public assistance and other social services occurred in 1936 with the adoption of the Residence and Responsibility Act. 10See chap. % p. 47. A Decade of Progress—Public Assistance 119 This replaced eleven separate and unrelated schemes, expressed in statutes or in regulations, to determine the "residence" of persons claiming social services and therefore the responsibility of municipalities or the provincial government to provide service or to contribute towards its costs. A memorandum issued by the Provincial Secretary's Department on September 1, 1936, for the consideration of provincial and municipal authorities, outlines the problem as follows: The existing situation regarding municipal responsibility for relief, health, and welfare cases is definitely unsatisfactory. . . . The existing rules to determine responsibility for particular cases . . . are not at all uniform. This lack of uniformity gives rise to quarrels regarding responsibility, the denial of service to certain persons otherwise entitled to it on the ground of non-residence in a municipality, claims that certain of the rules are inequitable in their incidence upon the municipalities, barriers of "red tape" in the way of the expeditious and socially desirable handling of certain cases, and a good deal of administrative confusion and waste effort. Much stronger language might have been used, had it not been expedient to state the situation mildly. Many communities simply denied relief or other services to those whom they claimed (rightly or wrongly, with the applicant having no right of appeal to any other authority) to be non-residents; and if they did give assistance to outsiders it was usually for very brief periods with the understanding that the recipient would return to his "home" community, even if he had not been there for ten years or if his own best interests and personal feelings were totally disregarded. Relief officials were under pressure from their municipal councils to save money in every way possible and one of the most obvious means was to disclaim responsibility for applicants on the ground of non-residence, to ship them back to other communities, or to persuade or coerce some other community or agency into accepting responsibility; and the existing jungle of varying and poorly formulated rules provided great opportunity for this sort of practice, commonly described as 120 Public Health & Welfare Reorganization "passing the buck." It represented, in essence, a callous disregard for human well-being for the sake of prospective financial gain to the municipal authorities (and to some provincial agencies). But the gain was largely illusory, even to the migrant-receiving municipalities, because of the high administrative costs of quarrelling rather than co-operating, the costs of transporting indigent persons from one place to another, and the hidden public welfare charges (health and hospitalization, delinquency, child welfare service, etc.) arising out of failure to meet elementary social needs. The new act, which was worked out with the collaboration and approval of the Union of British Columbia Municipalities, established a uniform residence rule for family heads of one year in a municipality (or in unorganized territory, in which case a person became a "provincial resident" for whom the government was responsible) without public assistance of any kind or, alternatively, for three years. This alternative provision was repealed in 1943. It was further provided that "non-residents" within any municipality should receive from that authority the same services as "residents," the costs being charged back to the responsible local government, and that regulations might be issued to govern the orderly removal of destitute persons from place to place. Controversies were to be settled by a .Board of Arbitration consisting of one governmental representative, one municipal representative, and a third person chosen by these two. Although it has been necessary to amend the act on several occasions and although there have been some difficulties of administration, it has very largely cleared away the serious problem it was designed to solve and "has met with an increasing measure of approval from the municipalities."1 The work of the Board of 11 Canadian Welfare Council, Residence and Settlement Legislation in Canada (1939), p. 33. This pamphlet, prepared by Dr. George F. Davidson, who was a member of the British Columbia Board of Arbitration for several years, gives an excellent analysis of the British Columbia act as well as of similar legislation in other provinces. A Decade of Progress—Public Assistance 121 Arbitration has contributed greatly towards the success of the scheme. The Board has handled over 100 appeal cases annually since it was first established in 1937, and has also done much, informally, to settle cases by agreement "out of court." Since 1939 there has been a full-time secretary, Mr. W. Crouch, who was originally the municipal representative. The fact that the municipalities have had adequate representation on the board has clearly done much to assure them of its impartiality and to give them confidence both in its rulings and in the equity of the system. Public Assistance and the Administrative Problem By 1939 the scandalous conditions and the gross problems of 1933 had been largely conquered and great progress had been made towards giving the province a modern, efficient set of social services. The unemployment relief system had been stabilized and much improved so that it was probably better than in any other province, public health had moved forward dramatically, most of the musty corners of the Provincial Secretary's Department had been given a wholesome housecleaning, and there was at least the beginning of a new approach towards the control of delinquency. Reorganization had brought relative order into the health and welfare services under the Provincial Secretary in place of the disorderliness of haphazard development which had prevailed in 1933. This will be apparent if Chart III, on the next page, showing departmental organization at the beginning of 1939, is compared with the 1933 chart on page 70. Six major branches, each under a responsible official, had emerged,12 along with the Welfare Field Service and the Collections Office which performed general service functions; within the Board of Health there had been established four operating divisions; in some of the other branches there were reasonably clear divisional units; and the Provincial Health Officer 12Not including the Medical Services Branch established in 1935, which became really a division of the unemployment relief system. u ».• « c "S'§ eh ^ 1 1 '% *" i t," *» O c"q -2 | 1 i I a | |i 8 u ii is I "1 a | ^ | o 1 fill L..J H JLpJ "1 f J -rJ y. u 1 a 1 « c (5.2 a g_ 1 S-g gsu g< fl« .... mm L-J fa c £ < o .« <: b3 g.j<:iji§ " Sz q| |< E< gen p < ^> N 1 ^ i = "i fill SO « §H ^ 1 CHAR OF THE P lNIZATION a . Q S 8 ■ SjSE = o , i<3 1 c§ 6 i o "; o a 1 |l | i | • w • I 1 o & « Q j^j- . j 1 i So is & ■3.2 8 i £" Q la ||| gl £ £ " <3 ■^rs-3 if < pa B 3 I if ,5 ? I O Hip I'l i fa O t^facgej 2 &. 8 £ E u.a 1 '1 ■1* 1 .5 i <5 O O 3 ^"a 35 8 1 o :'!■ = si 3 2 ;KO . 1 s >S J3 J> ■§ B H •§ Q H O il. -JMf ital, E Farm, idale prthe 4 O.J.. ST 5 -s «* a U a j [ Hos Colon Public Menu Home Child A Decade of Progress—Public Assistance 123 had been relieved largely and the Deputy Provincial Secretary partially of the detailed administration which had cluttered up their offices. If internal organization was still far from satisfactory it was nevertheless a great improvement over that of six years earlier. But the advances in health and welfare and the internal reorganization of the Provincial Secretary's Department had not solved a fundamental problem, that of over-all lack of sound organization and co-ordination of the provincial and local social services. Indeed, the more work that was done in improving specific programmes, such as tuberculosis control, or child welfare, or mothers' allowances, or in cleaning up the Provincial Secretary's Department, served only to bring out in bolder relief the great need for the better integration and co-ordination of the whole system. It became increasingly apparent that the full promise of various reforms that had been made could not be realized until the over-all administrative problem was solved, and that the limits of constructive work within some branches, and indeed within the Provincial Secretary's Department itself, were rapidly being reached. The larger problem of organization was particularly acute in the field of public assistance, and this aspect of it calls for some exposition. The basic difficulty lay in the fact that the closely related public assistance services of the provincial government were divided between three main agencies, the Welfare Branch of the Provincial Secretary, the Unemployment Relief Branch of Labour, and the Old Age Pensions Branch of Workmen's Compensation. Some of the problems incidental to this division were the following: 1. There was unnecessary overlapping and duplication of work. The major administrative procedures of the three branches, such as investigation of applicants to determine eligibility, record-keeping, budgetting family needs, issuing relief grants, and reference of cases to other agencies for non-relief services, were substantially similar. All three had a social work job to do and all had to serve clients throughout the whole vast expanse of the province. Yet they depended upon separate field services, the Welfare Field Service, the Unemployment Relief Branch investigators, and a small 124 Public Health & Welfare Reorganization group of Old Age Pensions visitors. This meant that three sets of visitors covered the same territory, each dealing only with the cases of his own agency when he might have been working at the same time on cases of the other two in the same neighbourhood. This was a great source of unnecessary work, time, and expense in the unorganized territory of the province where population is sparse, distances are great, and the costs of travel are high. The division of public assistance functions led frequently to successive investigations of the same family. Cases were often transferred from unemployment relief or poor relief to mothers' allowances or old age pensions, when reinvestigations were made. It was also possible for the three agencies to be concerned at one and the same time with the same family. These circumstances involved duplication of case records and annoyance to bewildered clients, who thought of the provincial government as a single organization rather than a conglomeration of separate agencies. There was also some overlapping of medical service. After partial integration of medical care programmes for employable and unemployable relief recipients under the Medical Services Branch, the office of the Deputy Provincial Secretary continued to make grants to resident physicians in unorganized territory in recognition of their work for the poor. The Unemployment Relief Branch made certain payments to hospitals in respect of relief cases, which continued until 1943, while the main system of hospital grants was handled by the Inspector of Hospitals. The provincial infirmaries came under the Provincial Secretary at the same time that Unemployment Relief operated Allco Camp Hospital for similar patients. The Old Age Pensions Branch and the Welfare Branch made separate arrangements for the medical examination of applicants for blind pensions and for disabled husband grants under the mothers' allowances scheme. Another weakness of the three-way division of functions was that each agency had to undertake similar overhead functions, such as the preparation of forms, the drafting of rules regarding eligibility and standards of assistance, the compilation of statistics, and the recruiting and training of staff, and that none was large enough or secure enough to delegate such work to specialists. In the city of Vancouver several different offices had to be maintained—those of the Unemployment Relief Branch, the Welfare Branch, and the Old Age Pensions Branch. In addition, of course, was the office of the A Decade of Progress—Public Assistance 125 city Social Service Department and the office of the federal Department of Pensions and National Health which administered public assistance to veterans. These were all physically separated, and applicants were shunted from one to another. 2. There was sharp variation in the approaches, the policies, the standards, and the methods of work of the three agencies, and this bred friction and lack of co-operation. The Unemployment Relief Branch emphasized temporary aid to employable persons, it was always under pressure to curtail the very high costs of relief, and it was more interested in finding jobs for its clients or in forcing them into work than it was in their personal and family problems. The Old Age Pensions Branch was concerned with a somewhat legalistic administration of pension laws that were rigid and unimaginative in their provisions. The Welfare Branch, on the other hand, had a relatively liberal mothers' allowances scheme to administer as well as a poor relief programme unhampered by the rigidities of statutes so that, under socially minded administrators, it could emphasize comparatively generous and humanitarian policies. These different approaches were epitomized in the personnel of the three staffs—the male unemployment relief investigators who, however generous and sympathetic towards the needy they might be at. heart, were commonly driven by the pressures from above and the attempted "chiselling" from below to become "hard-boiled" in their attitudes; the "practical" visitors of the Old Age Pensions Branch, men and women, who had so many applications to take and so many forms to fill out that they had no time or energy to do more than a routine job; and the girl social workers of the Welfare Field Service, fresh from their training at the provincial university, committed to a social-case-work approach, and keenly aware of a multitude of social problems calling for attention. It would have been strange, indeed, if such different agencies and such different staffs had worked together in complete harmony. Differences in policy and procedure were numerous. The assistance scales of the Unemployment Relief Branch varied considerably from those of the Welfare Branch—leading to bewilderment and criticism on the part of recipients when they were transferred from one relief roll to the other. After 1935 women in the unemployment group were given special prenatal allowances, but not those in the poor relief group. The welfare visitors attempted to provide a good deal of "service" for their mothers' allowances 126 Public Health & Welfare Reorganization cases, but the old age pensions visitors offered little to theirs. The unemployment relief investigators and the welfare visitors dealt quite differently with problems of children in the home. The Welfare Branch referred cases freely to other branches of the Provincial Secretary's Department and to other agencies, while the other two organizations made only few referrals. 3. Case transfers from one agency to the other caused a good deal of trouble. This was particularly true as between the Unemployment Relief Branch and the Welfare Branch with respect to "unemployable" cases. The Relief Branch held the whip-hand, for it both made and administered the rules regarding employability, and to the Welfare Branch it often seemed that both the rules and their application were very arbitrary. Thus decisions by the Welfare Branch whether to accept an application or not often involved reference to the other agency, leading to delays and arguments. 4. The policies of the three branches were not well co-ordinated with those of other provincial agencies. For example, Unemployment Relief rulings often made but little allowance for the interests of various divisions of the Provincial Secretary's Department. In 1937 and 1938 limitation of relief for certain classes of single men, thereby forcing them to "take to the road," caused serious interference with the work of the Division of Venereal Disease Control, which wanted to hold infected men for treatment in Vancouver or Victoria or to have them report regularly in other centres. Limitation or curtailment of relief for certain classes also handicapped the Division of Tuberculosis Control in releasing patients from institutions to their homes, and made more difficult the efforts of the Child Welfare Branch to keep children with their parents. 5. There was a serious lack of central planning on public assistance and related problems. No minister or official was concerned with over-all thinking about public assistance and its relation to the other social services. There was no provision for central records, statistics, or research, which are necessary to provide the basic information for sound policy. On many problems which arose, such as the preparation of the Residence and Responsibility Act and of plans for indigent medical care, several departments or agencies had to be consulted, with the delays and difficulties inherent in co-operative effort when one participant could veto action. In the absence of central direction each public assistance agency tended to A Decade of Progress—Public Assistance 127 go its own way, planning its own affairs without much reference to the interests of the others. This lack of common policy was particularly unfortunate with respect to relations with the Dominion government, on the one hand, and with the municipal authorities, on the other. Particular ministers and their officials negotiated with both levels of government regarding the matters under their limited jurisdiction, often they expressed different views on general questions of policy, and neither the Dominion nor the municipal groups obtained from the provincial government a balanced and complete point of view on public assistance. Ottawa was also dealing with public assistance compartmentally at this time, and British Columbia did not set a better example that might have influenced the federal government. The divided provincial approach was frustrating and annoying to the municipalities. Their public assistance work (unemployment relief and poor relief) was integrated, under the same departments or officials; and they were frequently confused and irritated by different rulings and attitudes from the Unemployment Relief Branch and the Provincial Secretary's Department. The poor integration at the provincial level was a major contributing factor to the most serious difficulty of all—most unsatisfactory co-ordination between the work of the provincial and municipal public assistance agencies. Many of the municipalities failed to provide either wholly or in part services for which they were technically responsible. Some would grant no relief to single men, thus pressing them to leave home and become transients. Many of the small places made no provision for the medical care of the destitute, in spite of the availability of provincial grants towards the costs of this service for the unemployment relief group. Only a few provided special diets and other extras needed in certain cases to supplement bare relief grants. As we saw in preceding pages, relief scales for employables varied a good deal from place to place, in spite of provincial standards for reimbursement purposes, and there was even more variation in the provisions for unemployables, with standards for both groups being commonly below^a subsistence level, Apart from Vancouver and Victoria, 128 Public Health & Welfare Reorganization which were stimulated by the special arrangements made for purposes of the hospital clearance plan, little was done to provide boarding-home or institutional care for the chronically ill and the handicapped. The municipal welfare agencies offered scarcely any case-work service for their clients. The failure of the municipal agencies to provide, quantitatively and qualitatively, relief and other services for which they were technically responsible handicapped seriously the provincial and other agencies, such as the tuberculosis and venereal disease divisions and the children's aid societies, which had specialized jobs to do for municipal residents. Successful health treatment was difficult or impossible in the case of patients who had substandard homes and diets. Effective child welfare work was very hard in a family trying to subsist on a mean relief allowance. Partly recovered patients could not be discharged from the general, tuberculosis, or mental hospitals to homes where there were not enough comforts and resources to keep healthy members of the family well. The rapid advance of the specialized provincial programmes had outstripped greatly the basic social service of local relief; but their further progress was constantly held back by failure of the laggard municipal welfare agencies to do their part in what ought to have been a co-operative enterprise. This is not intended as a blanket indictment of the municipalities. Some of the welfare departments, notably those of Vancouver and Victoria, improved their work materially during the 1930's and co-operated more and more with the provincial agencies. But even where the municipal officials realized the need for better local service and desired to provide it, the existing system of provincial- local relationships, financial and administrative, placed strict limits on what they could do. As wTe have seen already, the municipal councils felt that they had been given very unfair financial treatment by the provincial government, and they were unwilling to put up any more money for social services than was absolutely necessary. Without sufficient funds (particularly for administration, which A Decade of Progress—Public Assistance 129 was entirely a local charge) there was not much that the best disposed local welfare administrator could do to improve the situation. Moreover, the provincial government gave but little constructive guidance to the local authorities. The province accepted implicitly the ancient doctrine of municipal responsibility for social services and was reluctant to interfere seriously in local administration or to take other steps that would appear to relieve the local authorities of their traditional obligations. It is true that there was strict provincial control of local unemployment relief administration in certain respects. But this was directed primarily towards limiting the expenditure of federal and provincial funds, it was considered a necessary part of an emergency programme, and it could be justified as only a temporary and unavoidable lapse from the permanent sound policy. As we have seen the province did not do much to prescribe standards of good administration, covering such points as methods of issuing assistance, records and statistics, personnel, and administrative organization. The underlying provincial policy of non-intervention in local affairs was well illustrated by the grant provisions for medical care, which left to the municipalities the difficult problem of working out specific arrangements for service with local physicians, druggists, and nurses. Until poor relief grants-in-aid were inaugurated in 1938 the government had no authority to set standards for this residual programme which, in theory, was supposed to cover all needs otherwise unmet. Since local poor relief was governed only by the simple phrase of the Municipal Act, that the municipality should "make suitable provision for its poor and destitute," each one naturally interpreted this in its own way, usually in the most parsimonious sense. With little in the way of general standards went weak provincial supervision. The inspectors of the Unemployment Relief Branch adopted largely a negative attitude towards the municipal welfare agencies, conceiving their function to be primarily that of protecting the province against municipal cheating and "chiselling" on 130 Public Health & Welfare Reorganization financial matters rather than to act as friendly counsellors and technical advisors. Most of them were not well qualified to assume this latter role, for they were typically without training or expert knowledge in social welfare administration—although as time went on the stronger ones learned a great deal on the job. The relative absence of provincial standards and supervision meant that the municipalities were left largely to their own devices in operating their public assistance services. The lack of uniformity from place to place, the poor administration that was common, and the slight co-ordination of local with provincial services were natural consequences of weak central leadership. And there could not be effective leadership until the public assistance programmes of the government were unified. Several provincial bandmasters could not be expected to call the same tune for their own people or for the local authorities. Problems of organization affected seriously other branches of the social services besides public assistance in the 1930's. But the confusion in the public assistance field was much the worst and this had evil effects on the whole system of social services. This was the core of the total organizational problem. Gradually it became clear to the provincial authorities that something must be done about it. Administrative Reorganization during the War By the latter part of the 1930's the relative importance of unemployment relief was declining rapidly, with other forms of public assistance gaining in relative importance.13 The gradual improvement in economic conditions and the decline in unemployment was the major reason for this shift. But an important contributing factor was a change in policy early in 1938, resulting from a new Dominion-provincial agreement, whereby the unemployment relief rolls were cleared of about 8,000 persons, consisting of i3See Table 1, p. 116. A Decade of Progress—Public Assistance 131 single individuals or heads of families who were considered unemployable, together with their dependents. Most of these were transferred to poor relief, provincial or municipal. The municipalities claimed that they should be helped by the province to maintain the transferred cases. There was justice in their claim, from a purely financial point of view, and the way was paved for the first important step to solve the problem of provincial-municipal co-ordination—government grants towards local poor relief. As from March 1, 1938, the province agreed to meet 40 per cent, of the costs of relief for the transferred cases (but not for the cases already on the municipal rolls); and, after protests from the municipalities that this was not enough, the rate was increased to 60 per cent, in September. The grants were made through the Unemployment Relief Branch, under substantially the same conditions as those for relief to employables. Early in 1939, following negotiation of a new relief agreement with the Dominion government, the province raised the amount of the grant for unemployables to 80 per cent., the same as for employables, and extended it to cover all cases except those that required nursing-home or institutional care. The next important step was taken on April 1, 1940, when all but a few provincial poor relief cases (mainly those requiring boarding-home care) were transferred from the Welfare Branch to the Unemployment Relief Branch. The Superintendent of Welfare wrote shortly afterwards that "we have the * horizontal cases' and the Relief Branch have all the 'vertical cases.'" After March 31, 1941, when federal unemployment relief grants were discontinued, the province assumed full responsibility for the 40 per cent, of costs which had been paid by the Dominion and continued to reimburse the municipalities at the 80 per cent, rate for both employables and unemployables. Thus the unemployment and the poor relief systems of the province were merged, apart from minor exceptions, under the direction of the Relief Branch of the Department of Labour. The general election of October, 1941, cleared the way for further important developments. In the new government Hon. George 132 Public Health & Welfare Reorganization Pearson, the former Minister of Labour, retained his old post and succeeded Hon. G. M. Weir as Provincial Secretary. For the first time all public assistance services came under the same minister14 and there were no political barriers or ministerial rivalries to stand in the way of complete reorganization. Plans were soon made for the integration of all public assistance in the Department of the Provincial Secretary. The first step was the adoption of legislation in February, 1942, to shift old age and blind pensions from the Workmen's Compensation Board to the Provincial Secretary. However, the Dominion government objected to straight departmental administration of this service, insisting that it must be handled by a board of some kind, and this led to delay in the transfer until the spring of 1943, when new legislation authorized the establishment of an administrative board within the Department of the Provincial Secretary. The board that was appointed consists of three departmental officials. In October of 1942 the Social Assistance Branch was organized under the Provincial Secretary to take over the work formerly handled by the Welfare Branch and the Unemployment Relief Branch. The new branch also absorbed the Welfare Field Service, which was renamed the "Field Service" and was increased in size by the addition of some forty of the former relief investigators. The Medical Services unit of Unemployment Relief (referred to previously as the Medical Services Branch of the Provincial Secretary's Department) became a division of the Social Assistance Branch, as did child welfare, mothers' allowances, and the administration of general relief or (as it was now termed) social allowances. The New Field Service There followed much recasting of the Field Service. In place of the fifteen districts of the Welfare Field Service, five broad regional 14Although the Workmen's Compensation Board, which administered old age and blind pensions, was an independent agency, it reported to the government through the Minister of Labour. A Decade of Progress—Public Assistance 133 districts were established, centering in the cities of Vancouver, Victoria, Kelowna, Nelson, and Prince George, to serve the whole province. The field staff was divided among these districts, each with a regional supervisor. The district offices were to administer all forms of public assistance for provincial cases, were to supervise municipal administration within their areas, and were to serve all branches of the department as the Welfare Field Service had done in the past. A still more striking innovation followed in 1943. In order to overcome the duplication of offices and of administrative work inherent in the provincial schemes of mothers' allowances and old age and blind pensions and local operation of general assistance, the administration of the two systems was integrated in Vancouver. This was done by making an arrangement with the Social Service Department of the city to handle all applications for the several types of public assistance through its four unit (or district) offices and to undertake the field work necessary for eligibility determination, subject to provincial decisions in the provincial programmes.15 The province agreed to assume its fair share of administrative costs by assigning staff from the Field Service to these offices, roughly in the ratio of one to each two city employees. There was precedent for this scheme, for since 1940 the city had handled provincial as well as its own general relief cases through its offices, with the assistance of provincial investigators who had been assigned to them. The joint provincial-city staff works as a unit under a city director, carrying undifferentiated case-loads of the several types of public assistance and of both provincial and municipal cases. In addition the joint staff is expected to perform the usual range of services for the various branches of the Provincial Secretary's Department, and to do a generalized family welfare job in its district. This latter obligation is more in the realm of aspiration than of achievement, for at present case loads are too high, staff is 15The system was not fully extended to cover bid age and blind pensions applications until the spring of 1944. 134 Public Health & Welfare Reorganization too new to the work and too unequipped for it, and the system is too recent to permit much development in the realm of constructive social service. But the programme contemplates this, the administrative set-up is favor-able, and it is a potentiality for the future. Thus Vancouver now has a unified system of public welfare offices which deal with all types of need.16 No longer, as in the depression period and as in other Canadian provinces, is it necessary for the citizen in need of public aid to travel in bewilderment from one office to another seeking the one authorized to deal with his particular problem. In Vancouver there has been largely realized one of the leading recommendations of both the Beveridge and the National Resources Planning Board reports on social security, that in each community there should be one center for public assistance applications, rather than the confusing array of offices which has been common in Canada, Britain, and the United States during the recent past. The new system has also been established in the municipalities of Victoria and Burnaby, and it is proposed that it be extended to the other larger communities throughout the province. Already the provincial field service helps the municipal officials in the smaller communities to a considerable extent, so that in these places amalgamation has begun on an informal basis. Personnel was a central problem to be faced in developing the Field Service and the system of joint provincial-municipal administration. The staff of the Welfare Field Service, accustomed to a very broad generalized programme, was much too small for the new undertakings; the great majority of the unemployment relief, old age pensions, and municipal staff members were professionally untrained for social work and were familiar only with the work in which they had been engaged; and there were no reserves of qualified social workers upon which to draw. Moreover, it was a delicate 16With these exceptions, that welfare services for war veterans and other wards of the Dominion government are still handled independently and that the city probation service is quite separate. A Decade of Progress—Public Assistance 135 question as to how successfully the two very different groups, the erstwhile "hard-boiled" relief men and the college-trainee! girl social workers, could be merged into the one organization. Higher policy was forcing them into a shotgun wedding and romance would have to develop, if at all, after the event. Nobody could predict with assurance what the results would be. In the summer of 1942, some months before the transfer of unemployment relief to the Provincial Secretary, an intensive training programme for a selected group of the relief workers who were to join the new staff was inaugurated in Vancouver. The course, consisting of lectures from departmental officials and others, study of legislation, regulations, and procedures, and field work in provincial, municipal, and private agencies, lasted for six weeks. Five of the men who took this course (all of them officials with considerable experience in relief administration) were appointed supervisors of the new regional offices. Later courses followed for other staff members from the field. In 1943 a training supervisor was appointed and in May of that year a more formal in-service training programme began, in co-operation with the Vancouver Social Service Department, for the benefit of both provincial and local employees. Municipal personnel from the communities where the joint plan of administration operates are required to take this training and it is available also for employees of other municipalities. Courses under this scheme extend over a period of three months. In addition, the programme has been opened to a number of carefully selected trainees, men and women, who aim to qualify for social work positions in provincial or municipal service. Maintenance allowances of $50 a month for single persons and $75 for married have been provided for these trainees, whose employment is conditional upon good performance in the course. The admission of this group to training was frankly an emergency measure to develop new staff quickly. The policy of the Field Service is to recruit trained social workers as members of the staff, but too few have been available during the reorganization period. However, 136 Public Health & Welfare Reorganization K-il out of twenty-seven new appointments from April 1,1943, to the end of November, fifteen were trained social workers. Another aspect of the new personnel policy is even closer collaboration than previously with the curriculum in social work of the provincial university. All through the 1930's the curriculum was weak, and yet it made an invaluable contribution in giving at least the rudiments of social work training to prospective employees of the provincial and local services. In 1942 the Provincial Secretary's Department took the initiative to strengthen and develop the curriculum by offering a special grant to the university. This led to the appointment in 1943, for the first time, of a full-time director, a competent and experienced social work teacher from the United States. Since then the curriculum has been reorganized, further development is in prospect, and plans are now in hand for the development of a full-fledged graduate school of social work measuring up to the standards of the American Association of Schools of Social Work. Adjustment to the new policies has not been easy. The burden thrown upon an inadequate and ill-prepared field staff has been tremendous. The work incidental to the assumption of responsibility for some 15,000 old age and blind pension cases from the first of April, 1943 (with the help of only three out of the six former staff members of the Old Age Pensions Branch), was overwhelming. Increased war service work for federal agencies during the same period as that of the reorganization complicated the situation still further. Yet the amalgamation seems to have gone forward with considerable success. Most of the former relief workers accepted the in-service training with interest or even with enthusiasm. It is reported that they have learned to look with new respect upon the trained social workers—who in turn have discovered among their male colleagues administrative capacity, broad knowledge, common sense, and adaptability sufficient to win their regard. Apparently the two groups are working together with reasonable harmony. Frequent conferences of field workers, at which the new policies are A Decade of Progress—Public Assistance 137 explained and common problems are discussed, have built up morale and enthusiasm. There is optimism in the Social Assistance Branch and in the co-operating municipal welfare departments that basic problems of policy, organization, and personnel are being solved and that British Columbia is on the march towards the establishment of a first-class welfare programme. But the Assistant Superintendent of Welfare realistically writes, in a memorandum prepared in November, 1943, regarding personnel and other problems, that "the machine is moving slowly, and it is my belief that it will take the whole of 1944 to bring us really out of the doldrums." Other Changes in Policy A few other organizational changes in the Department of the Provincial Secretary deserve brief mention. When Dr. G. F. Davidson vacated the position of Director of Social Welfare at the beginning of 1942 the post was abolished. This was quite proper, for it had outgrown its usefulness. This dual arrangement at the top of the department with the Director of Social Welfare and the Deputy Provincial Secretary equal in status was replaced by the appointment of the former Unemployment Relief Administrator, Mr. E. W. Griffith, as Assistant Deputy Minister; and of Miss Laura Holland, the senior woman social worker of the department, to a new position as Advisor on Social Welfare Policy to undertake special assignments for the minister and his deputies. By virtue of legislation adopted in 1942 two of the miscellaneous units of the department, the Provincial Museum and the Provincial Library, were transferred to the Department of Education. Along with the reorganization of the last few years has gone considerable liberalization of public assistance policies. As from April 1, 1942, the province made special provision to supplement the standard rate of old age and blind pensions ($20 per month) by $5 monthly, in recognition of increased costs of living. When the Dominion raised the standard rate to $25 in 1943 the province 138 Public Health & Welfare Reorganization continued the bonus at its own expense, so that pensioners without other resources now normally receive $30 per month. In 1943 the Mothers' Allowances Act was amended to include grants in respect of children from sixteen to eighteen years of age attending school and in the same year grants were generally increased up to the maxima authorized in the act, $42.50 in the case of a mother with one child. As prices increased during the war period both the province and various municipalities increased their relief allowances, with efforts being made not only to advance them in accord with increases in the cost of living but also to bring them above the sub- subsistence levels which had been common in depression days. The Premier announced in his budget speech before the 1944 session of the legislature that provision was being made for an increase in social allowance grants to the extent of 25 per cent, of the maxima previously allowed for single persons and 21 per cent, for persons with dependents—this in addition to increases of 20 per cent, in the preceding year. These advances are much greater than increases in the cost of living, which amounted to 17.5 per cent, in Vancouver from August, 1939,17 to December, 1943. "As a result of this increase," the Premier stated, "single persons will receive assistance nearly equalling that received by old-age pensioners and families nearly as much as mothers' allowances cases."18 These advances raise British Columbia's public assistance scales well above the levels prevailing in other provinces and probably, although adequate data to support this are not available, bring them substantially up to or above minimum health standards for most classes of recipients. Medical service provisions have also been greatly expanded. -As poor relief was amalgamated with unemployment relief in 1938 and 11 Labour Gazette (XLIV), January, 1944, p. 113. 18Hon. John Hart, Budget Speech to the Legislative Assemlfty, February 21, 1944, p. 16. The new provincial "Social Allowances Guide," effective April 1, 1944, provides for grants covering food, shelter and sundries to maximum amounts ranging from $27.50 monthly for a single person, through $62.50 for a family of five, up to $77.50 for a group of seven. A Decade of Progress—Public Assistance 139 1939 the medical care plan for the latter group was extended to the former; and in 1943 it was broadened further to cover mothers' allowances and old age and blind pensions cases. Thus there is now a medical care programme for all public assistance recipients which operates in virtually all municipalities. The municipal boarding- home and nursing-home problems described above19 have also been met in large part by recent arrangements, somewhat complicated, whereby the province undertakes to meet part of the costs of municipal residents maintained in boarding and nursing homes. Still another recent scheme provides that the government will bear 50 per cent, of local expenditures for "emergency health aid" to provide special diets, etc., for certain individuals or families costing more than the reimbursable social allowance scales. The problem of care in their own homes or in nursing homes for tuberculosis patients came to a head at the beginning of 1944 and very constructive action has been taken to deal with it. As a result of the large number of new tuberculosis cases discovered through the intensified case-finding programme initiated last year by the Division of Tuberculosis Control, public criticism arose regarding the lack of provision for tubercular patients, either in hospital or in their homes. A front-page story in the Vancouver Sun of April 12, 1944, refers to the "unforeseen cruelties inflicted on helpless citizens in the widely-praised tuberculosis detection drive"; and goes on to say that "the same government which tells them they are forbidden to work until cured tells them that it can't find beds for them in institutions and consigns them to a lingering disintegration on relief." It was somewhat ironic that this outburst should occur as a result of the good work of the Tuberculosis Division in bringing the problems to light and pressing for their solution. In his annual report for 1943 the Director of Tuberculosis Control stated that: At one point in the year an analysis made showed that there were 120 patients in tuberculosis institutions who had received !9P. 128. 140 Public Health & Welfare Reorganization maximum institutional benefit but for whom no satisfactory arrangements could be made outside of hospital. The inability to make satisfactory arrangements was due to finances, housing, or personnel to care for the patient in the home. Pressure for beds has necessitated every consideration being made to placing the patient back in the home at the earliest possible moment.20 This problem, as we have seen, arose out of the inadequacies of the local welfare services. The government attempted to remedy the situation at the end of 1943 by agreeing to meet 60 per cent, of the costs of nursing-home care for municipal tuberculosis cases up to a maximum figure of $45 per month. But it was difficult to obtain suitable nursing-home accommodations under wartime conditions of housing shortage and high prices at a rate as low as $45. Moreover there was municipal opposition to the scheme, on the ground that it would require the expenditure of more local money. At the beginning of May, 1944, the government made more generous provisions to assist the local authorities. The new order authorized a provincial grant of 60 per cent, for nursing-home care for tuberculosis patients costing up to $70 per month and a grant of 80 per cent, towards the costs of special diets and other extras for patients in their own homes. At the same time provision was made to penalize municipalities which did not arrange promptly for suitable home care for any patient ready to be released from institutions, by charging these authorities a higher institutional rate for the remainder of the patient's stay. A Decade of Progress The record that has been sketched in this and the preceding chapter is one of great achievement. The public health services have been thoroughly reorganized and tremendously expanded. Up to 1939 there had also been much progress in the welfare services, but these had lagged seriously behind public health. However, the 20Provincial Board of Health, op. cit., p. 77. A Decade of Progress—Public Assistance 141 administrative reorganization and the improvements in public assistance during the war period have corrected the most serious problems in the welfare field. More than in any province of Canada except Nova Scotia the health and welfare services of the provincial government are now integrated; and important steps have been taken towards the effective co-ordination of provincial and municipal activities. Professional personnel of competence and energy have been given positions of leadership during the decade and there has also been a large amount of success in recruiting trained personnel for the more junior positions. Health and welfare legislation has been thoroughly rewritten and modernized, and regulations have been well revised.21 There is a new vigour in the system as a result of wartime developments and it appears to have a healthy capacity for further improvement and for facing up to the new problems of the postwar period. Two statistical comparisons will illustrate further and will support the summary statements that have just been made. In the low year of the depression period, ending March 31, 1934, expenditures on the health and welfare services under the Provincial Secretary's Department were $2,203,870, a decline of more than $1,000,000 from the level at the end of the 1920's. By the fiscal year 1942-1943 they had risen to about $5,000,000,22 more than double. In part this represented the assumption of costs charged to the municipalities in 1933-1934; but to a much greater extent it represented expanded budgets for social services. At present a much larger proportion of the total budget is going into constructive and preventive work than ten years ago; so that qualitatively as well as quantitatively the programme has made great strides. The following table shows per capita expenditures on public health and welfare in the Canadian provinces during two recent years. 21Out of twenty-eight acts which make up the code governing the administrative work of the Provincial Secretary's Department all but three are new or have been amended since 1933. 22Summary figures compiled from the provincial Public Accounts. 142 Public Health & Welfare Reorganization TABLE II Provincial and Municipal Expenditures per Capita of Population on Public Health and Welfare (excluding Unemployment Relief), 1937 and 1940, by Provinces* Province 1937 1940 Prince Edward Island $2.96 6.30 4.42 5.56 8.63 7.47 7.18 7.11 10.47 7.26 $3.56 Nova. Scotia 6.61 New Brunswick 4.40 Quebec 7.02 Ontario 10.16 Manitoba 9.59 Saskatchewan 9.98 Alberta 8.02 British Columbia 12.44 Total. All Provinces 8.73 *Based upon figures from Rowell-Sirois Commission, Report, Book I, p. 220 ff. and from Dominion-Provincial Conference, Jan., 1941, Comparative Statistics of Public Finance, 1936-1940. Census figures on population for 1941 have been used to calculate per capita expenditures for 1940. Costs of virtually all health and welfare services except those concerned with delinquency were included in the basic figures. The table brings out clearly the fact that the level of expenditures on public health and welfare was much higher in British Columbia than the national average and than that of any other province in the latter part of the 1930's. Inclusion of unemployment relief figures would not invalidate this conclusion, but would have distorted the picture somewhat, for heavy expenditures on relief, on account of great variations in need from province to province, are not necessarily an indication of liberality in social services. Specific comparisons between the various services of British Columbia and those of the other provinces, which may be made by reference to later chapters, will show that in most branches British Columbia is leading the country or is one of the top provinces. By these two tests, progress during the last decade and comparison with other provinces, British Columbia's health and welfare services rank very high. But there are still other and more exacting tests to be applied, standards of the desirable and the possible. The application of these leads to a lower rating, as we shall see in the next chapters that deal with outstanding problems and measures that should be taken to solve them. Transition to Social Security _HE PROBLEM OF THIS CHAPTER and of the next two is to outline the major changes in British Columbia's social services necessary to adapt them to the requirements of a national system of social security. Here we will deal chiefly with what was termed the "content" of the social services in Chapter l,1 leaving questions of organization and administration to the two that follow. However, these phases of the subject are so closely related that it will be difficult to separate their treatment entirely, and some overlapping is unavoidable. In Social Security and Reconstruction in Canada the writer outlined ten standards of the social services,2 which provide a basis for appraising the British Columbia system and formulating plans for its improvement. According to these standards the g stem should have the following characteristics of content. All important types of service under the jurisdiction of the province should be available in every community. There should be, everywhere, some reasonable approach towards minimum standards of performance. Nobody should be denied the social treatment which iSee p. 29. 2Pp. 63-64. Transition to Social Security M5 he needs merely because he has not acquired residence in the province or in some municipality. The provincial and local agencies should undertake positive measures to prevent the occurrence of social casualties and should make adequate provision for the rehabilitation of those who can be helped to independence. The public social services should accept as a first principle that it is their duty to provide humane and understanding treatment for all beneficiaries. Specialized programmes are necessary to deal with a wide range of distinct problems; but these must be integrated and co-ordinated to make up a unified system. The British Columbia system must be modified and improved greatly to measure up to these requirements. It will be well to remind the reader also of two premises for provincial planning which were stated in Chapter 1—that a national system of social security will call for substantially the same range of health and welfare services as those now to be found in British Columbia, along with workmen's compensation and a broadened scheme of medical care; and that the Dominion will have to provide enough financial aid to make possible the proper development of the provincial and local programmes. The central objective of Social Security and Reconstruction in Canada was to outline the elements of a good system of social services for Canada; and the objective is the same here with respect to those branches that are likely to be, in the postwar period, within the jurisdiction of British Columbia. Local Public Health Service In spite of outstanding improvements in the public health system during the past ten years, it still falls seriously short of doing all that it should to protect and improve the health of the people. What is needed, essentially, is more of the kind of service now being offered. The health officers know very well what is required and their annual reports contain many proposals for improvement. Outstanding needs are listed below. 146 Public Health & Welfare Reorganization :i B'! Further development of the local health services is much to be desired. The advantages of full-time local health service are so clear as to need no further argument. The tried and tested method of bringing this to the small towns and rural communities is through the establishment of health units. These should be extended to all parts of the province—and this, indeed, is the objective of the Board of Health. Thus far the provincial authorities have tried to develop the system by methods of education and persuasion. In spite of the inducement of provincial grants amounting to about 25 per cent, of total costs there are many local authorities which have not yet been converted. In the Victoria area, for example, the idea of a metropolitan health district embracing the four municipalities of Victoria, Saanich, Esquimalt, and Oak Bay (only the first two of which now have full-time health officers) has been discussed for years, but no amalgamation has occurred because of doubts and misgivings on the part of some of the affected parties. Some of the municipalities in the Vancouver area have not yet joined the Metropolitan Health Committee. It may take years for the present policies to yield full success. Therefore there is a strong case for the adoption of legislation to make full-time health service mandatory and to provide for the establishment of health units in all districts where the existing municipalities are too small or are otherwise unsuitable as operating areas. It may also be desirable to include provisions to require metropolitan systems for Vancouver and Victoria.3 Such action would no doubt lead to serious local 3The present Vancouver system, under the Metropolitan Health Board, is based only upon a gentlemen's agreement between the participating municipalities and is open to various objections besides the obvious one that any municipality can withdraw as and when it pleases. Health regulations are made by each separate . unit and are not uniform for the whole district; staff members are appointed and paid separately by each authority and this is an obstacle both to good appointments and to the discharge of incompetent persons; the budgets of the different units are not uniform on a per-capita-of-population basis and cannot easily be pooled for common purposes; and there is not adequate provision for the maintenance of common overhead and supervisory services. Hence there is reason to believe that greater efficiency might be obtained by means of complete amalgamation. When the Provincial Transition to Social Security 147 opposition if it were taken arbitrarily and without consideration of municipal financial interests. But if it is coupled with generous provisions for provincial grants towards both health and welfare services, it should be free from valid local objection. With a uniform system of local services operating everywhere the public health machinery of the province will be immeasurably improved. The specialized provincial divisions, notably Tuberculosis Control and Venereal Disease Control, have been forced to do a good deal of work which would not be necessary if the local health departments had been better. Such work as tuberculosis and venereal disease case-finding and follow-up visiting can be transferred, to a considerable extent, to the local agencies when they are strong enough to handle it; and in a variety of ways they can forward the work of the specialized services by performing a good generalized job within their own communities. A strong local programme is the very foundation of the whole public health system. This means, of course, that there must be more personnel for the local agencies—public health physicians, sanitary inspectors, and nurses. Perhaps twice as many as at present are needed. At the end of 1943 there were about 110 public health nurses in the employ of the provincial and local health departments, or one to every 7,500 of population. The Medical Health Officer of Vancouver claims in his annual report for 1942 that the ratio should be one to 4,0004; and the Provincial Health Officer and other officials have advocated the same standard. On this basis the number of nurses in the province should be doubled. This is a conservative conclu- Board of Health proposed to achieve this, in 1943, by replacing the present plan with a union board of health, under provisions of the Health Act, there was vigorous opposition from the municipalities concerned. According to the Vancouver Sun, September 22, 1943, "'This same rock nearly wrecked the plan once before,' said Alderman G. C. Miller [of Vancouver], who feared that municipal councils would balk at surrendering any of their autonomy to a separate agency." 4P. 17. 148 Public Health & Welfare Reorganization sion, for a standard commonly accepted in the United States is one nurse to every 2,000 or 2,500 of population.5 The Tuberculosis Programme ■ More beds is the most pressing need in the tuberculosis field. There should be "two, and preferably, three, beds per annual death."6 But in 1940, when the number of tuberculosis deaths in British Columbia was 578, the number of beds was only 680,7 a ratio of about 1.2 beds per death. The situation has remained approximately the same since 1940. With 573 deaths in 1943, application of the two-bed standard leads to the conclusion that the province is short about 500 beds. This is the number recommended by the Director of Tuberculosis Control in his annual report for 1943, with the proposal that 300 be provided immediately.8 In addition he asks for a new surgical unit at Vancouver and for the construction of additional buildings at Tranquille Sanatorium. The Provincial Secretary has announced that plans are in hand for a new tuberculosis institution to care for 250 to 300 patients, at a cost of about $750,000, but has added that construction may not begin for another year.9 The bed shortage has been a serious handicap to the Division of Tuberculosis Control all through its history. It is the major explanation of British Columbia lagging behind the other three western provinces and Ontario in prompt admission of newly found cases to institutional care. In 1940 only 47.5 per cent, of the new cases were admitted to hospital in British Columbia within a month after discovery, as 5Ira S. Hiscock, Community Health Organization (New York: 1932), p. 155. 6Testimony presented by Dr. G. J. Wherrett, Secretary of the Canadian Tuberculosis Association, House of Commons, Special Committee on Social Security, Minutes of Proceedings and Evidence, No. 6, April 9, 1943, p. 194. ^Dominion Bureau of Statistics, Annual Report on Tuberculosis Institutions for 1939 and 1940, p. 99. sProvincial Board of Health, Report, 1943, p. 78. 9 Vancouver Sun, April 12, 1944. Transition to Social Security 149 compared with 83.2 per cent, in the leading province, Saskatchewan, and over 60 per cent, in Ontario, Alberta, and Manitoba.10 The new provisions made in 1944 regarding municipal care for tuberculous patients in their own homes or in nursing homes11 should go far to solve one of the most difficult problems of the tuberculosis control programme. But for the scheme to work well the local welfare services will have to be further strengthened, along the lines to be indicated later. Other Public Health Needs The Division of Laboratories also needs more and better physical facilities. The four old dwellings in downtown Vancouver which now house the main laboratory are quite unsatisfactory for the purpose. About the time the Division of Laboratories was organized, in 1937, the director proposed a plan for the construction of a modern building at the University of British Columbia which would house the laboratory and the university Department of Public Health, making up an I Institute of Preventive Medicine." This was to be a research centre at which the joint resources of the government and the university would be mobilized in the interests of public health. The plan was approved by the government, but action was not taken before the beginning of the war, and it remains as a most essential project to be implemented. The estimated cost of the building is $500,000. The venereal disease programme has been outstanding. But even here there is need for expansion of the work. The further development of the local health services will go far to help out. The attack on sources of infection must be pressed further, with the collaboration of the law enforcement authorities. In 1943 there was a sharp upward trend in infections in Vancouver, which the Provincial Health Officer attributed to^inadequate control procedures. More epidemiological personnel, he suggested, was 10Dr. G. J. Wherrett, op. cit., p. 192. uSeepp. 139-140. 150 Public Health <Sc Welfare Reorganization necessary.12 At the same time the City Health Officer pointed out that there must be more nurses on his staff to co-operate effectively with the Division of Venereal Disease Control. The annual report of the division for 1943 points out that better provisions for the hospitalization of certain classes of venereal disease patients are badly needed.13 The annual report of the Provincial Board of Health for 1943 contains a number of other suggestions for improvement and expansion. Among these are more central staff for visiting and assisting the part-time health officers throughout the province; more supervisors for the public health nurses; extension of the nutritional programme begun in 1942; the co-ordination of public health education under a specialist in this field; the addition of an officer trained in veterinary science and public health to the Public Health Engineering Division to take charge of a programme of raw milk control; the further development of the scheme of preventive dentistry for school children; and the addition of medical social workers to the staffs of all tuberculosis institutions. There are two or three new activities that might also be suggested. Diseases of the heart and cancer are now the two leading causes of death in the province, and it has been demonstrated that the latter, at least, can be controlled to a considerable extent by means of a public health approach. Yet British Columbia has done little about it. Saskatchewan and several other provinces, as well as a number of the American states, have set up cancer clinics, with some success, and their example might be followed by British Columbia. There is also need of a specialized programme to deal with problems of crippled children. Present arrangements (with treatment being done in two grant-aided hospitals) are not sufficient, particularly in the way of case-finding, social service, and 12Vancouver Sun, March 15, 1944. The legislature has authorized the appointment of four additional epidemiological workers for the fiscal year beginning April 1, 1944. gill 1 Provincial Board of Health, op. cit., p. 32. Transition to Social Security 151 vocational training. With a small staff assigned to this work by the Provincial Board of Health much might be done to improve the programme, through co-ordinating present activities and gaining the active co-operation of the local health and welfare agencies. Still another innovation to be suggested is the establishment of birth-control clinics, under the auspices of the local health departments. This has been done to some extent in Ontario as well as in some parts of the United States. Such a proposal, of course, will not meet with the favour of Catholics; but since birth-control advice is so much in demand by non-Catholics there are strong arguments for the public agencies providing this service which Catholics are under no compulsion to use. The coming of health insurance will create a new situation which will demand certain adjustments in the public health system. The proposals that have been made at Ottawa for a national scheme contemplate its close integration with public health. When medical service for all is a reality the task of the public health authorities will certainly be greatly eased. Probably it will be possible for them to give up some of the work they have been doing. For example, the special programme in preventive dentistry for school children will become unnecessary if all children are assured of adequate dental care; and much of the work of diagnosis and treatment now carried on by the tuberculosis and venereal disease divisions may be taken over by general practitioners and specialists engaged in health insurance practice. The cancer-control and birth-control provisions that were suggested above will be much less needed if there is a general scheme of medical care. It all depends upon the details of health insurance, and it is not proposed here to prescribe how the two services should be dovetailed. Suffice it to say that it will probably be appropriate for most of the present structure of public health to remain and that the problem of integration and co-ordination of the two programmes is one that must be given very careful attention both before and after the specific provisions of health insurance have been worked out. 152 Public Health & Welfare Reorganization To develop the public health system along the lines suggested will call for considerably increased budgets. The Provincial Board of Health does not have accurate data on local health expenditures. However, it is clear that these have been well below accepted standards of adequacy. During the last few years annual expenditures in municipalities under the Vancouver Metropolitan Health Board have been about 75 cents per capita of population, and they must have been a good deal less in most other parts of the province. A commonly accepted pre-war figure for desirable local expenditures in Canada and the United States was one dollar per capita. The Provincial Health Officer estimates that $1.25 is now required for the Vancouver district and at least $1.00 for smaller places. An equal amount, in his opinion, is needed for a good provincial service (excluding, of course, the costs of institutional care for tuberculosis patients.)14 For the fiscal year ending March 31, 1944, the budget of the Board of Health, excluding the hospitalization of tuberculosis patients and grants to the local authorities, was about $450,000. It is unlikely that total local expenditures exceeded this amount. It seems probable, therefore, that an adequate budget for both the provincial and the local services, at $2.00 or $2.50 per capita of population, would be from $1,600,000 to $2,000,000, about double the amount expended in 1943. Medical Care One of the most important, as well as the most difficult, jobs of provincial planning for postwar social security will be the preparation of a new health insurance scheme. The Dominion legislation thus far proposed will leave to the provinces a broad range of discretion regarding such important questions as coverage, nature and extent of benefits, methods of remunerating physicians and other persons and agencies providing medical service, co-ordination, with public health, and administration. It is not possible for any 14Interview, December 17, 1943. Transition to Social Security 153 province to make final plans for its system until the details of Dominion policy are settled. However, a good deal in the way of preparation can be undertaken in advance of Dominion decisions and it is not too soon for British Columbia to get to work on its planning. The existing Health Insurance Act represents a good beginning, and many of its provisions ought to be appropriate for the new scheme. Since health insurance is a tricky and difficult subject, as full of political dynamite as it is of technical problems (which the government of British Columbia ought to know from its own experience) the work of planning calls for the direction of as good a technical advisor as can be obtained. No attempt will be made here to make detailed suggestions regarding the content of the new health insurance scheme. But its probable effects upon some existing services deserve comment. We have seen already that it will no doubt lighten the burdens of the public health authorities considerably. It will also (if it is extended, as the Ottawa proposals and as sound policy dictate, to cover most of the population and in particular the indigent group) render unnecessary the present system, recently expanded, of medical service to the needy. However, pending the introduction of health insurance this system ought to be continued and extended to all municipalities which have not yet accepted it. The small grants to resident physicians still made by the Provincial Secretary's Department have outlived their usefulness. They are clearly incompatible with health insurance; and with the present provisions for indigent medical service they are dubious in the extreme. They could probably be abolished at present, when the wartime shortage of physicians makes for high medical earnings, without injustice to anyone and with no loss to the public service. The extensive medical programme for injured workmen now conducted by the Workmen's Compensation Board might be transferred to the health insurance authority—probably with some contribution from workmen's compensation funds towards the costs. The effects of health insurance upon hospitals will be most 154 Public Health & Welfare Reorganization important. For the first time they will have an assured source of revenue to cover virtually all of their services. Complete coverage of the lower-income and the needy groups by the health insurance scheme and provision of all the hospitalization that they require would make government grants towards hospital operating costs totally unnecessary. But such completeness in the health insurance system is by no means assured, and it is to be expected that, particularly in the early stages, it will have various gaps and exemptions which will make it necessary for the hospitals to offer some free service. In this case operating grants should continue. However, the amount required will be far less than is now being paid.15 The present grant system should be abolished entirely. There is no reason to delay this until the introduction of health insurance makes clear how much continuing aid the hospitals will need, for the system is quite defective even for present purposes. A new plan can be set up which will be better for the present and which will lead to an automatic reduction of grants to the appropriate amount when the health insurance scheme begins to relieve the hospitals of the problem of unpaid service. Under the present system, it will be remembered, the province subsidizes every patient in hospital, whether he is able to pay his bill or not, at a basic rate of 70 cents per day16; and the municipalities also make grants at 70 cents per day in respect of their own residents. This means that Mr. X, a municipal paying patient, may meet his hospital bill of $5.00 per day, which covers the full cost of 15In 1942 the per-capita grants for operating purposes were $1,622,314, of which $1,024,109 came from the province and $598,205 from the municipalities—not including municipal special subsidies of $245,412, most of which was a Vancouver contribution to cover the deficit of the Vancouver General Hospital. Department of the Provincial Secretary, Report on Hospital Statistics and Administration of the Hospital Act, 1942, p. 7 ff. 16To small hospitals with from 500 to 1,000.days' treatment in the course of a year the daily rate is $1.25, then lesser amounts per patient day are granted for additional hospitalization until 70 cents is payable for days in excess of 10,000 per year. Transition to Social Security 155 service to him as nearly as it can be calculated; and that the hospital will receive in addition at least $1.40 for each day's treatment of Mr. X, 70 cents from the responsible municipality, and the remainder from the province. The theory of the scheme is that this surplus revenue in the case of paying patients will enable the hospitals to meet the deficits for service to the non-paying group, in respect of whom only the public grants of $1.40 per day, more or less, are received. Unfortunately there is no necessary correlation between the amount of aid the hospitals receive and the amount of free service they actually provide. The following table shows the costs of "free service," and of "deductions" as compared with provincial and municipal per-capita grants, for a random sample of hospitals in 1942, according to the provincial Report on Hospital Statistics, 1942. TABLE III Free Service, Deductions, and Provincial and Municipal Grants, Selected Hospitals, 1942 Hospital Abbotsford Chilliwack Kamloops Kelowna New Westminster, Royal Columbian North Vancouver Vancouver General Victoria Jubilee Queen Alexandra Solarium Free Service Deductions* Provincial and Municipal Grants $1,162 7,648 12,323 8,582 88,588 12,449 674,065 125,734 39,424 $2,714 12,302 31,868 21,122 94,041 14,988 780,423 165,084 53,930 $7,929 19,087 37,519 19,367 -88,474 30,624 528,134 137,693 19,167 ♦This item includes the value of free service to indigent patients and also the costs of rebates, courtesy service, and adjustments in accounts for certain patients (largely doctors, nurses, and hospital employees) and the losses incidental to bad debts, or uncollectable accounts. 156 Public Health & Welfare Reorganization The table shows that six of the nine hospitals received more in grants than the amount of their free service in 1942, some a great deal more, while three received less. In the case of two of these, Vancouver General and the Queen Alexandra Solarium, the deficit was large. Five of the nine hospitals actually received more in the way of grants than the total of their deductions. This is a reflection of the fact that in 1942, with good incomes general, the amount of free service was proportionately much less than during the depression period and that in general the present grant system operates to the advantage of the hospitals. But in the 1930's the very reverse of this was true. When the hospitals most needed help they received no more than they do at present. Moreover, the present grant system does not distribute aid equitably among the different hospitals. Their needs for assistance vary greatly. Two of the chief problem cases are illustrated in Table III. Vancouver General has never found the grants sufficient to cover its costs of free service because it is in many respects a provincial general hospital, to which difficult cases involving long and expensive treatment are sent from all parts of the province. For this and other reasons its proportion of free service is unusually high, and it has had to depend each year upon special city donations to cover its deficits. Queen Alexandra Solarium is a hospital for crippled children which deals with many cases from unorganized territory. Thus it is doubly handicapped because it receives only the provincial grant for numerous patients and because it renders long and expensive treatment for which many people, even those who normally meet bills for short periods of hospitalization, cannot pay. The essence of the problem of hospital aid is that the amount required varies from time to time, on account of changing economic conditions; and that the requirements of each hospital vary with demands for free service. The present grant system, dating back in its central provisions for many years, is an inflexible scheme which does not recognize these basic factors. It is an unscientific, rule- Transition to Social Security 157 of-thumb method which does not do the things it professes to do, compensate the hospitals equitably for the care they offer to the medically indigent. It has given to some hospitals more than they need, has enabled them to set lessrthan-cost rates for paying patients, and has subsidized loose and careless management; while to others it has given not enough, thereby forcing skimping on service or the soliciting of private donations, or throwing upon a municipality an unfair burden of special deficit financing, as in the case of Vancouver. The obvious alternative to this outdated and inequitable system is one which will apportion grants to the hospitals more in accordance with their needs, as indicated by the amount of legitimate free service which they give. In other words, they should be paid by the government and the municipalities the actual costs of the care rendered to the medically indigent group; with perhaps some allowance to compensate them also for reasonable losses from uncollectable accounts in respect of persons classified originally as paying patients and for some other deficit items (such as those arising from a policy of keeping rates moderately low in a few high- cost hospitals in isolated districts). Such a policy would call for the setting of rates by the hospitals high enough to cover their costs (including losses from such "rebates" and "courtesy services" as may be reasonable for members of the medical and nursing professions and hospital employees), an efficient programme of business management and collection of accounts, and the careful appraisal of the capacity of patients to pay. And of course it would call for very good cost accounting. The system would be more difficult to administer than the present one, but good administrative machinery is at hand through the office of the Inspector of Hospitals, and the uniform accounting system installed under provincial direction during the last few years provides the indispensable accounting mechanism. Plans of the kind have been worked out in the Department of the Provincial Secretary and have been discussed with the British Columbia Hospitals Association, but they have been 158 Public Health & Welfare Reorganization resisted by some of the hospitals, the government has been fearful of offending the politically influential hospital group, everybody is accustomed to the present policy, and the schemes for reform have been filed for future reference.1 The proposed system of grants would be similar in principle to those of other provinces, notably Ontario and Manitoba, where payments are made by the government specifically in respect of the indigent group; and of various American states where the public authorities purchase hospital service from private institutions. Another financial problem of the hospitals is that of obtaining funds for capital extensions and improvements. Neither the province nor the municipalities have had any real policy on this subject. The hospitals have approached them cap in hand when they could not raise capital funds by subscription or by floating their own securities, to obtain help, if at all, only after persuading one or more provincial ministers or a municipal council that public money was urgently needed to meet a critical situation. There have been no principles to govern the distribution of capital grants; and the political functionaries who make the decisions, whatever the purity of their personal motives, cannot fail to be influenced by political pressures. Moreover, there has been no planned policy, either provincial or municipal, of making long-term budgetary plans for hospital construction, so that during the depression period there was no public money available to meet needs, such as those for 17An equalization plan of the sort proposed, no matter what its logic and equity, always seems to run foul of the fact that some of the grant-aided units, those that appear to gain from the going system, would lose by redistribution of the subsidies. The voices of those that will lose are raised loud in opposition and often prevail, even if they are only a minority, over those that may benefit. The potential beneficiaries tend to be suspicious of a government that comes bearing gifts (for they have been disappointed before, and once bitten twice shy), they are perhaps confused by the complexity of the new scheme, they find, some details they do not like, and they dislike the idea of administrative changes and troubles that arise out of the scrapping of an old method, even one they do not like very well. So the nays get the floor in meeting, the potential ayes don't say very much until it is too late, and presto!—an influential association has voted against a perfectly good scheme! Transition to Social Security 159 additional construction at the Vancouver General Hospital, that everybody admitted to be acute. Under health insurance it seems possible that the situation can be met, in part at least, by setting hospital charges high enough to cover capital costs, thus permitting the hospitals to issue bonds (perhaps with government guarantees) to finance legitimate expansion and improvement. In addition it will probably be desirable for the government to appropriate funds for outright capital grants, to assist in the building of hospitals in new districts and to meet other special situations. Pending the introduction of health insurance this should certainly be done. The distribution of these funds should be entrusted to a non-political board of some kind rather than to any minister or departmental official, for obvious reasons. There should also be very definite governmental control of all hospital development, both to discourage expansion where it is not really needed or is not likely to be needed in the future and to encourage construction where it is required. With or without health insurance the programme of hospital inspection and regulation must continue, and it should aim to develop an integrated hospital system throughout the province. There is much to be said for the various institutions being managed by their lay boards, as at present; but since they are dependent upon public funds to so great an extent at present and since this dependence will increase greatly under health insurance, it is eminently proper to regard them as public utilities which must always be conducted in such manner as to serve the community interest, under fair rules laid down by the government. Closely related to the hospital problem is that of infirmaries. There is a serious shortage of infirmary beds—and those at the Provincial Infirmary, Marpole, and at the Allco Camp Hospital are of poor quality. The Provincial Home at Kamloops has many inmates who are senile or chronically ill, its original function of caring for aging pioneers is no longer very important now that there is provision for the aged living on pensions in their own homes or in 160 Public Health & Welfare Reorganization boarding homes, and it would be better used as an infirmary for people of various ages. In addition it is quite clear that new infirmaries to provide simple and relatively inexpensive care for several hundred more patients at least are much to be desired. The provision of these beds will help materially to clear hospitals and to release their more expensive beds for the acutely ill. Mental Hygiene More beds is the outstanding need of the mental hospitals. The present buildings, designed for 2,500 patients, now house about 4,000. In consequence recreation rooms, offices, occupational space, and even corridors must be used for beds. Patients cannot be suitably classified, so that the early, acute (and hopeful) cases must be mixed with hopeless chronics. It has been very difficult to segregate tuberculous and other infectious patients. In a dozen and one ways serious overcrowding has handicapped doctors and nurses and has stood in the way of effective treatment. The general superintendent modestly says that "when we allow 20 per cent, for so-called normal overcrowding, we still have 1,000 more patients than our buildings should look after. This shows plainly that accommodation will have to be provided. "18 A more generous estimate would allow for 1,500 new beds, which would probably cost some $4,500,000. The government is well aware of the problem and has promised to provide more buildings as soon as it is feasible. Recently the Provincial Secretary announced that definite plans had been made to undertake new mental hospital construction at a cost of $1,200,000—which will obviously go only part of the way to solve a long neglected problem. In addition there are at least two special institutions that should be established—a psychopathic hospital at Vancouver and a training school for mental defectives. These were both recom- 18Department of the Provincial Secretary, Annual Report of the Mental Hospitals, 1943, p. 12. Transition to Social Security 161 mended by the Royal Commission on Mental Hygiene which reported in 1925, but no action on the proposals has ever been taken. The hospital in Vancouver would be similar to the psychopathic hospitals in Toronto, Winnipeg, and other cities. It would provide psychiatric clinic facilities for outpatients, as well as a limited number of beds for patients admitted for diagnosis and short-term treatment. The present facilities for mentally deficient children, in the old asylum buildings at New Westminster, are totally unsatisfactory. It has been necessary to lump together both children and adults who are feeble-minded, and while brave efforts have been made to provide some training for the children the physical environment has made this difficult in the extreme. At New Westminster, as the superintendent says in his last annual report, "some of the buildings . . . are very old and in poor repair. Definite danger exists from fire. "19 He might have added much stronger words. Those who know the institution well call it a fire trap. Another obvious need is extension of the psychiatric clinics, which have done such excellent work with limited resources. One or more travelling clinics to cover the province, in addition to those now operated at four centres, may be suggested. Staff should be very considerably increased, both for hospital and for clinic service. The number of physicians authorized in the budget for the fiscal year 1944-1945 would have to be doubled, approximately, to reach the standard recommended by the American Psychiatric Association of one doctor for every 150 patients. The social work staff of the hospitals and the clinics (a supervisor and three assistants) is too small for adequate service. There should be staff and funds available to conduct a vigorous educational programme in mental hygiene, in collaboration with the educational system, the public health agencies, and other organizations, public and private. The emphasis of the whole programme should be far more upon preven- 1QIbid., p. 12. 162 Public Health Sc Welfare Reorganization tion, cure, and rehabilitation than it is at present, when the overwhelming mass of patients to be maintained with inadequate resources makes it inevitable that effort is centred upon routine institutional care. Still another progressive step which should be taken is the extension of extramural care, including the placement in boarding homes of patients who cannot be returned to their own homes. British Columbia ranks highest among the Canadian provinces in the proportion of population resident in mental institutions (47.9 per 10,000 of population at the end of 1939, as compared with 38 for all of Canada).20 Yet it ranks well below the national average in ratio of patients on parole to the total under care. On March 31, 1942, the number on parole (or on probation, to use the British Columbia term) was approximately 5 per cent, of the total "on the books"21;' while in Oniario, the province with the greatest proportion on parole, the percentage Vas 9.8, about a third of whom were in boarding homes.22 In California 18.8 per cent, of the patients under the jurisdiction of the state mental hospitals were on parole on June 30, 1942.23 These figures suggest that British Columbia has been laggard in moving patients out of the hospitals and limiting the growth of patient populations by this means. Ontario, California, and New York, which have followed an active parole policy in recent years, including the boarding-out of patients who could not be returned to relatives or friends, have succeeded in stabilizing or even reducing their mental hospital populations! While the policies of extramural care followed by these jurisdictions do not explain this success entirely, they have played a very large part in it. Striking testimony to the potentialities of parole and boarding- 20Dominion Bureau of Statistics, Annual Report of Mental Institutions, 1939, p. 11. 21Annual Report of the Mental Hospitals, 1942-1943, p.*24. 22Department of Health, Annual Report on the Ontario Hospitals, 1942-1943, p. 22. 23Department of Institutions, Statistical Report, 1942, p. 68. Transition to Social Security 163 out comes from the progress report of the Temporary Commission on State Hospital Problems appointed by Governor Lehman of New York in 1940. Careful psychiatric studies of hospital patients which were made under the auspices of the commission led to the conclusion that from 6 to 10 per cent, could be released for extramural care—"if psychiatric service is available for .the necessary individual examinations and if social service, adequate in numbers and suitable in qualifications, is also available."24 The fact that so many could be cleared from a group which had already been combed vigorously for parolees over a number of years suggests the great possibilities of the parole method in a system like that of British Columbia, where it has been used but little. The New York commission draws the obvious moral from its findings that very large sums of money will be saved by avoiding the costly construction of hospital beds and the expensive institutional maintenance of patients in favour of the cheaper method of extramural care. Thus there is good reason to believe that a vigorous programme of parole would contribute materially to the relief of overcrowding in the mental hospitals of British Columbia. If such a policy could be initiated promptly it might give relief sooner than would new buildings—for construction takes much time. Moreover, it might reduce materially the number of new beds required—perhaps to 1,000, instead of the 1,500 that have been suggested. But there must be skilled staff to operate the system—psychiatrists, nurses, and social workers. The New York commission declares one social worker for every sixty parolees to be essential. Therefore the first efforts to develop the system must be directed towards the recruiting and the training of suitable staff. Delinquency Control The major wea#hess of the British Columbia machinery for delinquency control is the lack of good provisions for probation and 2*New York State Charities Aid Association News, December, 1942, p. 4. 164 Public Health & Welfare Reorganization parole. Referring particularly to the problem of juvenile delinquency, Magistrate H. S. Wood of Vancouver, in a report made to the provincial Attorney-General on June 25, 1943, said that "a programme of probation should greatly reduce committals to Industrial Schools and Penal Institutions. . . . We found that in most places there was no real programme of probation, and no probation officers, and in some places the word was new to those concerned. The Magistrates generally were loath to commit to institutions, but very often owing to the lack of other remedy they felt that there was no alternative." Magistrate Wood was referring to the smaller towns of the province. There are full-time probation officers for juveniles only in Vancouver, Burnaby, and Victoria; and there is only one adult probation officer for the province, serving courts in the Vancouver'area. Clearly probation service, provided by full-time probation officers with professional training in social work, ought to be available for all courts, both juvenile and adult.25 This must be under the direction of a provincial officer, or else it will be headless, unco-ordinated, and unevenly developed from place to place, as at present. The Advisory Committee on Juvenile Delinquency of 1936 recommended to the government that the province should take over full responsibility, administrative and financial, for the operation of juvenile courts and probation service; and Magistrate Wood, in his recent report, stresses the need for a provincial supervisory officer. The committee of 1936 recognized that it would not be feasible to maintain full-time officers in all small centers of the province and proposed that members of the staff of the Welfare Field Service perform probation functions in these places. Now that good local welfare departments, with trained personnel, are in prospect, members of their staffs might be designated as part-time probation officers to serve the smaller communities and the rural districts. This would be infinitely better than the compromise 25This was strongly recommended by the Dominion Royal Commission on the Penal System in 1938. Report, p. 360. Transition to Social Security 165 suggestion of Magistrate Wood in the latest report, that provincial policemen should be engaged. Probation service is social service of a particularly delicate and difficult kind, and a policeman, be he ever so good in his own work, is no more equipped for it than he is for accounting, or public health, or teaching, or other professions for which he has not been trained. A provincial parole service, for both juveniles and adults released from the institutions, should also be developed from the small beginnings represented by the "follow-up" officers of the industrial schools and the Borstal institution, and this might be provided by the same staff that handles probation. Another reform that is needed is extension of the juvenile court system to all parts of the province. At present courts are not operating in many small centres. Moreover, there should be central direction of the work of the juvenile court judges. At present they are appointed casually by the government, on the advice of the Attorney-General's Department, without any particular reference to their having special qualifications for the work, and then they are left to their own devices, without guidance or assistance. Except for the judges of Vancouver, Victoria, and Burnaby they deal with only a few cases each year, and they have little opportunity of obtaining good advice and technical assistance which would develop in them real understanding and skill in their work. To overcome the problems of poor standards and great lack of uniformity in the juvenile court programme, the Advisory Committee on Juvenile Delinquency proposed the appointment of a senior juvenile court judge, to be assisted by a small number of deputy judges presiding over courts in different centres. This procedure, the committee thought, was permissible under existing legislation. The proposal remains worthy of very serious consideration, as one which should do much to improve the quality of the juvenile courts. The institutional situation is far from satisfactory. It has been recognized for some time that the present quarters of the Boys' 166 Public Health & Welfare Reorganization Industrial School at Coquitlam, next door to the Essondale Mental Hospital, are not good and that they should be moved. The government has stated that plans for a new institution are being made. The closing in 1942 of New Haven, the Borstal institution, was a backward step. It ought to be re-established and developed still further. The provincial jails (Oakalla, Kamloops, Nelson, and Prince George) have a poor reputation among people who are well informed about delinquency problems. There have been some advances at Oakalla in recent years, including improvements to the women's jail and the appointment of better women officers, the development of an educational programme, increased co-operation with the mental hospitals, the Tuberculosis Division, and the Division of Venereal Disease Control to provide care for inmates, the addition of new library facilities, some provision for parole service, and greater concern with the reclamation of young offenders. But Oakalla, if it is not a bad prison by contrast with other Canadian institutions, is not a good one. The Royal Commission on the Penal System did not exempt it from the general condemnation of Canadian prisons which it made in 1938. Clearly it falls far short of measuring up to the standards of good administration proposed by the Royal Commission, which include careful classification of prisoners, the appointment of specially' trained staff on a merit basis, the abolition or modification of restrictive regulations like the "silence rule," and carefully planned programmes of recreation and education. The latest edition of "Gaol Rules and Regulations," issued in January, 1940, gives little hint of modern penal practice at Oakalla. The only educational qualification prescribed for a guard is that he " should be able to read and write understandingly "; for disobedience of rules and for other offences "including idleness or negligence at work" the warden may order that prisoners be flogged "with the leather paddle or strap," "shackled to cell-gate during working hours," or condemned to "solitary confinement in a dark cell with or without bedding"; and it is prescribed that "the Transition to Social Security 167 first duty of a prisoner is strict obedience." But there is no mention of any measures to prepare prisoners for a useful life after they leave the institution. It appears that Oakalla is essentially a place of punishment and detention rather than a place where rehabilitation is at least as important an objective. The smaller jails of the province are no different in this respect. Transfer of jurisdiction over all delinquency services to a new department of public welfare (succeeding the Department of the Provincial Secretary) should help materially to improve the delinquency services. What is urgently needed is integration and co-ordination of the whole system of delinquency control under vigorous provincial leadership. The prospect of such integration and leadership under the Department of the Attorney-General, which now operates the jails and has a loose jurisdiction over juvenile courts and the probation and parole services, is not very good. The jails come directly under the Commissioner of Provincial Police. But the operation of penal institutions is not a police job. Rather is it a job of social treatment in which the welfare approach is likely to be far more effective than the law enforcement approach and for which the administrative personnel should have training predominantly in social welfare rather than in police science or in law. The relatively backward state of the adult institutions by contrast with the progressive characteristics of the juvenile industrial schools is to be explained largely by lack of interest in a progressive penal programme on the part of the provincial police26 and the Attorney-General's Department. For years interested citizens and organizations have pressed the Attorney-General's Department to improve the delinquency services; and the advances that have been made, notably the establishment of New Haven, have come as the result of pressure from the outside rather than from within. The department has 26However, tribute must be paid to the present Commissioner of Provincial Police for a keen interest in improving the situation and for various practical measures of reform which he has initiated or supported. 168 Public Health & Welfare Reorganization taken no action upon many excellent suggestions such as those for a provincial probation service made by the Advisory Committee on Juvenile Delinquency in 1936. Apathy on the part of departmental permanent officials, based as much upon ignorance of the delinquency problem as upon traditional civil service conservatism, goes far to explain this lack of action. On the other hand there is both knowledge of the problem and keen interest in it on the part of officials in the welfare services and there is much more hope of their planning and supporting progressive policies. Still more important than the reform of penal institutions, of courts, and of probation and parole, is the development of recreational and educational projects to provide constructive activity for young people in their leisure time. During the 1930's there developed under the Department of Education a most interesting programme for unemployed youth which became known as the "Pro-Rec" (Provincial Recreation) scheme. Physical training was mainly emphasized in this enterprise but it was concerned also with other types of recreation. Thousands of young men and women, the employed as well as the unemployed, enrolled in the Pro-Rec groups established throughout the province. The groups have remained active during the war period. This scheme might be extended and modified to become the core of an integrated public recreation programme for the province. Specific tasks for the provincial agency might include provincial grants to the local authorities to assist them with the establishment and the operation of parks, playgrounds, and community centres; the stimulation of club activities for different groups at the local centres; the continuation of physical training on a large scale; the stimulation and the co-ordination of recreational activities by private agencies; and co-operation with the educational authorities to meet common objectives and avoid overlapping. In this field, as in others, it will be appropriate'for the provincial government to take the lead in the postwar period whether it assumes much in the way of direct Transition to Social Security 169 administration and financial responsibility or whether it leaves this mainly to the local authorities and to private groups. The Royal Commission on the Penal System recommended that the Dominion government take over all penal institutions for other than short-term offenders and juveniles and if this recommendation is adopted a good many of the adults now committed to provincial jails will no doubt be sent to federal institutions. However, no action to implement this recommendation is immediately in prospect and the fact that something may be done by the Dominion in the future should not deter British Columbia from integrating and improving her delinquency services now, for a large sector of the delinquency programme will remain in provincial hands whether the Royal Commission's proposals are adopted or not. Public Assistance It is to be hoped that never again will the same strains be placed upon the public assistance system as during the depression period, both because of more stable economic conditions and because of the coming of federal measures of social insurance. But neither of these developments will do away entirely with the need for public assistance, and case loads in the immediate postwar period are likely to be heavy. Despite recent advances, it will be necessary to modify and improve the present system in a number of ways for x it to fit properly into a national programme of social security and for it to contribute its fair part. The existing programme of old age pensions should be continued to provide protection for those who will not be eligible for federal old age insurance benefits. But the present system has various deficiencies. It is widely agreed that the age limit for pensions should be reduced from seventy to sixty-five years in the case of men and to sixty years in the case of women. Rigid eligibility rules including British citizenship, twenty years of residence in Canada, and five years in the province where the application is made, limit 170 Public Health & Welfare Reorganization considerably the number of persons who can obtain grants. The denial of pensions to old people whose children are presumably in a position to support them (whether they are actually doing so or not) is much to be questioned. Allowances (perhaps at half the basic pension rates) might be made for wives or other dependents of pensioners. The recent increase in the maximum grant to $30 per month (including the provincial bonus of $5) has brought the rate for the first time to something approaching decency; and while it may be desirable to raise it still further other improvements are more urgent. If the scheme is to provide security on a decent level and under decent conditions for old people other than those who obtain protection from social insurance it should be thoroughly amended to make it more generous and more flexible.2 However, since its amendment must wait upon Dominion action on social security policy, there is not much that British Columbia can do now to improve the scheme beyond providing better administration and raising grants further, entire!^ at provincial expense, as it has already begun to do. * Reform of the system of blind pensions must also wait upon the formulation of Dominion policy. These allowances should not be limited to persons over forty years of age, as at present, but should be payable to any blind person who is unable to support himself. Moreover, there is need also for allowances for other disabled groups —those afflicted from childhood or by virtue of accident or disease who have no means of support and who are likely to be permanently handicapped. Under the present system of social allowances in British Columbia substantial numbers of such persons are being maintained entirely at provincial and local expense. There is much to be said for this group being supported by a new system of disability allowances into which the present scheme for the blind would be merged. But here, too, action must await Dominion 27There is a useful discussion of possible improvements in the old age pension system in House of Commons, Sess. 1943, Special Committee on Social Security, Report on Social Security for Canada, by L. C. Marsh, pp. 71-73. Transition to Social Security 171 policy, for this question is one that is intimately related to federal decisions regarding disability insurance. The existing system of mothers' allowances is reasonably good and it should be continued. However, if a federal scheme of family allowances is established the provincial programme can be modified to cut out grants for children or else to scale them down to allow for such federal payments as may be made. A new system of disability allowances would make it possible and proper to do away with the present provision of the Mothers' Allowances Act for grants in respect of disabled husbands in any family. Such changes would modify the mothers' allowances system considerably. It would then become simply a device to provide support for the needy mother of fatherless and dependent children so that she can keep her home together and offer them suitable care. As time goes on and as provisions for general assistance are improved concurrently with the development of family allowances, the case for maintaining a separate category of mothers' allowances will become progressively less strong. But the needy mothers are such a distinctive group and the system is so useful and so popular that it does not seem proper to propose its abolition until alternative provisions are firmly established. This leads to the* question of why there should be "categories" of aid for the aged, the disabled, and needy mothers at all. It may be argued that these categories are no longer necessary when the standards of general assistance become adequate. On the other hand, there is a case for giving preferred treatment to these groups, including the psychological security of assured allowances without a too rigid means test, for circumstances have placed them in the position of being more or less permanently unable to maintain themselves. If it is conceded that society should care for them, it seems reasonable to place them decently on protected shelves, somewhat apart from and above the level of the general assistance recipients, where they can be assured that they will remain undisturbed for considerable periods of time and where they will be 172 Public Health & Welfare Reorganization relatively free from the public scorn which is all too likely to be directed for a long time against the "failures" and the "misfits" who will make up a considerable proportion of the general assistance group. While there must be a means test for those receiving categorical aid it can properly be less rigid than for general assistance. For example, categorical aid recipients may be permitted a certain amount of property ownership as well as small amounts of income without deductions being made from maximum allowances payable. Thus they need not be reduced to absolute destitution before becoming eligible for help. The final item in the system must be a good scheme of general assistance. The elements of this are now present in British Columbia, thanks to the marked improvements which have been made recently. This programme should be elastic and flexible. Relief should be sufficient to meet minimum needs for maintenance and for development. Since needs vary from person to person, and from family to family, there should be no definite limits to the grants, such as are justifiable under social insurance and the categorical aids. On the other hand, relief should be given on a "budgetary deficiency basis" (the difference between budgeted needs and the applicant's resources) to provide so much income for all recipients as they actually require. The fixed rules regarding social insurance benefits and categorical aid will mean inevitably that all the needs of all beneficiaries of these schemes are not met. In such cases the general assistance programme must provide supplementary aid to cover such items as special diets, the purchase of household equipment, necessary expenses of travel, unusual medical charges, certain costs of useful training not otherwise provided, and other extras. This is the residual scheme which will not only carry regularly those persons who fall through the network of protection offered by social insurance and the categorical aids, but will also provide for those myriad special problems of individuals which no rigid benefit or grant system can possibly cover. Such a system would solve the problem of boarding-home and nursing- Transition to Social Security 173 home care which has been mentioned frequently in the two preceding chapters, for the general assistance programme would provide, among other things, to meet such costs as might be necessary to place needy people in homes. The prospective federal system of family allowances should curtail considerably the amount of the grants that will have to be made to needy families. Under the budgetary deficiency method of issuing assistance, the children's allowances will count as family income and will be deductible from the full budget needed by the family for maintenance. In effect, therefore, the general assistance scheme will be called upon to provide relief only for adults if the family allowance system is generous enough to cover the full costs of maintaining children. This will have the great advantage, among other things, of doing away with the argument for a ceiling on relief in order to keep all allowances below the level of the earnings of independent workers. It was stated in the last chapter that the present scales of general assistance are probably "up to or above minimum health standards for most classes of recipients." It was not possible to be more definite because good budgetary information is not available to show the costs of maintenance at minimum standards. Such budgets for family units differing in size and composition should be worked out with great care and should be priced periodically in the various parts of the province. Only when the administrative staff have good budgets at hand will it be possible for them to calculate properly, for the various applicants, the grants that they require on a basis of budgetary deficiency. As we have seen, the province has no general assistance legislation at the present time except a simple phrase regarding municipal responsibility for the destitute which appears in the Municipal Act. It is most desirable that so important a programme should be operated under statutory authority. A simple act should be passed to state clearly the broad objectives of general assistance policy and to outline the main provisions of the scheme. Insofar 174 Public Health & Welfare Reorganization as the municipalities are made responsible administratively and financially for this service, their obligations should be clearly defined so that they will have no excuse for denying appropriate aid to persons in need of it. In this act as in other public assistance legislation there should be inserted clear provisions regarding "fair hearing and appeal," such as are required in state laws conforming to the requirements of the Social Security Act of the United States. These provisions should go far to make public assistance a right instead of the privilege, often capriciously granted, which it has been in the past. If there is to be local administration of public assistance in British Columbia, the rights of applicants should be sufficiently guarded by the opportunity of appeal to a board of provincial officials with perhaps a few outside members. The appeal board must be closely in touch with the administrative authorities for it will actually have the power to make policy to a considerable extent by virtue of the decisions it hands down in particular cases. It should be essentially an administrative tribunal designed to guarantee equity in passing upon individual claims rather than a court of law. It would deal with questions of fact rather than of law. Where these latter questions are involved, of course, court appeals would be proper. But an administrative tribunal which has simple procedure, which permits and encourages claimants to state their own cases, and whose members are thoroughly familiar with the problems of assistance administration, is in many ways better equipped to review the facts in appeal cases than are the lawcourts. Moreover, it can deal more expeditiously with appeals, and it should be able to satisfy claimants as well as a court that they are receiving justice. If the Dominion policy includes the proposal in Chapter 1 to establish "work and maintenance" schemes for needy employables not protected by social insurance, or even if Dr. Marsh's alternative recommendation of a national system of unemployment assistance is adopted, there will be little need for work relief as a complement of general assistance, for there will be few persons on the relief rolls Transition to Social Security 175 with any capacity for work. But failure to implement these policies fully and logically would mean that a good many employables would enter the general assistance group. Indeed, should unemployment become heavy they would soon outnumber the unemployables. Therefore, partly to prepare for this contingency and partly to provide for the limited number of employables or semi-employables who are likely to be eligible for general assistance even if the best of social security policies are adopted, it will probably be wise for the provincial authorities to make some plans for work relief. There can be no objection to recipients making a work contribution in return for their aid providing the work is useful, is reasonably within their capacities, is conducted under decent conditions, and is remunerated at fair rates. These conditions may sound simple of attainment. Actually, this is not the case. Canadian experience with work relief has been very unsatisfactory,28 and the infinitely better WPA undertakings of the United States were much open to criticism. Nevertheless the writer ventures the opinion that there is a limited place for well-conceived work projects in conjunction with a general assistance programme, even when the great bulk of employable persons are protected by other social security measures. Janitorial work, the improvement and maintenance of grounds, clothing repair and distribution, and many other light jobs, for both men and women, are among the small-scale projects that might be feasible. The question is one for study and administrative planning. More staff is an outstanding need of the public assistance system, even under present conditions of reduced numbers of recipients. The ratio of cases to welfare workers is far too high, both in the provincial and the local departments. In December of 1943 members of the provincial field service carried case loads ranging from about 250 to over 500 in the various districts through- 28See, for example, the writer's Unemployment and Relief in Ontario, 1929-1932 (Toronto: 1932), chap. 6, for a detailed account of difficulties in the early part of the depression period. 176 Public Health & Welfare Reorganization out the province.29 In the Vancouver East district'office the ratio of visitors to cases was one to about 340 in December, 1943. Some 15,000 old age and blind pension cases were carried by six visitors, about 2,500 per person, just before the Old Age Pensions Branch of the Workmen's Compensation Board was transferred to the Department of the Provincial Secretary in April, 1943—with some assistance, it should be added, from provincial police and municipal officials outside of Vancouver who took initial applications and made some reports. It is clear that these loads are far too heavy to permit efficient service. Various studies in the United States have shown that it is not possible to specify standards of case loads in round numbers except in terms of particular situations—such as the types of cases being handled, the nature of the administrative processes involved, the concentration of population and the problem of transportation in the district served, the number and the quality of supervisors, and the training and experience of staff members. Subject to these qualifications, it may be said that American experience has shown ratios of cases to workers (exclusive of supervisors) exceeding 300 for old age assistance, 125 for aid to dependent children (the counterpart of mothers' allowances), 100 for general assistance, and 50 for child welfare to be generally too high for satisfactory work. It is impossible to be even so categorical with respect to the mixed case loads (predominantly old age pensions) now carried by the members of the provincial field service and some of the local welfare departments, for the burden of work depends upon the proportions which the various types of cases contribute to the total: but it is unlikely that the ratio should be higher than 150 or 200 cases per worker under the conditions now prevailing in British Columbia. These rough-and-ready statements on standards suggest that 29By letter from the Assistant Superintendent of Welfare, December 29, 1943. The average load in the lowest district was 235 and in the highest 548. The term "case load," which .is open to various interpretations, is used in the simple and unrefined sense of ratio of total active cases to workers. Transition to Social Security 177 the personnel of the provincial field service should be nearly twice as large as it was in December, 1943, and that the staffs of the local welfare departments should be greatly increased. The need for more staff is keenly recognized within the Provincial Secretary's Department. The Assistant Superintendent of Welfare wrote, in a memorandum prepared in November, 1943, that at the beginning of the year "many of our workers were carrying three times the load they should have been expected to carry. We knew that they must get holidays, and yet the situation was so serious during the summer months that we wondered at times if we could survive." The Assistant Deputy Provincial Secretary testified before the Social Welfare Committee of the legislature in February of 1944 that the department needed thirty additional social workers. The legislature, in the annual Estimates, approved seventeen new positions for the fiscal year beginning April 1, 1944. This brought the authorized number of social workers up to eighty-seven (six supervisors and eighty-one staff members) as compared with seventy for the preceding year. This represents a good advance, but it falls considerably short of meeting needs. The argument for lower case loads for welfare visitors does not rest wholly upon the desirability of relieving overworked staff or even of providing better and more sympathetic service for clients, valid although these points are. It also includes the point that "Adequate Staff Brings Economy," to use the title of a bulletin issued by the American Public Welfare Association in 1939. This bulletin reports the results of a carefully controlled experiment conducted by the Chicago Relief Administration in 1938, when average case loads per worker were cut in half, from 169 in December, 1937, to 80 for the period of the experiment; and when administrative practices were generally revised to bring them into line with good social work standards. Although administrative costs were increased by about $6,500 monthly, the estimated savings in the costs of relief were $20,000 in the last month of the experiment, $o that the net gain was $13,500 monthly, or 9 per cent, of estimated 178 Public Health & Welfare Reorganization total expenditures (for both relief and administration) under the preceding system. The savings arose from a lower rate of case openings in relation to applications and a higher rate of case closings than previously, the result of more intensive and effective work by a better organized and less overburdened staff. Various other American studies have shown similar results.30 The point is also supported by the results of a special project undertaken in Vancouver in 1940, when the city Social Service Department, assisted by the provincial Unemployment Relief Branch, undertook an experiment with about 1,000 relief cases in South Vancouver. Visitor's case loads were reduced to 100 each and a positive programme of assisting clients to find employment or other means of support was undertaken. Five months later the case load had been cut in half. No doubt much of the reduction occurred because the economic situation was improving steadily. But the conclusion within the department was that "as a result of a careful analysis of every case at least 30 per cent, had been closed as a result of methods used."31 The fact that adequate, even generous, provision for competent staff does not cause higher total costs in public assistance, but actually brings lower total costs, calls for emphasis here because it has not been recognized in the past by the provincial and local governments in British Columbia or any other Canadian province. Welfare administrators have known it well, and have pointed it out to their political superiors who control appropriations. But the view has prevailed in appropriation circles that there should be "economy" in administration, and that low administrative costs were synonymous with efficiency. These are complete fallacies which must be overcome if there is to be a really economical dis- 30See, for example, Herbert A. Simon et al., Determining Work Loads for Professional Staff in a Public Welfare Agency (Berkeley: University of California, Bureau of Public Administration, 1941). 3i"The Tide in Public Welfare," a typewritten article prepared by Miss Amy Leigh, Welfare Director of the Vancouver Social Service Department, July 10, 1942, Transition to Social Security 179 tribution of public assistance funds. It is ironical to reflect upon the fact that those in British Columbia and elsewhere who have called most stridently for "economy" in public administration (such as the members of the Kidd Committee ofT932) have really been voting for extravagance insofar as they have opposed the appointment of adequate personnel to operate the public assistance services. Vocational Rehabilitation At present there is great interest throughout Canada in the rehabilitation of handicapped war veterans, for which the federal government has already made generous provision. There is a similar need for the vocational rehabilitation of civilians. Although this is a problem that falls within the jurisdiction of the provinces at present and that will probably remain with them when a national policy on social security has been worked out, there is no province which has made a thorough attack on it. In British Columbia, the Department of Education is conducting vocational training classes, with the assistance of federal grants under the Vocational Training Co-ordination Act of 1942. Programmes for special groups are operated by the Canadian National Institute for the Blind, the Provincial School for the Deaf (under the Department of Education), and the Vancouver Occupational Industries (for the tuberculous). Up to 1943 there was no provision for the rehabilitation of workmen injured in industry. But in that year, following a recommendation by the Sloan commission of inquiry in 1942, the Workmen's Compensation Board was authorized by law to spend up to $75,000 per year on rehabilitation work. However, there is no integrated programme for the benefit of the various handicapped groups. The importance of the problem suggests that there should be established a bureau of vocational rehabilitation to co-ordinate existing activities, to undertake service for groups that are neglected, and to exercise general jurisdiction over public and private 180 Public Health & Welfare Reorganization efforts in the field (excepting, of course, the federal programme for war veterans). Among those requiring service are the blind, the deaf, the victims of industrial and other accidents, persons handicapped by chronic heart disease, asthma, tuberculosis, and other diseases, middle-aged widows familiar only with housework, and various groups of older people who are maladjusted vocationally. Much more than the opportunity of training is needed for these people. Each group, and each person within a group, has a special problem, which must be analysed with care before appropriate measures of rehabilitation (which may or may not include training) can be suggested. Among the resources to be drawn upon will be those of" medical care, public assistance, psychiatric service, vocational guidance, training, and employment service, each proffered by different agencies. It would not be the task of the bureau of rehabilitation to compete with other organizations, public and private, by rendering such services. Rather its major contribution would be case work in behalf of the individuals referred to it by other agencies and the mobilization of all possible resources to assist clients, together with the administration (should this prove necessary) of special measures not otherwise available, such as the provision of training grants, or the operation of hostels for trainees. Perhaps the work for the blind now carried on by the Canadian National Institute for the Blind, with the support of a provincial grant, should be taken over by the new bureau. But there is no compelling reason for doing this if the C.N.I.B. work can be fitted into an integrated programme, and there may prove to be good reasons for leaving it in the hands of a private organization which has an excellent record of accomplishment to its credit. Good decisions on this point, as on others, can only be made after careful survey of the whole problem. The provincial bureau might arrange for its civilian clients to obtain the benefits of some of the federal facilities for the rehabilitation of war veterans, or it might perform some services for the veterans' administration. Certainly the two programmes should be co-ordinated as much as possible, Transition to Social Security Other Welfare Measures 181 The child welfare programme is relatively good. There is little to be suggested for its development except that it be given more—and better—staff resources. Improvement in the quality of the work now being done by the three children's aid societies and the Child Welfare Branch is the chief objective to be sought, and this should come as more highly qualified child welfare specialists are recruited. It is possible that additional children's aid societies should be formed to take over work now being done by the Child Welfare Branch and the provincial field service throughout much of the province, but there is no great urgency about this. The provincial welfare code should be amended to provide that newcomers from other provinces are entitled to the same social service benefits as British Columbians. As* this is done by British Columbia, so should it be done by other provinces. Uniform rules for provincial residence and reciprocal agreements between the provinces regarding the fair distribution of the costs of service to the residents of one province who are cared for by another will probably be necessary to protect interprovincial migrants against discrimination. This is clearly a problem which calls for a nationwide solution under the leadership of the Dominion.32 British Columbia has already made a useful contribution by pressing the idea of uniform residence rules and reciprocal agreements upon the federal government and by writing interprovincial agreement provisions into a number of its statutes. This line of policy should be pursued still further, with agreements being made with other provinces wherever possible, even in advance of an over-all Dominion policy on the subject. The private health and welfare services have a significant part to play in a total programme of social security. The children's aid societies, the hospitals, and the Canadian National Institute for 32Detailed suggestions for a national policy are given in a paper by the writer, "Uniform Residence Rules and Procedure to Meet the Transient Problem," Proceedings of Sixth Canadian Conference on Social Work, 1938. 182 Public Health & Welfare Reorganization the Blind are now closely related to the public social services of British Columbia. Indeed, they may be said to be indispensable elements of the system even if technically they are not public agencies. There are other organizations, not so closely connected at present, which might well be brought into closer relation—such as the family welfare societies of Vancouver and Victoria, the prisoners' aid societies, the community centres and other recreational agencies, the visiting nursing organizations, and the institutions and hostels for the old and the young. Such organizations, when they have sound objectives and are well managed, can undertake useful tasks which the public agencies, necessarily limited by law and appropriations to main-line jobs which have general public approval, often find it difficult to do. Potentially the private agencies have a capacity for adaptability and flexibility which is greater than the public organizations, and they are often more free to undertake pioneering and experimental jobs. The fact that in practice many of them have been much more conservative proves only that they have lacked imaginative leadership. They can be helped materially to realize their potentialities through a positive public policy of encouragement and support. The provincial agencies should give special attention to the part that private agencies can play in supplementing and complementing public services and should do everything possible to see that public and private efforts are co-ordinated. This will involve, among .other things, reconsideration of various grants to private agencies now made by the Provincial Secretary's Department and the formulation of a more clear policy on financial aid to such organizations. There is one other type of service which the public welfare agencies should offer which is of the utmost importance, even if it is not possible to define it so clearly as others. This is what may be called "constructive welfare service." The individualized case work approach should permeate the administration of the public assistance system. But over and above this there is the special need for constructive service in the district welfare offices, Transition to Social Security 183 whether they are operated by the provincial or the local authorities. Their major function at present is that of determining eligibility for public assistance, and as we have seen they do not have enough staff even to do this properly. Most of the applicants with whom they deal need "service" as well as money. The aged require help regarding housing, medical care, recreation, friendly contact; the mother with dependent children has problems of household management, of occasional respite from the ties of small children, of planning for the children's welfare; the wandering boy or girl from out of town needs more help than bed and board for a few days; the husband who can't hold a job and who comes back periodically for relief for himself and his family may need psychiatric advice. These are problems of the type the family welfare agency has been designed to meet. But even in Vancouver and Victoria, where there are such agencies, they do not reach nearly all the people who might profit from their assistance. The local public assistance office is a natural port of call for a great many people who have difficult personal problems besides that of economic maintenance. Hence it is a focal point for discovering these problems and aiding in their solution. Therefore every local welfare office should become something of a family welfare bureau. This should be as much a part of its regular work as the issuing of public aid. In the performance of this function it can do much to curtail the need for public assistance. For through individual case work service, through referring cases to specialized agencies like the psychiatric clinics or the proposed bureau of vocational rehabilitation, through drawing upon the resources of private organizations, and in a dozen and one other ways, it will contribute to the rehabilitation of clients. Thus far there have been only small beginnings upon this type of work in the public agencies of British Columbia. Workmen's Compensation The workmen's compensation system of British Columbia is relatively good. It was improved considerably by amending legis- 184 Public Health & Welfare Reorganization lation in 1943 which put into effect many of the recommendations for change made in the preceding year by Mr. Justice Sloan after an exhaustive inquiry into various grievances which had accumulated.33 Benefits were increased, various anomalies were corrected, hernia was included as a compensable ailment, and the scheme was generally liberalized. In detail it seems now to be fairly satisfactory—although it does not cover all workers, the notable exclusions being those engaged in domestic service and in agriculture. Certain adjustments to the scheme will be required when a national system of social security is established. Desirable changes are suggested by the following quotation from Social Security and Reconstruction in Canada, which refers to all of the provincial systems: Their benefit scales would require revision to bring them up to or better than the levels of the national superannuation, disability, survivors' and death benefits, and they might cut out children's grants because of the national family allowances scheme. Their medical care work might be transferred to the medical care authorities to be established, to which they might contribute the costs of this service. Expansion of the workmen's compensation schemes to cover workers not now included and losses from industrial disease would probably not be necessary on any substantial scale because these losses and these workers would be covered by the national benefit provisions.34 It might be added that the recently authorized programme of vocational rehabilitation for injured workmen could be taken over by the bureau of vocational rehabilitation which was proposed above, in order to obtain the advantages of an integrated system covering a'l handicapped groups. In this case, as in the case of medical care, it might be appropriate for the Workmen's Compensation Board to assume some or all of the costs for its beneficiaries. These various changes in the compensation system, of 33Report of the Commissioner Relating to the Workmen's Compensation Board, 1942 34P. 149. Transition to Social Security 185 course, will not be necessary or desirable until federal social security policies are worked out—except for the last one, which might be made as soon as a provincial rehabilitation programme is inaugurated. In Conclusion The main suggestions for reform in this chapter may be summarized as follows: 1. Extension of full-time public health service throughout the province by developing metropolitan health departments and health units and greatly increasing trained personnel, perhaps to the extent of doubling the present local staffs. 2. Provision of about 500 additional beds for tuberculosis patients. 3. A new health insurance scheme, to provide medical care for the great bulk of the population. 4. Development of an integrated hospital system for the province and adoption of a new system of hospital grants according to which the hospitals would be aided in accordance with their needs, as indicated by the amount of necessary free service which they render. 5. Provision of a large number of new infirmary beds. 6. An extended mental hygiene programme involving perhaps . 1,500 additional mental hospital beds, a psychopathic hospital, a training school for mentally deficient children, extension of psychiatric clinics, a large programme of extramural care, and more professional staff. 7. An integrated programme of delinquency control, including vigorous extension of probation and parole service throughout the province, re-establishment of a Borstal-type institution, and adoption of more progressive methods of penal administration. 8. A planned programme, under provincial leadership, of recreational services. 9. Revision of the public assistance system to include more liberal old age pensions, integration of blind pensions in a new system of disability allowances, the building of a strong and flexible system of general assistance, and the strengthening of administrative staff, perhaps to the extent of doubling present personnel. 186 Public Health & Welfare Reorganization • 10. An integrated system of vocational rehabilitation, to include the present rehabilitation work of the Workmen's Compensation Board. 11. The provision of constructive welfare service by all local welfare agencies. These main points, together with the minor suggestions in the preceding pages, make up a lengthy list of desirable improvements in British Columbia's social services. Many of them, the reader will have noted, have been recommended by responsible public officials or groups within the province; while others follow from the application of good standards of the social services commonly accepted by authorities in the field. Yet further study of the British Columbia scene and the adoption of more rigorous standards would certainly yield many additional and more precise proposals. These pages do not profess to contain a complete blueprint of what ought to be done. The formulation of policy in detail demands far more careful study of the situation than the writer has found it possible to undertake. This is a task which should be carried forward in British Columbia as part of a general programme of post-war planning. The desirable reforms in the content of the social services will be costly. It is clear that the annual budgets of most of the public agencies will have to be increased well beyond the levels achieved during recent years. And there must be a large amount of capital construction. There will be no attempt here to estimate the costs of improved services. This could not be done without making much more precise plans than those which have been hastily sketched. Finding the money for the programme is contingent largely upon Dominion policy on social security, but it should not be impossible if the Dominion makes the right kind of financial settlement with the provinces. While it is probable that total expenditures on the provincial and local services will have to be increased materially their future growth should be kept under control if policies of the kind advocated Provincial-Municipal Relations CHANGES in the public assistance system have gone some distance to solve the problem of low standards in the municipal social services and of poor co-ordination between provincial and local programmes. But the problem still exists and it may become acute again in the postwar period if the local authorities are badly pressed financially. The whole system of provincial-municipal relations regarding the social services calls for re-examination and further reorganization. The Present Distribution of Responsibilities The transfer of social service functions and costs from the local governments to the province, which has been general throughout Canada, has gone even farther in British Columbia than in most provinces. Administratively the municipalities remain responsible only for generalized public health, school medical service, general assistance (including the support of the chronically ill and the physically handicapped not in hospitals or provincial infirmaries), medical care to the needy, and juvenile courts and probation. All of these programmes except the last are supported partially by 188 Provincial-Municipal Relations 189 provincial grants, which have been described previously. It will be useful to summarize here the grant provisions in effect in April, 1944, as follows: Programme Provincial Grant Conditions Public Health Vancouver Metropolitan Health Committee $35,000 for 1943-1944 Special arrangement. Health units 25 per cent, of costs, including nursing. Contribution to salaries of health officers, sanitary inspectors, and clerks, and to associated expenses. Public health nursing (Board of Health) $480 per nurse per year. Excluding Vancouver. Municipal participation in a health unit or compliance with simple standards. Public health nursing* (School Act) Not to exceed $800 per nurse per year, according to statutory formula. Performance of school health work, which may be included within the generalized nursing service of a health unit. School dentistry* (School Act) Not to exceed $800 per year per dentist, according to statutory formula. Performance of school dental work. Preventive dentistry (Board of Health) $1.50 per child per year. Additional to preceding item. Service to children in dentist's office according to prescribed procedure. General Assistance Social allowances 80 per cent, of costs. Excluding administrative costs. Essentially for home relief cases, up to specified limits per case. *Administration of these grants, authorized in the School Act, was transferred from the Department of Education to the Board of Health on April 1, 1944. Provincial-Municipal Relations 191 Institution or Agency Children s aid societies Provincial jails Municipal Charge Reasonable costs of maintenance, presumed to be average costs of society's care of children, but not less than $4.00 per week. One dollar per inmate day. Residence Rules R. and R. Act. Summary conviction for offence committed within the municipality. All of these municipal charges are prescribed by statute. But none of the provincial grants to the local authorities are statutory except those for school nursing and dentistry. The others have been arranged from time to time, almost altogether during the last ten years, to meet special problems, and the legislature has, in effect, ratified the action of the government after the event by voting funds to continue the grants year after year. The terms on which the non-statutory grants are made and the general policies governing their administration do not appear clearly in public documents, and it is doubtful if most members of the legislature (or of the municipal councils) have much understanding of the nature of the grant system. Thus a very important body of policy and practice, involving the transfer of large sums of money to the local authorities, has grown up without explicit legislative action and with very little public understanding.1 1 There has been a good deal of official hush-hush about the grants. Provincial officials and the ministers immediately concerned have favoured them because they would stimulate the local authorities to provide or improve essential services. But during the depression decade the financial difficulties of the provincial government were such that ministers were unwilling to go very far in undertaking new obligations. Officials took their cue from this general line of policy, quietly made "deals" with the local authorities in individual cases (e.g., dentistry, hospital clearance, medical care), and avoided general statements of policy which might have alarmed the leading exponents of economy in provincial affairs. Whatever the justification for following these practices in the depression period, the need for them has clearly passed, and the legislature and the public ought to be fully informed about a most constructive and commendable trend of policy. 192 Public Health & Welfare Reorganization The financial results of this system of distributing responsibilities for health and welfare are shown in Table IV for the years 1936 to 1940. TABLE IV Distribution of Provincial-Municipal Expenditures on Health and Welfare, British Columbia, 1936-1940* (Thousands of Dollars) Year Provincial Per cent. Municipal Per cent. Total Per cent. 1936 8,642 8,943 9,770 9,552 8,305 66.8 69.5 72.9 74.0 72.3 4,295 3,919 3,628 3,350 3,185 33.2 30.5 £7.1 26.0 27.7 12,937 12,862 13,398 12,902 11,490 100.0 1937 100.0 1938 100.0 1939 100.0 1940 100.0 *Basic figures from Dominion-Provincial Conference, January, 1941, Comparative Statistics of Public Finance, 1936-1940. The figures cover virtually all health and welfare expenditures except those on the delinquency services and also include small amounts for labour services. Figures approaching accuracy are not available for any later year than 1940, for it is impossible to calculate municipal expenditures on health and welfare from the published reports of the Department of Municipal Affairs—and the writer has not found it possible to make the special analysis of municipal accounts which is required. However, it appears that the total expenditures by the provincial and the local authorities have declined only moderately during the war period from the levels of the late 1930's. The province had to assume the whole burden of relief grants to the municipalities when Dominion unemployment relief subsidies ceased at the end of March, 1941, and the costs of old age pensions, public health, and other provincial services have increased. Total provincial expenditures of about $9,500,000 were authorized for the fiscal year ending March 31, 1944. On the other hand, municipal charges have fallen considerably, thanks to the sharp decrease in public assistance and Provincial-Municipal Relations 193 to the extension of provincial grants, so that they probably did not exceed $2,000,000 or $2,500,000 in 1943. From the table and from the partial information available for 1943 it appears that the municipal share of health and. welfare costs has decreased sharply. By 1940 the local governments were carrying only 27.7 per cent, of the total burden, as compared with 33.2 per cent in 1936; and it is probable that their share in 1943 was not more than about 20 per cent. The various changes in policy that have occurred in recent years have worked very much to their advantage. Table V shows how the burden of health and welfare charges (exclusive of Dominion grants) was shared between the provincial and local governments in all provinces in 1940. TABLE V Provincial-Municipal Distribution of Health and Welfare Expenditures, 1940, by Provinces* (Thousands of Dollars) Provincial Municipal Total Province Amount Per cent. Amount Per cent. Per ' Amount cent. Prince Edward Island 416 2,264 1,232 21,223 26,345 5,378 8,829 4,967 8,305 94.3 55.7 57.8 65.9 63.5 58.2 71.3 64.1 72.3 25 1,800 900 11,000 15,000 3,750 3,550 2,800 3,185 5.7 44.3 42.2 34.1 36.5 41.8 28.7 35.9 27.7 441 100.0 Nova Scotia 4,064 100.0 New Brunswick 2,132 100.0 Quebec 32,223 100.0 Ontario 41,345 100.0 Manitoba 9,128 100.0 Saskatchewan 12,379 100.0 Alberta 7,767 100.0 British Columbia 11,490 100.0 Total 78,959 65.3 42,010 34.7 120,969 100.0 *Source of figures the same as for Table IV. See footnote. 194 Public Health & Welfare Reorganization In 1940, it appears, the British Columbia municipalities were bearing a lighter share of the combined provincial-municipal health and welfare bill than those of any province except Prince Edward Island. Their, relative position is probably even more favourable at present. Therefore by two tests, comparison with preceding years and comparison with other provinces, the local governments of British Columbia are not unduly burdened with social service charges. mi The Problem of Provincial-Municipal Relations Several major factors combine to explain the lack of uniformity from place to place, the low standards of service, the absence of essential programmes in certain communities, the non-co-operation with provincial agencies, and the other weaknesses which have characterized the municipal sector of the health and welfare system. The first of these is financial inability, real or imagined; the second, the unsuitability of many of the municipalities as administrative units; the third, inadequate leadership by the province; and the fourth, a rather general weakness in local government. 1. The Financial Problem Despite the relief from social service charges which they have gained in recent years, the municipalities are not yet satisfied that they are being fairly treated by the province. Their revenues, apart from provincial grants, come mainly from taxes on real property, the yield of which is quite limited. They note that the costs of education and the social services have increased greatly during the last thirty or forty years and that even although the provincial government has assumed a great part of these expenditures the trend has been for a larger portion of the municipal tax dollar to be spent on these programmes. In consequence they attribute the financial difficulties which they faced in the 1930's largely to these relatively new burdens and they fear that trouble Provincial-Municipal Relations 195 may come again for the same reasons. Hence they have pressed for years the claim that they should be relieved entirely of both educational and social service costs, and they have been largely supported in this view by public opinion. In 1933 the provincial Royal Commission on Municipal Taxation (the Harper Commission) stated as one of its recommendations "that social services should not be a charge upon the land,"2 and this phrase has been a municipal slogan ever since. At every session of the Union of British Columbia Municipalities resolutions are passed urging the province to assume additional social service and educational costs. Since these views are so widely held it is not surprising that the local authorities commonly balk at spending any more than they must upon the health and welfare programmes under their jurisdiction. Rightly or wrongly, most of them feel that even if they have the money expansion and improvement of the social services should be financed by the province. Is their financial grievance valid? There can be no doubt about the merits of their leading argument, that in general the costs of health and welfare should not be assessed against the general property tax, for the yield from this source would be far too little and the burden would be placed inequitably upon one class of taxpayers, the owners of real property. And it is clear that the local governments had a very real grievance in the early 1930's, when their relief and other social service expenditures rose sharply while their revenues declined, leading to drastic economies on other services and to defaults on bonded indebtedness for many of them. But to concede these two points does not lead to the conclusion that the problem is still acute. For only a minor part of the social service bill is now paid from general property taxes; and the general financial position of the municipalities is vastly better than it was ten years ago. Two questions demand examination—first, is the present bill too large in total for the local governments; and 2Report, p. 89. 196 Public Health Sc Welfare Reorganization second, is it divided inequitably among them, so that it presses too heavily upon some? Table VI throws some light on the first of these problems. The table shows that the financial position of the municipalities was much better in 1940 than it was in 1936, and that the pressure of health and welfare charges upon their budgets was considerably less. In 1940 health and welfare costs made up only 14.4 per cent of total revenues, as compared with 20.9 per cent in 1936. On the other hand, the relative burden of educational costs was rising, from 22.5 per cent of total revenues to 24.4 per cent. Since 1940 the proportion of health and welfare charges has fallen sharply. Partial figures suggest that this item, now about $2,000,000 or $2,500,000 annually, did not make up more than 10 per cent of current revenues in 1943. The burden will undoubtedly increase in the postwar period, both absolutely and in relation to revenue, if economic conditions are depressed; but it seems likely that the present system of provincial grants will prevent its becoming much if any higher than in the late 1930's, perhaps not more than 15 per cent of revenues. This slight examination of the, finances of the local governments does not yield a definite answer to the question as to whether their health and welfare charges are too high in total. Sufficient data for a good answer could only be obtained by careful analysis of the potential yield from a well administered system of local taxation and of the competing claims of various local services for budgets, and such data are not available. However, the few figures that have been cited point to the conclusion that the total burden is not too great at present; and that even if it were at the 1940 level (which may be reached again after the war) it would not be unreasonably heavy. It is easier to give a better answer to the second leading question, regarding the distribution of the health and welfare burden. Table VII shows that in 1937 it was divided most unevenly among the local governments. Provincial-Municipal Relations 197 5© GO PQ «o ■* -* 8 rft t*i B 8 i (S3! N <© OS s c .© ^O «5 s a a 'CO ^ r* s <sr. o © g GO *r (sf <s* (S* <s* 1 •*i 8 a «0 c Wft$ | «■ 1 2* <50 £* 1 (S3 OS So O i> "* i> 8 «5 (S3 co o *o s or or. ©* (S* 1 GO V (S* (N (S3{ ©3{ i 1 1 OS «q «" : tof§ 8 CO GT HH ' '£i' • £•& 8 ©3 00 $ fts ° 2s 8 oc n t- "* (S3 » »> «5 T-H 8 CC *o Oi CO i <T «: ©f ©* Q* ^3 if § «=> 00 ■to «c ©) SO OS n 8- 8 a | 8 Oi ©31 GO Oi *tf Oi O CO CO 8 Ol C CO © m i GC »0 (sT ©* ©3t i 1 § «0 Ol *« °ft^ 8 c Ol OO m Is H 8 (S3 (S* 8 »C fg <s* O (SI Oi GC i> «i ©* 8 © CC CO «5 00 § -^ m rH o o< ©< | n S.S 1 I § i ures, C includ nt u 3 o o +J jj1 CJ 4» a Expendi Accounl . retirem Revenu 9 T3 a i 8* $1 a> c otal, rent debt otal W H H H Q 1 1H So B M M O 4> O ass Q ca ca a? | | £ « 3 o a> ^ * _g & 198 Public Health & Welfare Reorganization TABLE VII Health and Welfare Expenditures Per Capita of Population in Relation to Taxable Valuations, Selected Municipalities, 1937* Municipality Expenditures Per Capita Taxable Valuation Mills per Dollar of Taxable Valuation {Total Per Capita Burnaby $219,500 24,000 8,000 22,100 2,000 1,661,000 230,000 13,400 $8.40 10.42 4.44 3.52 1.18 6.09 5.89 2.77 $554 445 199 1,254 1,292 804 995 1,193 15.2 Fernie 23.4 Ladysmith 22.2 Oak Bay 2,5 Summerland Vancouver 0.8 7.6 Victoria 5.9 West Vancouver.. 2.3 *The figures in the first two columns are approximate, and are derived from a special analysis by an interdepartmental committee in 1938, as recorded in an unpublished report by the writer, Reorganization of British Columbia's Health and Welfare Services, tabled in the 1942 session of the legislature; and those in the third column are derived from figures on taxable valuation and population in the Report of the Department of Municipal Affairs, 1937. Lack of uniformity in assessment makes the figures on taxable valuation very uneven, and good figures would make for substantially different results in the fourth column. But the great spread in mills on taxable valuation would still remain. The table contains figures for municipalities severely and only slightly affected by social service charges, as well as for Vancouver and Victoria whose position was close to the provincial average. The figures on per-capita expenditures are a rough index of needs for social services. These varied widely, having been about nine times greater in the depressed mining town of Fernie than in the prosperous rural district of Summerland. The working-class suburb of Burnaby, in the Vancouver area, also had heavy per-capita expenditures, much greater than those of its more fashionable neighbour, West Vancouver, and of Oak Bay, a wealthy suburb of Victoria. But the communities with the high social service charges Provincial-Municipal Relations 199 were the ones least able to finance them, as the figures on taxable valuations show. Per-capita valuations in Oak Bay, Summerland, and West Vancouver were about six times as high as in the poorest community, Lady smith, and more than twice as high as in the two municipalities of Burnaby and Fernie which had the highest rates of expenditure. The last column of the table shows the mill rates per dollar of taxable valuation necessary to meet social service costs. The rate was about thirty times as high in Fernie as in Summerland. The actual tax levies in 1937 were 44 mills for Burnaby, 50 mills for Fernie, and 40 mills for Lady smith, so that one-third of the total general property tax yield in the first municipality and about one-half in the other two were required for the health and welfare services. There can be no doubt that this burden was much too high. The fact that these three municipalities were in default on their bonded indebtedness at the time supports this conclusion. On the other hand, it is quite clear that social service costs were not a serious problem for Summerland, Oak Bay, and West Vancouver, where the tax levies for all purposes were respectively 37 mills, 25 mills, and 61 mills. More recent figures than those for 1937 would, of course, yield very different results in detail. But they would certainly give the same general result—evidence of wide variations among the municipalities both in needs for social services and in capacity to pay for them. Even at present, with a marked improvement in municipal revenues since the depression period and with much lower demands for social services, it is possible that the burden upon some local governments is severe; and it is certain that it will become very serious again for some should economic depression and great need for social services follow in the postwar period. Clearly the present system of imposing charges upon the local authorities uniformly and of assisting them by means of provincial grants on a percentage- of-cost basis does not spread the financial burden equitably, The idea that the municipalities are given equality of treatment by a system of the kind is based upon the false premise that all are 200 Public Health <fc Welfare Reorganization alike in their capacity to pay and in their needs for assistance— a premise which is denied completely by the available facts. It may be concluded, therefore, that some municipalities have a valid claim for relief from social service charges, while others have little or none. The nub of the problem is not the total burden but its maldistribution among the various municipal units. This fundamental point has been obscured by the loudness of municipal complaints about the total problem (commonly supported by examples from the worst situations) and by the failure of the Provincial Department of Municipal Affairs or other government agencies to prepare and issue statistics which would bring out the truth. There are also some other objections to the present system of grants and charges. One of these is that, while the charges are all statutory, none of the grants are except those for school nurses and dentists. This means uncertainty for the local governments as to what they will receive in the future. It also means that grant policies may be changed in detail from time to time by provincial ministers and their officials, who likewise are free to make rulings at their discretion which may affect considerably the amounts payable to municipal units. These are both factors that tend to irritate the local councils and their officials. Moreover, the system is unnecessarily complex and inconsistent. The local authorities naturally wonder why there should not be uniform grants for all general assistance cases, instead of four different rates for different groups of clients; or why there should be two separate grants towards the salaries of public health nurses. Each of these separate schemes involves additional administrative work. The existence of each one encourages argument and negotiation about it separately, without reference to the total picture of provincial-municipal financial relations. To some extent the present system of grants and charges discourages sound practice in dealing with individual problems. There is some evidence that occasionally juvenile court judges, thinking Provincial-Municipal Relations 201 of their municipal financial problems, have committed boys or girls to the provincial industrial schools, where they would be maintained without cost to the local authority, rather than to the children's aid societies at municipal expense; and that magistrates have levied fines against adult offenders instead of committing them to provincial jails so as to save their municipalities the maintenance charge of one dollar per day.3 The failure of the local governments to provide boarding-home or nursing-home care for patients who might be released from hospital is another example of their preferring the cheaper method (to them) of social care. 2. Unsuitable Municipal Units The second major factor to explain the weakness of the local health and welfare programmes is that most of the municipalities are too small to be satisfactory administrative units. According to the population estimates published by the Department of Municipal Affairs in its annual report for 1942, only six of the sixty- three city and district municipalities had populations of 20,000 or more, nine were over 10,000 and twenty-five were over 5,000. The smaller communities do not have a volume of work large enough to warrant the employment of full-time, professionally trained, public health officers, sanitary engineers, welfare workers, or probation officers—and efficiency in the operation of the local social services is not to be expected without such personnel. They are also too small for the efficient operation of other services, such as education, police and fire protection, and recreation. Thus one of the outstanding characteristics of the British Columbia municipal system stands squarely in the way of good administration, even if the financial resources are available. As the Rowell-Sirois Commission has said, "Where settlement is sparse, municipal areas require extension for purposes of efficiency and economy."4 3Ibid., p. 77. ^Report, Book II, p. 139. 202 Public Health & Welfare Reorganization 3. Inadequate Provincial Leadership The limited extent to which provincial standards have been developed and the relative weakness of provincial regulation and supervision, at least until recently, have been discussed in preceding chapters and need only be mentioned here. Without standards or supervision from the province, as in the probation field, the local authorities have done very indifferent work; whereas the quality of their administration in public health, where they have had provincial regulations and considerable technical assistance to guide and assist them, has been very much better. The local public assistance programmes are now improving rapidly under provincial direction. This is tangible evidence of the need of the local authorities for guidance and of the fact that they have not had nearly enough of it. 4. General Weakness of Local Government It is a commonplace among students of the subject that local government is "the dark continent" of public administration. There is not a single up-to-date book on Canadian municipal affairs,5 the subject is not taught in the schools, and it is scarcely mentioned in the universities. Dominion and provincial reports on local affairs are meagre and uninformative, and newspaper reporting of municipal business is generally dull and unenlightening. In consequence the ordinary citizen in the cities knows little about his local government except the amount of his tax bill, and what he does know does not arouse his interest very much. In the smaller communities there is naturally much more knowledge of what goes on at the municipal council; but the personal interests of taxpayers in roads and bridges and small contracts and "boarding the teacher" too often make for a petty brand of parish-pump politics. 5The nearest recent approach to a comprehensive study is one of the reports prepared for the Rowell-Sirois Commission and published as an appendix to the Commission's report in 1940—H. Carl Goldenberg, Municipal Finance in Canada. Provincial-Municipal Relations 203 For these and other reasons the quality of men and women who seek and obtain local political office has not been very high. With occasional exceptions, municipal council members have been dull and unimaginative. Their great pre-occupation has been "keeping the tax rate down," as they have announced annually in their election campaigns, rather than building up civic services.- They have felt'that it was their business to attend to the details of local affairs, rather than to limit themselves to matters of policy and to delegate responsibility for administration to competent civil servants. Naturally such political masters have not attracted very good servants. Personnel standards for municipal work have been low or non-existent, salaries have been poor, and there have been few incentives for good work. Hence local government, on the whole, has been stodgy and unenterprising. The local health and welfare departments have not had a favourable environment within which to work. Much that they might have achieved in improving their work, even within the financial and the other limitations of the existing system, has been virtually impossible because of the unwillingness of municipal councils to support progressive innovations. The provincial authorities have their share of blame for this general weakness of local government. They have regarded the municipalities more as annoying claimants and competitors for a larger share of provincial revenues than as partners in the government of the province; and they have given legalistic answers that "the problem is your responsibility" instead of seeking ways and means of solving it jointly. The Department of Municipal Affairs, established in 1934, has not lived up to its promise, for it has given but little leadership to the solution of municipal difficulties.6 The whole municipal system calls for re-examination and revi- 6The writer's impression, after visiting the departments of municipal affairs in the six provinces from British Columbia to Quebec in the summer of 1942, was that the British Columbia department was the poorest of the six in programme and in personnel. 204 Public Health & Welfare Reorganization sion. The financial problem is basic. But there are also other important issues, such as those of small units, provincial-municipal distribution of administrative functions, uniformity of assessments, standards of administration, and the development of good personnel. The government has recognized the need for an investigation of fundamental difficulties. At the 1944 session of the legislature it was announced that a commission would be appointed to make a thorough inquiry into the financial and other aspects of the municipal problem. Should the Province Take Over? The solution most commonly proposed to the problem posed by the local operation and financing of social services is that they should be transferred, lock, stock, and barrel, to the provincial government. This is a view which is held not only by municipal councils, for financial reasons; it is also accepted widely by provincial officials and others keenly interested in the development of good social services, who believe that it is the only way in which their objectives can be attained. The proposal has its counterpart in other fields. After a comprehensive study at the request of the government, Major H. B. King, an educational advisor, recommended in 1935 that the province "as soon as possible take over complete financial responsibility for education," abolish the "multiplicity of School Boards (826)," and establish a centralized administrative system under the Department of Education.7 Recently there has been renewed agitation for the adoption of such policies with strong representations of this nature being made to the government by the Union of British Columbia Municipalities, the organized teachers, and other groups. The problems of police service in small communities had led forty municipalities, by March 31, 1941, to take advantage of legislation permitting contractual arrangements with the Provincial Police to perform 7School Finance in British Columbia, p. iii. Provincial-Municipal Relations 205 local duties, and periodically it is suggested that they should assume jurisdiction everywhere. There is no doubt about the great advantages, both financial and administrative, of central operation of the social services. A centralized system permits uniformity of policy and procedure everywhere, district operating units suitable in size and other characteristics for efficient work, avoidance of the complexities of central-local administrative and financial relationships, abolition of local residence rules, the development of specialized services that would not be economical for small population units, more adequate and more stable financial resources, and effective co-ordination of the whole system. Such arguments may also be used, in large measure, to support the thesis that the Dominion should "take over the social services." In Social Security and Reconstruction in Canada the writer pointed out that, on the other hand, there were also strong arguments for decentralization, and listed a number of these in support of the position that "a substantial range of the social services should be left in the hands of the provincial and local authorities."8 A premise for this position was that "administrative capacity to handle the job well should be the chief criterion to be followed in distributing operating functions between the three levels of government, rather than financial resources, tradition, protection of provincial or local rights, or other factors, although all of these must be given consideration."9 Main points in the case for delegating responsibility for the social services in part to the local governments may be summarized as follows: 1. Local administration permits greater flexibility in policy and procedure and some variation from place to place, to take account of differences in local conditions. Within reasonable limits there is much to be said for such variations. 2. The local system permits experimentation by progressive sp. 165. Hbid., p. 164. 206 Public Health <& Welfare Reorganization communities, without their being held to a dead level of province- wide uniformity. Such districts should have the opportunity of providing for their citizens services broader and better than those of minimum standards which must be operated everywhere and upon which a provincial agency would have to concentrate its attention. For example, the political objections of the influential Catholic group might make it impossible for a provincial public health organization to set up a general system of birth-control clinics; whereas it might be possible for local departments to establish such clinics in predominantly Protestant communities. 3. The co-ordination of health and welfare services with other aspects of municipal administration, such as education, public works, town planning and housing, and recreation, can often be more easily arranged when the former are locally administered. For example, the municipal engineer is more likely to plan suitable work projects for public assistance recipients if his council has some responsibility, direct or indirect, for social service problems. There are better chances of municipal action on housing reform or on the provision of adequate playgrounds if local health and welfare officers point out the importance of decent housing to health and of recreation facilities to the prevention of juvenile delinquency than if this is done by the representatives of the province. 4. Decentralized administration permits and encourages the making of decisions locally without the necessity of obtaining approval from a provincial head office. This is a matter of real importance to the many communities in British Columbia which are a long distance from Vancouver or Victoria. 5. Co-ordination with private services and the mobilization of community resources to support the public programmes are more easily achieved, as a, rule, by local than provincial agencies. Local responsibility tends to encourage an awareness in any given community of social problems which must be met and a disposition to deal with these problems at home rather than to leave them to the provincial or the Dominion governments. 6. The local system opens the way to participation in planning, policy formation, and administration by a substantial number of citizens serving on municipal councils and advisory boards and acting as volunteers, thus increasing public understanding and support of the social services. 7. The relative autonomy of the local agencies gives a degree of Provincial-Municipal Relations 207 freedom to their professional personnel to criticize the social service system and to work for its improvement which they would not have if they were members of a provincial bureaucracy. For in this case they would be prevented, as civil servants, from criticizing provincial programmes and from proposing measures of reform not in accord with government policy. The continued health of the system requires that it be subject to the appraisal of competent professional critics. 8. There are important democratic values in the local administration of the health and welfare services, including several which have been mentioned above. Their retention at the local level tends to strengthen local government, which is potentially one of the chief foundations of a democratic system; whereas their transfer to the province would take away one of the leading municipal functions and would be a precedent for the transfer of education and other functions, thus reducing greatly the importance of the municipal system. The arguments for centralization and decentralization are not in direct conflict to any great extent. It is clear that each policy has advantages as well as disadvantages. The various arguments apply with different force to different services. There is no question about the overwhelming case for Dominion rather than provincial operation of unemployment insurance; while local operation would obviously be impossible. But when we turn, for example, to generalized public health the situation is quite different. In this case the arguments for central administration have much less weight and those for local operation correspondingly more. Thus it is impossible to say that all of the social services should be taken over by the Dominion, or even by the province. Some should; but there are some, notably generalized public health and public assistance, which should generally be left with the local authorities. This view is widely, if not unanimously, accepted by leading writers on the social services in Canada and the United States. The Canadian Welfare Council and the American Public Welfare Association support local administration of public assistance as a general rule, and various state advisory commissions have reached the same 208 Public Health & Welfare Reorganization conclusion. Canadian and American public health authorities agree that it is usually best to leave the basic health services with the local governments. The weight of expert opinion, if not of public opinion, supports the writer's position. But the principle of local administration can only be applied successfully subject to certain conditions. These include redistribution of certain health and welfare functions, protection against unreasonable financial obligations for any local authority, operating units large enough for efficient administration, and provincial standards and supervision. These considerations lead to the view that, while the municipalities of British Columbia should be charged with primary responsibility for the administration of public assistance and public health, as at present, there should be important changes in provincial-municipal relations. Four recommendations for change are presented which are designed to correct leading problems of the present system. The recommendations are based upon the assumption that changes must be made within the framework of the existing municipal pattern. Redistribution of Functions Complete responsibility, administrative and financial, should be assumed by the provincial government for two specialized services which none of the municipalities, with the possible exception of Vancouver, are large enough to operate efficiently. These programmes are juvenile courts and probation and medical care for the needy. As we have seen previously a provincial juvenile court and probation system was recommended by the Advisory Committee on Juvenile Delinquency in 1936. The arguments used by the committee are still applicable. A provincial programme would permit the appointment of a few judges to serve the province and of a small staff of full-time probation officers for the courts in Vancouver and Victoria. Probation work in the smaller centres might be undertaken by members of the provincial field service, Provincial-Municipal Relations 209 or by social workers from the local welfare departments, on a part- time basis. The present Detention Home of Vancouver, the only one in the province, might be used for boys and girls from various communities. It would be decidedly more useful as a provincial than as a civic institution. Transfer of juvenile probation to the provincial government would have the further advantage of making possible its integration with the juvenile parole service and with the adult probation and parole work now conducted by the province. One central staff concerned with probation and parole, for both adults and juveniles, would probably be better in a sparsely settled area like British Columbia than separate staffs for adults and juveniles and for the two types of service. Medical care for the needy, of course, should be absorbed by health insurance, a provincial service. Even in advance of this development the province might take over the medical care scheme. In 1935 the Hearings Committee on Health Insurance recommended that there should be a provincial programme for indigents. The making of satisfactory arrangements with physicians and druggists to perform this service demands knowledge, skill, and influence which the local welfare authorities cannot be expected to have. The programme should be directed by a physician, but it is not large enough in most local communities to warrant the engagement of a doctor, even on a part-time basis. Typically the local welfare departments do not have the resources to deal effectively and constructively with the problems of medical care. The transfer of these two programmes to the province would leave the local authorities only with generalized public health (including the school medical services) and general assistance. As we have seen previously, strong local health departments could perform a certain number of functions, such as tuberculosis and venereal disease case-finding, now carried on largely by the specialized provincial divisions, and this would increase the substance of the local programmes. The recent amalgamation of public assistance administration in Vancouver, Victoria, and Burnaby 210 Public Health & Welfare Reorganization m through the local welfare agencies represents a partial transfer of administrative responsibility from the province to the local authorities in connection with categorical aids which has very great merit. The mixed system of provincial and local staff members in the one welfare office is ingenious and has much to commend it. The great thing that it does is to make possible a single public assistance centre in every important community. However, it seems likely that problems of dual control are likely to arise under this system and that there may be friction between the two elements in the local offices. It would seem more logical to put them fully under the direction of the local welfare departments, which would then become completely responsible for the administration of the categorical aids as well as general assistance—subject to provincial standards and supervision and to local participation in the costs, along the lines to be proposed later. The amalgamation begun in j 1942 will pave the way very well for full-fledged local operation of C^public assistance, for not until the local departments are strong should they be given so heavy an obligation. The core of work involved in public assistance administration will be the nucleus around which the constructive welfare service advocated in the last chapter may be developed. The two elements will make up the substance of the strong generalized welfare programme which is urgently needed in every community—a programme which should go far to enlist the helpful interest and support of local residents. Local Administrative Units Local operation of the health and welfare services should be limited to districts large enough in population, and suitable in other ways, for efficient administration. This means that volume of work must be great enough to warrant the employment of full- time, professional staff. The appropriate minimum size of the local units varies for health and welfare. There is substantial agreement among the public Provincial-Municipal Relations 211 health authorities that health units should have a population not less than about 20,000 or 25,000. The Provincial Board of Health has endeavoured to organize rural units varying between 20,000 and 30,000 in size. The problem is more difficult in the case of welfare units, for volume of work depends much more upon changing economic conditions and the specific obligations imposed by law upon the local authority. When the unemployment relief rolls were at their peak, in the early 1930's, there was enough public assistance work for full-time personnel even in small communities of 3,000 or 4,000 people. But now, with much reduced case loads, the situation is very different. Permanent policy regarding organization should be based upon probable minimum needs for staff, so that the present case load situation may be taken as a suitable premise for planning. It is too much of a burden for the junior social worker to take charge of a welfare district by himself, for he (or more likely, she) lacks the training and the experience necessary to assume administrative responsibilities. Therefore a director of supervisory grade is essential. But it is obviously uneconomical for such a person to perform detailed tasks which can be done satisfactorily by more junior personnel. Hence it may be concluded that there should be a small welfare team in every local office, consisting at a minimum of an administrator-supervisor and two or three social workers, with clerical assistance. Under present circumstances there are about 20,000 cases in receipt of general assistance and the categorical aids throughout the province, or about one case to every forty people. This means that there would be, on the average, about 250 cases to every 10,000 of population—approximately sufficient, along with other duties, to occupy the energies of the minimum welfare team. This statement is a very rough-and-ready approach to standards on a subject where further study is needed. But it will suffice, perhaps, as a rough guide to policy. There is the same need in the field of education as in health and welfare for larger administrative units, and it is much more widely 212 Public Health & Welfare Reorganization lift recognized. While other factors besides population (geography, composition of the population, health conditions, economic status, etc.) must be taken into account in determining the size of unit suitable for educational administration, it is interesting to note that a minimum population of 25,000 has been commonly suggested.10 It would be most desirable to have health, welfare, and educational districts the same, for this would greatly increase the likelihood of co-operative relationships between the three services. Hence the preceding analysis leads to the conclusion that health and welfare (and if possible educational) districts with not less than 20,000 population should be established. Only six of the existing municipalities would fulfill this requirement. New districts might be formed by the union of adjoining municipalities and the inclusion of contiguous unorganized territory, as* has been done already in the case of several health units. The provincial government would continue to bear the costs of health and welfare service to the residents of unorganized territory brought within any district. It might be necessary to modify the boundaries of some existing health units in order to fit them into the new scheme. Appropriate exceptions to the minimum population rule might be made to take account of geographical and other factors, so that in special cases districts with less than 20,000 population could be established. Exceptions to the general plan might also be made for the Vancouver and Victoria areas to provide for metropolitan units. This would permit the merging of the present Vancouver metropolitan health district into the new system. Still another possibility is that the scheme provide for metropolitan health districts but not for education or welfare districts, since administration on a metropolitan basis is less necessary in the case of education and welfare than in the case of health. 10B. A. Fletcher, The Next Step in Canadian Education—An Account of the Larger Unit of School Administration (Toronto: 1939), p. 51. This book contains an excellent account of problems and proposed solutions in the field of education very similar to those considered here in the case of health and welfare. Provincial-Municipal Relations 213 It would be essential, of course, for the provincial government to pass new legislation to establish the proposed districts. This might be permissive, authorizing voluntary union of the municipalities too small to comply with the requirements for administrative areas. In this case provision should be made for provincial administration of both health and welfare services within those municipalities which fail to join a district. Since provincial officials must be scattered throughout the province anyhow to provide service for people living in unorganized areas, it would be quite simple for them also to look after the needs of municipal residents within their territory. The costs of this service should be charged against the local authorities concerned, subject to reimbursement from provincial grants on the same terms as for other municipalities. Thus no local government would gain financially by surrendering administrative functions to the province. The permissive approach is more in accord with custom and tradition in provincial municipal relations than a mandatory approach. It should lead immediately to the development of full- time health and welfare service throughout the province because of the provision that there be provincial administration where small municipalities fail to join a health and welfare district. But it would not necessarily lead to the most logical and desirable division of the province into administrative areas because of the freedom to join or not to join a district which the municipalities would retain. Therefore there is much to be said for mandatory provisions in the reorganization legislation to affect all municipalities with less than a specified population. In so important a matter as the development of a logical system of social security, there should not be undue concern for the vested interests and preconceptions of a municipal system which is inefficient and sadly out of date. If the foregoing proposals for a comprehensive reorganization plan are impossible of attainment because of municipal opposition or for other reasons, something less drastic might be done which would go a long way to meet the problem of the small administra- 214 Public Health & Welfare Reorganization tive unit. There might be separate requirements for health units and for welfare districts. In the case of welfare, municipalities with as little as 10,000 population might be permitted to operate their own services while smaller places would be .required to join with others in forming districts or would have their administration taken over by the provincial authorities. There might even be provision that in exceptional cases, with the approval of the government, communities with as few as 5,000 people could administer their welfare work. This modified plan would be somewhat easier to work out because it would not involve the fitting of the variegated needs of the health, welfare, and educational programmes into one pattern. But it would probably prove to be much less satisfactory in the long run. Financial Arrangements Provincial-municipal financial arrangements should be thoroughly revised so as to protect every local authority against unreasonable costs, to divide the financial burden equitably between municipalities, and to make the system compatible with good standards of social practice and administration. The new policies which have been proposed in this and the preceding chapter would relieve the local authorities considerably of social service charges. The reduction or the virtual disappearance of hospital grants, to be anticipated with the introduction of health insurance, and the assumption by the province of financial responsibility for medical care for the needy and for juvenile courts and probation service would reduce municipal obligations by something approaching $1,000,000 per year. This in itself would call for changes in the grant system unless the local governments were to be almost wholly relieved of social service charges. It does not seem appropriate to propose this for two reasons. In the first place, the total burden of the social services upon the municipalities is probably not unreasonable at the present time nor will it be in the immediate future; while the capacity of the provincial government Provincial-Municipal Relations 215 to raise funds for health and welfare is not unlimited. Indeed transfer of income-tax revenues from the province to the Dominion s government and the other proposals for a Dominion-provincial settlement which were made by the Rowell-Sirois Commission would leave the province in a position where its revenue sources were very limited. If such Dominion-provincial financial arrangements are made some part of the revenue from the general property tax will probably be needed to provide the provincial-local share of social service costs. Should the municipalities not use part of the yield from this tax for social services, it is conceivable that the provincial government will have to levy property taxes to obtain the necessary revenues. A second reason for requiring the municipalities to contribute substantially toward the finances of health and welfare is the sound rule that financial responsibility and administration should go- together, at least to some extent. If the local governments are to administer the generalized health and welfare services they should have a substantial budgetary interest in these programmes. This will operate as a factor to discourage irresponsible administration and to assist the provincial authorities in supervising local activities. This means, among other things, that the local authorities should be expected to contribute part of the costs of the categorical aids whose administration, it has been proposed, should be transferred to them. The precise amount of the total municipal contribution towards health and welfare is something to be worked out after careful appraisal of municipal capacity to pay. This is a general problem of public finance which cannot be answered here. Whatever the amount, a system of grants and charges should be developed which will measure up to the criteria of equity and administrative efficiency which were outlined at the beginning of this section. The proposals which follow sketch such a system. The provincial government should make grants-in-aid to the local authorities with respect to only two general types of service, 216 Public Health & Welfare Reorganization health and welfare. The province might contribute a fixed percentage of local public health costs up to a reasonable max mum such as one dollar per capita of population annually. Welfare grants (toward the costs of public assistance and the charges for child welfare and institutional cases) should be distributed according to a formula that would limit welfare expenditures by each municipality (other than those for administration) to an amount that could be raised without undue difficulty from local taxes, and the province should meet a large percentage of local administrative costs. Finally, the present system of charges against the municipalities should be revised by eliminating those for hospital patients and the inmates of provincial jails. Health Grants In the case of public health the percentage-grant system would probably be satisfactory. Assistance at the rate of 25 per cent of costs up to one dollar per capita should encourage the local authorities to build their health programmes rapidly up to reasonable standards. Both the rate and the limit of shared costs might be higher. But the important point to stress here is the principle involved, rather than amounts. The single public health grant would replace the present schemes for the Vancouver Metropolitan Health Committee, for health units, for school nurses and dentists, and for public health nurses. Possibly the separate scheme for preventive dentistry might continue, pending the introduction of health insurance. This percentage-grant system will take no account of variations in the capacity of the local authorities to pay for public health. But there are two reasons for proposing it rather than a plan which distributes funds according to need. In the first place, the public health services are not very expensive,11 so that distribution of 11 At the rate of 75 cents per capita of population the total annual cost would only be about $450,000 for the municipal population of approximately 600,000—or about 2 per cent, of present municipal revenues apart from provincial grants. Provincial-Municipal Relations 217 grants on a needs basis would not make much difference to the total financial position of any municipality—which is the important point. Secondly, the percentage system would offer more incentive for all local authorities to build their health services up to good standards. Lack of knowledge of the importance of public health or lack of interest in it explains the weakness of the local health programmes as much as lack of money, so that even the more prosperous communities must be stimulated to improve their work. This result will probably be achieved more easily and with less friction by offering a substantial financial inducement to all communities than by the alternative device of specifying minimum standards with which all must comply and offering a good deal of aid to some and little or none to others. Welfare Grants In the case of the welfare services, which are both much more expensive than public health and more likely to fluctuate in cost from year to year, the problem of working out a satisfactory grant system is more difficult. Percentage-of-cost and per-capita-of- population schemes will not do, because they do not take into account the factor of variations in need for help. It is apparent that some different method must be discovered and applied. Recognition of this problem has led to many attempts in Great Britain, the United States, and Canada to work out systems of aid varying according to needs, which equalize the burdens of the assisted authorities—and these have come to be called "variable" or "equalization" grants. After experimenting for many years with unsatisfactory devices, Great Britain, under the Local Government Act of 1929, put into effect a new scheme, generally known as the "block grant," whereby a single grant-in-aid superseded a number of separate items. This aid was distributed according to a mathematical formula which took into account density of population, tax assessment, severity of unemployment, and number of 218 Public Health & Welfare Reorganization children under five years of age. The formula operates in such a way that poor districts with heavy social service charges may receive six or seven times as much assistance per capita of population as more prosperous districts with lesser burdens. Grants-in-aid are most common in the United States, both from the federal government to the states and from the states to the local authorities. For many years thought has been given to the formula problem and various equalizing devices have been employed. In the case of state grants for education, "the trend has been from simple to more complex methods, from school population to devices giving greater consideration to relative costs and burdens. ... In recent years almost every state has made some attempt, however feeble, to equalize burdens."12 The Federal Emergency Relief Administration distributed huge relief subsidies among the states from 1933 to 1935 largely in accord with their respective needs for assistance. Many states made relief grants to their local authorities during the depression period on a variable basis, and a number now follow this policy both for general assistance and categorical aids. Since 1937 the neighbouring state of Washington has had such a system. According to its present provisions the counties meet health and welfare charges only up to an amount represented by the yield from a three-mill tax on their total assessments, the remainder of the costs being met by state and federal aid. If any county has a surplus from the three-mill tax it is paid into the state treasury. Thus there is a uniform tax for health and welfare in all counties. The National Resources Planning Board, after an exhaustive inquiry into the whole problem of social security, has recommended that present federal percentage subsidies for public assistance should be replaced "by a grant in which the amount of the federal contribution would take into account differences between the states in need and in economic and fiscal capacity," and that the states should also distribute aid "within their political 12Henry J. Bitterman, State and Federal Grants-in-Aid (New York: 1938), p. 443. Provincial-Municipal Relations 219 subdivisions in accordance with relative need and fiscal capacity";13 and the federal Social Security Board has made similar proposals. Informed American opinion is virtually unanimous in favour of the equalization approach for purposes of health and welfare as well as education. In Canada there has been less concern with the development of formulae for the distribution of aid on a needs basis. However, the problem has been recognized by the practice of the federal government, from 1934 to 1938, of adjusting its direct relief grants to the provinces in accordance with its estimate of their respective needs and by various Dominion measures of special assistance to the hard-pressed Prairie provinces. Likewise Ontario, Quebec, Saskatchewan, and British Columbia have given special relief assistance to impoverished municipalities at one time or another. The Quebec system of aid towards the costs of local health units is an equalization scheme.14 Manitoba distributes school grants on a clear-cut equalization basis,1 and the principle has been applied to a limited extent in Ontario and other provinces. In British Columbia the complicated provisions governing provincial grants to the schools give relatively more assistance to the rural than to the urban districts; and in 1943 special efforts were made, in allocating a supplementary grant of $180,000 towards teachers' \ salaries, to work out a formula that would give the districts with low taxable valuations much more aid than the more wealthy ones. The most notable equalization proposal thus far made in Canada is that of the Rowell-Sirois Commission in 1940 that the Dominion make "national adjustment grants" to the provinces to enable them "to perform the functions entrusted to them without having to resort to oppressive taxation. "16 This would be a variable grant system on the grand scale. 13Security, Work, and Relief Policies (Washington: 1942), p. 548. 14See chap. 10, p. 368. ^See chap. 8, p. 327. ^Report, Book II, p. 274. 220 Public Health & Welfare Reorganization Thus there is nothing novel or impractical about the proposal for British Columbia to give aid to its municipalities according to the principle of needs. The practical problem at hand is how this principle should be applied. Experience has shown that there are real difficulties in finding a satisfactory method which is just to the subordinate units of government financially and which does not involve serious administrative problems. The methods that have been employed or proposed fall into three main groups, those involving (1) arbitrary decision on the part of the senior government, (2) application of a complex mathematical formula, and (3) assumption by the senior government of the expenditures of the subordinate unit beyond certain limits. The first method has obvious disadvantages, in that it opens the way completely to political decisions. Even if such decisions were fair, according to objective tests, there would always be strong suspicions on the part of interested parties that they were not. The second method is almost certainly the best of the three, if the right formula can be devised. In Great Britain a workable scheme has been adopted that has proven reasonably satisfactory, and in the United States considerable progress towards the development of good formulae is being made by the federal authorities and by some of the states. But a formula that is equitable is likely to be complicated, and it can only be devised and operated if detailed and reliable statistical reports on tax bases, population, individual incomes, volume of public services, public revenues and expenditures, and other items are currently available. Unfortunately such statistics, necessarily complex and refined, are not being compiled for the municipalities of British Columbia, nor could they be obtained except with much difficulty. The third method, that used in the State of Washington, has obvious merits of simplicity, objectivity, and equity. But since it relieves the local authorities of all responsibility for costs beyond a certain point, it is open to criticism on the ground that they are under no financial restraint in administering these excess expendi- Provincial-Municipal Relations 221 tures and that they may, in consequence, spend rashly and unnecessarily. To guard against this danger it is necessary, as in Washington, to set up strict control and supervision of local administration. But rigid regulation leads to what may be termed "the dilemma of control"—that it destroys the essential virtues of flexibility, local initiative, and democratic participation which are the chief arguments for local administration.17 As the process of control goes far the range of discretion for the local authorities becomes less and less, until their welfare departments become virtually branch offices of the central authority. The third model appears to be the best one to follow for welfare grants in British Columbia. The system has worked with considerable success in Washington. Its simplicity commends it greatly by comparison with other plans. With the modifications to the Washington plan which are suggested below and with provincial standards and supervision a grant scheme can be constructed which should not create problems of local irresponsibility in expenditure. An Equalization Plan A detailed outline of such a plan follows. It might provide that: 1. The municipalities meet all welfare charges in connection with functions assigned to them by law, apart from administrative costs, up to the yield of a fixed number of mills on their taxable valuations. 2. The province reimburse them for all but a small percentage of their expenditures, other than administrative, in excess of the quotas prescribed above. 3. The province contribute towards local administrative costs on a flat percentage basis. 17There have been serious complaints on this score from county representatives in Washington, particularly in the early period of the new system. But state officials assured the writer in December, 1943, that there was then little complaint from the counties and that there was effective local participation in the programme. Granting the accuracy of their statements, it still seems to the writer that there is a potential danger of undue state domination which even the most skilful and sympathetic administration may not be able to overcome. 222 Public Health & Welfare Reorganization The three rates involved (mill limit, percentage-of-excess-costs, and percentage-of-administrative-costs) should be fixed so as to limit the total obligations of the municipalities to a reasonable amount, this to be determined by reference to their general financial position. Assuming that the plan was not used to change materially the distribution of costs existing between the province and the municipalities in 1937, the most recent year for which detailed figures on local expenditures are available, these rates might have been respectively 5 mills, 5 per cent., and 75 per cent.18 From the figures that are at hand close calculations cannot be made regarding the probable results of such rates in later years, but it is apparent that the mill limit would have to be lower, perhaps about 4 mills, to keep the municipal contribution down to the 1943 level of $2,000,000 or $2,500,000 for health and welfare. The local share of excess costs is set very low deliberately. It must be small if it is not to offset substantially the equalizing effect of the mill limit on obligations. The rate of 5 per cent, which has been proposed would call for a total contribution by the local authorities of about 7 per cent, to expenditures above the mill limit, on account of the requirement that they should pay 25 per cent, of the costs of administration. For example, suppose that Victoria had excess costs of $100,000 in any one year and that the additional administrative charges involved were $10,000. The city would then be required to pay $7,500 towards the total amount of $110,000. Hence there would be a substantial financial restraint upon its administration of the excess costs, to supplement the control and supervision to be exercised by the* provincial government. The proposal that the province should share administrative expenses with all local units, including those that are not entitled to any grants in respect of costs beyond the fixed mill limit, is designed to discourage false "economizing" on administration and to encourage the development of good standards everywhere. 18Actually, these rates would have reduced the municipal burden slightly. Provincial-Municipal Relations 223 With such grants being made to all municipalities the province will have the power of the purse to supplement general regulations in enforcing good personnel and other administrative practices. There is precedent for this proposal in the payment of administrative grants to the states by the U.S. government under the Social Security Act and in the making of similar grants to counties by many of the states. Thus far in Canada the great value of this policy has been almost totally overlooked in connection with welfare sevices, both by the Dominion and the various provinces. This goes far to explain the skimping on administration and the unsatisfactory operating practices which have been so common. If the proposed system of health and welfare grants is to work properly several technical problems must be given careful attention. Municipal accounting for health and welfare must be uniform so that accurate statistics on expenditures, including those for administration, can be obtained. Accurate figures on taxable wealth are also necessary. At present assessment policies and practices differ widely from community to community. Some place high valuations upon their property and have low tax rates, while others follow an opposite policy. The obvious solution to this problem is a programme of equalized assessment conducted by, or under the direction of, the provincial government, as was recommended by the Harper Commission on Municipal Taxation in 193319 and as has been undertaken in Ontario and Manitoba, for purposes of calculating school grants, and in many American states. In addition, yearly population figures for each municipality would have to be obtained by census or would have to be estimated annually on a uniform basis for purposes of health grants. All three measures, as it happens, are very desirable for other purposes besides the 190p. cit., p. 26. A leading official of the Union of British Columbia Municipalities wrote on February 2, 1944, that "it is my opinion that the matter of assessments should be under the control of a central authority as owing to the differences in valuations the mill rate means nothing." It is a commentary upon the weakness of the Department of Municipal Affairs that it has not tackled this problem, one of the very first steps necessary to the reform of the municipal system. 224 Public Health & Welfare Reorganization grant-in-aid plans proposed here. The Department of Municipal Affairs has done something, during recent years, to improve the accounting and the statistical reporting of the municipalities, but much more remains to be done before municipal statistics are in proper shape for grant purposes. Even with good figures on taxable valuation there are some objections to their being used as indices of local fiscal capacity. With municipalities as small as those of British Columbia unusual circumstances (such as the presence of the Consolidated Mining and Smelting plant in Tadanac or of much tax-free federal property in Esquimalt) are bound to distort the value of the figures as indices. Moreover, the proposed method does not take account of a number of other factors besides taxable wealth in real property which affect the capacity of a local government to meet health and welfare charges. These include obligations to pay interest and amortization costs on capital indebtedness incurred in boom periods; the relative size of obligations for other municipal services such as education, roads, and police; and revenues or deficits incidental to the operation of public utilities. Still another factor may be the sheer lack of cash income on the part of residents of some communities which have a relatively high per-capita taxable valuation. This would be particularly important in rural districts where capital is mainly in land and buildings, but where cash incomes are low. But when all of these qualifications have been made, taxable valuation still appears to be much the best basis to be employed in a situation where statistical materials for more refined indices of capacity-to-pay are lacking, and where a simple plan is to be desired.20 The equalizing effects of the proposed plan of welfare grants are shown in Table VIII. 20Taxable valuation has been given major weight in many formulas for grants- in-aid to the local authorities which have been devised in Great Britain, in the United States, and in Canada. This is particularly true of those for educational assistance. Some amendments to the simple plan outlined above might be made to overcome some of the difficulties that have been mentioned. Provincial-Municipal Relations m 2 1 H H O I 1 W fe O GO 1 1 < Q i 1 1 fe * fe GO j I o fe 1 M m CO W w H 1 I 9 Q fe CO O fe O m Ph fe o CO H O H i fe m S ^ i °o e S § Q0Hq<f^00©MO g CD-^HOOHTptijiOTji 1 i *0 St3&- PI £1 eo©<©*©*cs*<s<aoc5*Q* £ -si •"N w (N05HH050}Tjli>a ^ |S GQ ooooooooo C> I t»00«5O»0)a«5© £1 £ K©<SO«5a^HM &h 1 J>. t» i—< GO ^ CO tF ^ CO 1 I OS rH rH ©* O O ©* «& ©^ ©* 1 I 1 1 C©«5«q©*«O«Ol>G0«5 I s <O^Ni>Ni>ril>:b '-S *e ^ 1 i> oo oo il ©* I 11 ooooooooo •fe "£ -Si to «5Wowo^o^a «o g^ *0 CO OOTi-HO^rH©^ 00 I > »o o" d h rt t-" a h «s 1 rH 00 ©< t- i> GO ©< j €©■ ^ l>MOO(N«5M<Nq 11 ^ rH <S< « ©«5«5a«500HOOH n n« fe s HH^fi6©sii(5bi(ji § I I00 ^ § •*J<*0©*GOC01>»0*0"«?< ooooooooo 9)l>HOtO{Cffli>H £ 'jiNtoft ■# a ^ os (o S i I '00^(Nl>O©HHO 1 CO ©< r-t r-t i> CO rH T-4 W H i 1 i «©■■ m Tf|«i«5r-j»rjOia>i>OJ Oi s£ osoo«5«dcoi>^© H '1 8 fts 1 «5^i>fflW5<rJI^«5 ooooooooo •§ e O00'fiiS(®i>OO^ & -s* £ ^ q i> ^ <« oe ©b -* © O CO S -^^ooiovfcoodrH^ 1 x*l CO rH r-t O* rH <5* i-H rH i «©• ^ j ooooooooo Qi <Ji S(O«5(S«500ffii>«5 *8 w S -2 00 00 <N 85 l> 00 00 OO S| "S !£» 1 1 ai CO h oo" »C «5 h oo" >o © "§*rO <» r-t © <N H ft< 00 00 N ^ of ooooooooo ooooooooo ooooooooo e e ^cw^o^co**ot-'"'*oo §4 OS*0<5*V}©©*«00-«# oo oo^ q w a ft a oo oo <§£ -* rH r* OOtFCOOOvJ s& ©* °^ n> CD > i *e o > c f- 'x\ t 1 i 03 CC 1 1 65 8 fe §.1 > & <~ pt r^ c |z « p> K» {> 225 S d_L 1 cu *j ° St? i s "8 ^ ^ •■§ -§ a * s S"5 h ^. c^^_S^ ^^ O1 13 m 53 o S ■« 2 .s a | s $ ^ 53 +j M PJ Xi m O ^?^H CP ■*J. >H ^^ * rd _b^ g J5i CO (V+jh Q n t$ ~a'o ^o»^ ^ i 3 «h 2h cu "-2 " cu « w F <U o .a ■& 'g ^e "3 * -h 68 " § ^2 k-§ S +J tn .: "d- CO rg o m 2 3 s ° a3 , "S ^ 2 cJ +3 o "O .h a) cy tn o3 +J i*^^^1s JS c?o J2 r£3 ^3 ?? O T3 ^ "" *i3 .2 ° d $ 213 S .a Js | i i > xi £ +» xJ h ■» « 2 s « Ch g <U O,,^ O « ^ S ^ _. "^ Onto «3 9 itj g cc fe o 2h ^ ^ «a d cu * o I fe S g .h CU _< tn Ph'S fe -S £ cc3 cu >? 0> g fl -a I -S J | 8 * KM & «* .a is il -a i? cfl -g 3^5 glis 3 o S ^> h m £26 Public Health & Welfare Reorganization The table is designed to show the effects of the proposed plan upon the cities of Vancouver and Victoria, upon three poor municipalities (Burnaby, Fernie and Ladysmith) where relief loads were very high in 1937, and upon four others that were relatively prosperous and much less affected by social service problems. Vancouver, with lower per-capita taxable valuation than Victoria, would have gained somewhat from the new plan, while Victoria would have lost. The three impoverished communities would have been greatly relieved of their welfare burdens, while the four prosperous districts would have had theirs increased, although not seriously. Provincial grants would have been redistributed, to the advantage of those places most in need of help. The effects of the plan on local taxation would have been very considerable, for it would have reduced the local obligation greatly in the poor communities and would have increased it in the others. Although the equalizing effects would have been far from complete, they would have overcome the gross disparities inherent in the existing system. Practically all municipalities would have been protected against welfare charges exceeding 7 or 8 mills. The cases of Fernie and Ladysmith are both extreme, because in both there was an unusually high concentration of unemployment and in the latter taxable valuation was exceedingly low. An additional safeguard, to protect such communities, would be to provide for full provincial assumption of costs above a certain point, such as 8 mills. It is not the details of the plan outlined here that are important, but rather the principles which it illustrates. Further study of the British Columbia situation, with the advantage of good statistical data which have not been available to the writer, should yield a plan better m detail and more satisfactory in results than the very simple one presented here. This is one of the most important problems of transition to social security which should be investigated very carefully by the provincial government. Provincial-Municipal Relations Revision of Municipal Charges 227 Revision of the existing system of municipal contributions to institutions and the children's aid societies is the final change in the system of provincial-municipal financial relations which is to be desired. One of the present charges, that for the maintenance of prisoners in provincial jails, is clearly undesirable, for it represents a financial barrier to good practice by the police and the courts and to the even-handed administration of justice. It is illogical that this charge should remain when those for the maintenance of municipal residents in mental hospitals and the industrial schools have been removed. It should certainly be abolished. The remaining charges (those for patients or inmates of hospitals, tuberculosis institutions, infirmaries, and the Provincial Home, and for children under the care of children's aid societies) have an administrative justification, because all of these forms of care represent, in some measure, alternatives to the maintenance of people on general assistance in their own homes or in boarding homes or nursing homes. If institutional maintenance is available for such people entirely at provincial expense there is a financial temptation for the local authorities to use their influence to gain admission to institutions for their residents, and, even more important, to avoid making suitable community arrangements for those ready for discharge. However, improved administration, the financial effects of an equalization-grant system, and provincial standards and supervision should go a long way to solve the problem of municipal failure to provide proper services, so that the case for continuing the charges will become progressively less as these new policies are made effective. One of the charges, that for hospital patients, will be inappropriate when the health insurance system is established. Probably the others should be continued for the immediate future, with rates and procedures being adjusted to some uniformity; although it seems quite possible that all of them might 228 Public Health & Welfare Reorganization be eliminated before long, in the interests of simplification. The addition of municipal contributions towards the categorical aids, which has been proposed earlier, will compensate for the savings incidental to local relief from institutional payments and from the costs of the medical care and delinquency programmes. With municipal obligations arising wholly, or mainly, out of the two programmes which they administer, generalized public health and public assistance, it will be simpler and easier to work out equitable systems of provincial grants than when the situation is confused by a number of separate contributions to provincial or private agencies. Advantages of the Proposals The proposed system of financial relations promises several advantages, over and above those that have been mentioned, which are listed below. (1) Comparative certainty would replace uncertainty regarding local health and welfare costs. The new system of grants and charges would be set forth in statutes, which should show clearly both the obligations the municipalities were to assume and the aid to which they would be entitled. Thus they would be able to make future plans with some assurance regarding the provincial policies most vitally affecting them. The system would permit them to estimate the approximate limits of their financial obligations for the social services. If the need for public assistance increased rapidly, they would not have to face a sharp increase in costs. For the province would assume the major risk of upward fluctuations in welfare expenditures, a risk that it is much better prepared to meet because of its broader tax sources and more elastic revenues. So far as health and welfare charges are concerned the revised system would do for the municipalities precisely what the Rowell-Sirois Commission aimed to do for the provinces through its proposals for Provincial-Municipal Relations 229 readjustment of Dominion-provincial relations—it would enable them financially to discharge the functions delegated to them.21 (2) The scheme would eliminate bickering between the province and the municipalities over a number of small items. With all provincial assistance consolidated into two main grants, for health and for welfare, to be distributed according to definite rules, there would be an end to negotiations and squabbling over the sharing of costs for particular services, over special grants, and over exceptional cases. Negotiation and controversy would still remain, but this would be confined to major issues such as the mill and percentage rates to determine welfare obligations. This would go a *k>ng way towards raising provincial-municipal discussions on the social services to a higher plane of policy than the one upon which they have usually been conducted in the past. (3) The plan would be an important step towards solution of the whole problem of municipal finance. By itself it would make only a partial contribution to this end. But its introduction would encourage application of the equalization principle to grants for other purposes, such as education, police protection, housing, and even capital improvements. The broader the coverage of grant- in-aid schemes based on the needs basis the better the results will be. Out of this there should arise a stabilized system of municipal finances that will place only a reasonable and definitely limited tax burden upon real property and that will put an end to the most serious financial difficulties of the local governments. (4) The whole system of provincial-municipal financial relations would be simplified. Record-keeping and accounting would be much less than is necessary now for the separate grants and charges 21The Commission did not recommend any specific system of provincial grants to the municipalities, but it pointed out that "there is a strong case for the equalization of the costs of [social] services as between municipalities in the same province" (Book II, p. 31), and at several points it spoke approvingly of provincial aid. Mr. H. C. Goldenberg, author of one of the Commission's monographs, Municipal Finance in Canada, advocates (p. 103) "provincial grants to municipalities in accordance with some criterion of needs." 230 Public Health & Welfare Reorganization and this should represent a considerable saving in administrative costs. The equalization-grant method holds out an even more important source of administrative economy, if it is applied fully and logically—which would mean going farther than in the detailed provisions proposed above. This source lies in the possible abolition of municipal residence rules. The object of these rules is essentially to protect any given community against unreasonable charges in respect of persons who do not "belong" to it. If the community is adequately protected by equalization provisions residence rules become unnecessary—and they may be repealed, as has been done in the states of Washington and Rhode Island. The administrative costs of applying these rules are very considerable—so much so that the New York State Department of Social Welfare, which has proposed abolition of residence rules, gives as one of its "main reasons the argument that they cost more to administer than they are worth for practically all local authorities.22 The possibility of doing away with residence rules in British Columbia, even with a partial system of equalization in effect, is very much worthy of careful investigation. Provincial Standards and Supervision To qualify for health and welfare grants from the province the municipalities should be required to comply with reasonable conditions. These should include faithful performance of functions assigned to them, maintenance of good standards of organization and administration, the keeping of accounts and records in prescribed form, and the employment of qualified personnel. The province should be empowered to inspect and supervise the work of the local authorities and to withhold grants or to take over administration from any that fail to conform to the prescribed conditions. Good administration depends more upon personnel than upon any other single factor, unless it be sound organization. Therefore 22" Commissioner Adie's Report to Governor Lehman on the Statutory Settlement Provisions in New York State," Social Service Review, September, 1942, p. 522. Provincial-Municipal Relations 231 the province should specify the minimum qualifications of persons to be employed in various health and welfare posts. Subject to this rule the actual control of appointments would remain in the hands of the local authorities. There is precedent for this proposal in the arrangements that have been made regarding provincial grants-in-aid to the Vancouver Metropolitan Health Board, in the provisions of the Health Act regarding the employment of sanitary inspectors, and in arrangements made between the Provincial Secretary's Department and the cities of Vancouver and Victoria in connection with grants towards hospital clearance work. Provin-" cial certification of teachers before they can be appointed by the local school boards is familiar to everyone. Under the American Social Security Act, all appointments to state and local agencies administering federally assisted programmes must be made in accordance with merit system plans to be approved by the Social Security Board, and this has led to great advances in the quality of social service personnel throughout the country. The need for other standards to be set by the province, covering accounting, statistics, scales of assistance to the needy, administrative procedure, and other items has already been indicated or is implicit in the analysis of the preceding pages. The ministers of the respective departments of health and welfare that are proposed in the next chapter should be empowered by legislation to issue regulations on these points, subject to approval by order-in-council. The system of "fair hearing and appeal" which was outlined in the last chapter would operate also as an important instrument of control. The sanctions to make this system of standards effective would be two in number—the power of the provincial government to withhold grants and the power to take over administration in any municipality that failed to observe the rules. The machinery to operate the system would consist of a few technical experts in the departments of health and of welfare who would exercise super- 232 Public Health & Welfare Reorganization visory functions. With competent supervision in effect there should be no occasion to employ either of the sanctions. The fact that they were available for use if necessary would give to the supervisory officers, and to their respective ministers, a degree of influence which could scarcely be disregarded even by the most independent local council. The supervisory officers, besides inspecting the work of the local authorities, should assist them positively with their various problems. Thus they should appear more as friends and useful advisers than as hostile inspectors, and through them a co-operative relationship should develop between the provincial and the local departments. The frank adoption by the provincial government of the principles of standards and supervision will mark a fundamental revision in policy regarding provincial-municipal relations. There has been a gradual approach towards the adoption of these principles. But always the idea that the municipalities were, and should be, autonomous within their own sphere has been tacitly accepted by both provincial and municipal political leaders, and this concept has constantly stood in the way of the full application of the doctrine of supervision. A change in thinking is necessary to face up to the realities of modern administration in the field of the social services, as well as in other fields of concern to local governments. The necessary changes in basic policy will no doubt be resisted not only by municipal councillors and officials with a vested interest in the present system, but also by many others who are tied by tradition to an out-moded view of municipal affairs. It will require vigour and courage on the part of provincial politicians to overcome this opposition and to enunciate a new approach. The more frankly and clearly this is done, the better will be the chance of developing a supervisory system that will achieve good results. Without it, delegation of social service responsibilities to the local governments will not be a success. Provincial-Municipal Relations Conclusion 233 The drastic changes in the system of provincial-municipal relations which have been proposed should bring to an end the longstanding conflict and lack of co-operation between the provincial and the municipal branches of the social services. In place of conflict and non-co-operation, a partnership towards a common purpose should emerge. The disadvantages of local administration can be largely overcome by the new approach, while the essential advantages should remain. Local government can be built up to play an important part in social service administration at the same time that a reasonable degree of uniformity and consistency is achieved throughout the whole province. But if proposals along the lines made here are not adopted, the future for local administration of any of the health and welfare services does not look very good. When crisis strikes again, as it did in the 1930's, many of the old weaknesses will come to light in spite of the great improvements in the provincial-municipal system which have been made during recent years. The agitation for complete transfer of the social services to the provincial level is likely to be renewed and its - chances of success will be considerable because it will represent the simplest solution to the difficulties of municipal administration. But the easiest way out will not necessarily be the best. The proposals in this chapter have been based on the premise that the reform of the social services must be undertaken within the framework of the existing municipal system. But the reader will have noted that the recommendations would affect this system materially, by taking the social services partly outside of the present structure and by establishing new financial and supervisory relations between the province and the local governments with respect to a broad range of their activities. These modifications, it is believed, are quite compatible with the major surgical operations which are necessary to give British Columbia a good system of local government. For other purposes besides those of health and 234 Public Health <$c Welfare Reorganization welfare there should be larger municipal units;23 there should be metropolitan districts in the Vancouver and Victoria areas; provincial grants to the local authorities should be varied in accordance with needs for a variety of purposes; there should be provincial standards of service and provincial supervision of local affairs in a number of fields; the province should assist municipalities in building up a competent civil service; uniformity of assessment, uniform accounting, and good statistics are general essentials; and the local authorities should be partners of the province rather than opponents in all spheres of government within their joint jurisdiction. Should there be a general reform of local government along these lines, it would no doubt be necessary to modify the proposals which have been made here regarding the social services so as to fit them into the revised municipal pattern. But the general principles of provincial-municipal relations which have been stated should be applicable whether local government in the province is thoroughly overhauled or not. 23There might be a county system, with the present broad expanses of unor- ganized territory being grouped around the urban and rural municipalities which now are spotted throughout the province. By this means virtually all portions of the province, except the uninhabited regions of the North, could be given the advantages of organized, local government. Urban districts might still remain as incorporated places to conduct limited functions. The counties, however, would be the appropriate units for the administration of health, welfare, and education. 7 Administrative Machinery and Personnel JLNTEGRATION MEANS THE BRING- ing together of related functions into one organization on one level of government, in an ordered relationship."1 For many years there has been a steady trend toward the grouping of related activities in the government departments of Canada and the United States. Among students of public administration the concept of the "unifunctional department" has grown up—that each department should be concerned only with one major "function," such as justice, finance, public works, postal service, or education. The application of this doctrine to the fields of health and welfare has led, in the United States, to separate departments in nearly all the states. There has also been a trend in this direction in Canada, but the results are not yet so clear or universal. The Problem of Integration The integration of the health and welfare services was very imperfect in British Columbia during the depression years. For as we have seen they were scattered among four departments xMarietta Stevenson, Public Welfare Administration (New York: 1938), p. 130. 235 236 Public Health & Welfare Reorganization (Provincial Secretary, Labour, Attorney-General, and Education) and two independent agencies, the Workmen's Compensation Board and the Health Insurance Commission. Developments of the war years have greatly improved the situation so that now nearly everything is concentrated in the Department of the Provincial Secretary. The only welfare services of importance still outside the department are the provincial jails and adult probation and parole, under the Attorney-General. Reasons were given in Chapter 5 for believing that these would be operated much more effectively under a department of welfare rather than one of law enforcement. Chart IV, which the reader may compare with Chart III on page 122 to obtain a graphic idea of organizational changes during the last few years, shows the present structure of the Provincial Secretary's Department. But with all of health and welfare under it, the integration of the department would still be defective because it includes a number of miscellaneous activities which have nothing to do with the social services. It should require no theoretical argument to show that they do not belong in an agency whose major concern is health and welfare. Their continued presence, in an organization which would be complex without them, is particularly unfortunate because they are mainly under the direct supervision of the deputy minister. Inevitably his attention is distracted from the major programmes of the department, organized in large branches, by the need to attend to the details of the miscellaneous services which crowd into his office and he is not so free as he should be to give leadership on more important issues. These odds and ends of business should be redistributed among other government departments—the King's Printer, perhaps, to Public Works; and Government House affairs, official entertainments, administration of The Elections Act and the Public Inquiries Act, and other small items probably to the Attorney-General's Department. The Civil Service Commission should be an independent agency, reporting to the Premier, which might also administer superannuation and teachers' pension funds. Q W 1 1 - si >SS 2<-> 0. v> £3 £* PS n s .2 ^5u < 11 0 .§ H Dh5 1 :£ c8 "i Mg3« 1 U | | Oca ■go T3 «~ «, C S S ill p a J" of: Health neering ulosis Con al Disease rol tatistics zfe £ .2 '§> £ £ a 2 M >© i * !|w| 1«|3 |$ a. i Q 238 Public Health & Welfare Reorganization The principles of integration apply to the grouping of related activities in branches and divisions—-the subunits of organization—? as well as in the department. Chart IV shows that these principles have been violated in several respects. The most glaring instance arises out of the reorganization of 1942, when the former programme of the Unemployment Relief Branch of the Department of Labour was consolidated with the Welfare Field Service and the welfare and child welfare branches of the Department of the Provincial Secretary to form the new Social Assistance Branch. This was a consolidation that went too far. Child welfare is a sufficiently distinct form of service to warrant separate organization as a major operating unit. Actually the Child Welfare Division appears to have this status for the Superintendent of Child Welfare reports directly to the deputy minister or the assistant deputy rather than through the chief of the Social Assistance Branch.- It is illogical to place the Field Service in this branch, for it serves the whole department. In this case, too, the formal consolidation does not seem to have meant very much, for the Assistant Superintendent of Welfare, who is in charge, reports to the deputy or the assistant deputy without the formality of going through the officer who is technically her superior. The medical service unit is also, to all intents and purposes, operating as a branch. There are several other instances of poor integration within the department. The two industrial schools, which were shown as the constituent units of one branch in the 1939 chart (Chart III, page 122), have grown apart, so that now they operate quite independently. The infirmaries are grouped together only loosely and the Provincial Home at Kamloops continues to operate by itself, although it is essentially an infirmary. The medical services unit is quite separate from the administration of grants to resident physicians, one of the small tasks which still clutters up the office of the deputy minister. Administrative Machinery and Personnel Line and Auxiliary Service 239 Another defect of the departmental organization is that it gives but little recognition to the need within it of two distinct types of operating units, which may be called respectively "line" and "auxiliary." The line units, following the familiar terminology of the military services, are those which are concerned primarily with major-purpose operations, such as the care of mental patients, the granting of pensions to the aged, or the care and protection of neglected children. But it is also necessary that there be various supporting, or auxiliary, services to make these primary activities possible. These include personnel management, training, accounting, business management, research and statistics, budgeting, manual preparation, legal service, reporting, and public information. Such administrative activities are undertaken as a matter of course by the director and his immediate assistants in any small agency. But as an organization grows there is need to delegate some of them to certain persons, in order to obtain the usual advantages of specialization and division of labour, and to set up special offices to serve the line units. For only if this is done, in the large and complicated organization, will proper attention be given to the auxiliary activities. There is also, in the large agency, the need for *'staff" service. Again, the term is familiar to all because of its use in the military world. "The staff service of advice and counsel operates upward, downward and outward, and across organizational lines. It is always advice, however, and never command."2 Staff work is concerned with thinking, planning, and advising, rather than with the execution of policies, which is line work. Only in very large agencies is there much place for separate offices concerned entirely with staff duties (e.g., the former National Resources Planning 2Leonard D. White, Introduction to the Study of Public Administration (rev. ed.; New York: 1939), p. 42. See Chapter III of this book for a good discussion of the theoretical points mentioned here. The term "auxiliary service" is taken from White. 240 Public Health & Welfare Reorganization Board of the United States Government), and it is quite appropriate in most administrative situations that line officers should perform some staff work. But often they need the help of administrative assistants or special advisers to perform staff duties when the volume of work is too small to justify permanent offices for the purpose. At present there is really only one unit in the Department of the Provincial Seoretary which is a genuine auxiliary service—the Collections Office. And there is one person who might be termed a staff officer—the Adviser on Social Welfare Policy—who, quite illogically, is listed in the departmental budget as a member of the staff of the Social Assistance Branch. Since her duties are to act as a roving adviser to the minister and his deputies on problems of policy she should be shown on the chart, and in departmental documents, as reporting directly to them. Recently a new officer has been added to the headquarters staff to undertake some personnel functions and to perform special jobs for the minister and the deputies. These represent small beginnings towards formal recognition of staff and auxiliary functions. At present departmental statistics are not uniform and are far from complete, some branches and other units publish annual reports and some do not, accounting practice and procedure vary a good deal from unit to unit, there is lack of common policy on personnel and on institutional management, and there is no general programme of public information. These and other problems of management, common to all branches, call for the attention of specialized central offices. Another principle of organization which should be generally observed is that of "unity of command." "Failure to secure unity of command is followed by disorganization, irresponsibility, confusion, and vacillation. It is elementary to good organization."3 Responsibility should be clearly delegated and lines of authority should be definite. The situation in the Social Assistance Branch 3Ibid., p. 43. Administrative Machinery and Personnel 241 is potentially one of conflict with these rules, because of the fact that in practice the Child Welfare Division and the Field Service report to the senior officers of the department rather than to their nominal chief, and removal of these units from the branch is desirable to overcome this possible difficulty. Another potential barrier to unity of command is the existence of the Old Age Pensions Board of three civil servants, which is charged legally with the administration of old age pensions and the operation of the Old Age Pensions Branch. The board members are empowered to make decisions and to take actions which, conceivably, might place them in conflict with the minister and his deputies, their superiors in the hierarchy—so that the members of the Field Service and the local welfare departments, who deal directly with applicants for old age pensions, would be subject to conflicting directions. It is unlikely that such events would occur, for a board of three departmental civil servants is in no position to differ publicly with the minister. Therefore the board is of dubious value to fulfil its apparent purpose, the rendering of independent, nonpolitical, administration. There is no more justification for this board than there would be for one to administer mothers' allowances or social allowances. The scheme was not conceived by the British Columbia authorities, who favoured straight-line administration under the minister when old age pensions were transferred from the Workmen's Compensation Board to the Provincial Secretary in 1942, but was worked out to satisfy the demands of the Dominion government. It is probably harmless, at present, for reasons that have been given, but it is unnecessary, illogical, and a possible source of trouble in the future. There is one other administrative board in the department, the Welfare Institutions Licensing Board. But this is different in status, for three of the members are appointed by the Provincial Secretary to serve at his pleasure while the other two are the Superintendent of Child Welfare and the Provincial Health Officer (or his nominee), and the Provincial Secretary is explicitly charged 242 Public Health & Welfare Reorganization with administration of the licensing act. The Act delegates certain specified responsibilities to this board, but there is ministerial control both because the obligations of the board are specific and limited and because of the power of the minister to change its personnel if he desires to do so. Apart from these examples, the present organization of the department provides reasonably well for unity of command. The existence of a number of advisory committees is not at all in conflict with this principle, for they have no administrative authority; nor does the Provincial Board of Health represent a conflict, for it is made up of the members of the cabinet, to which the Provincial Secretary belongs, and it is an agency for policy formation rather than for administration, which is carried out by the Provincial Health Officer and his staff under the Provincial Secretary. The various advisory committees in the department have proven very useful and represent a device for obtaining group opinion, lay and professional, which should be employed further. One or Two Departments Since practically all of the health and welfare services except those for adult delinquents are concentrated in the Department of the Provincial Secretary it is clear that the leading question of structure now to be faced is whether it should become a department of health and welfare or whether the two main branches of its work should be split into separate units. This issue has been recognized for a number of years, and opinions have differed among the officials as to which solution was the better. There are various arguments on both sides, which will be listed below. First, there are certain points to be made in favour of a combined department, as follows: 1. The two types of service have grown up together, and it would be difficult to disentangle them. 2. There are close interrelations between the various health and welfare programmes, so that co-ordination of policies and procedures is much to be desired, and this is more easily achieved if they are Administrative Machinery and Personnel 243 within the same department. The concern of the tuberculosis and venereal disease divisions with adequate provision for maintenance allowances in the home for their patients illustrates the point. 3. All branches at present obtain most valuable assistance from the Field Service, and if there were two departments it might be difficult to work out satisfactory arrangements for field work for the health divisions, which would have less need for a province-wide staff than the welfare branches, with which the present service would naturally be grouped. 4. It would be difficult to distribute certain programmes between two departments, notably mental hygiene, medical care for the needy, the infirmaries, and hospital control and inspection, for they have both "health" and "welfare" characteristics. 5. It is undesirable to increase the number of cabinet portfolios, which would be required if an additional department were established. On the other hand, there are substantial arguments for a two- department system, some of which are refutations of the points listed > above. 1. The differences be ween health and welfare, for purposes of administrative organization, are more significant than the likenesses. The clientele of the health agencies, at least potentially, is the whole population, irrespective of economic status; while the welfare agencies deal primarily with destitute, near-destitute, or badly handicapped groups. The two programmes have fairly distinct major objectives, in the one case the protection and the advancement of health, and in the other the provision of economic maintenance and the development of social adjustment for those who cannot make their own arrangements for livelihood or constructive participation in community life. These differences make for policies and administrative procedures that differ materially. Thus there are reasonably distinct "health" and "welfare" functions for government to perform, and the doctrine of the unifunc- tional department leads to the conclusion that there should be separate administrative agencies for the purpose. 2. The two programmes require different kinds of administrative personnel. Health agencies must be staffed primarily with persons who have a knowledge of medicine and related fields and whose basic 244 Public Health cfc Welfare Reorganization training has been in these subjects; while the equipment of welfare personnel is derived basically from the social sciences and from the applied science of social welfare. Inevitably, and properly, the two personnel groups have different approaches towards their work and it is not always easy (however desirable this may be) for them to work as members of a team in the same department. 3. Direction of a genuinely unified department of health and welfare would call for leadership from a deputy minister and other senior officers equally familiar with health and welfare, and not disposed to favour the development of one phase of the total programme more than the other. But persons with professional competence in both fields are not being trained anywhere and there are practically none of them to be found. Thus the appointment of a deputy minister for a health and welfare department will almost certainly pose serious difficulties, for the senior officers at hand will have been trained in the one field or the other and will, in spite of much knowledge of the other field that they may have gained through practice, represent primarily either health or welfare in the eyes of their associates and the general public. If a welfare officer is appointed he is not likely to be well received by the health personnel and by the medical profession, whose influence in the health agencies is very important; and if the post goes to a health officer he will be handicapped, in the same way, in his relations with the welfare personnel and the welfare groups in the community. A possible alternative is to appoint an administrator who professes to no technical knowledge of either field, and to give him two chief assistants, one for welfare and one for health. But this solution has obvious disadvantages, not the least of which is that it would deny the top administrative position in the department to experienced officials who had spent years with either a health or a welfare branch. 4. A combined department is too broad in scope for effective management by the top administrators, the minister and his deputies. The well known doctrine of public administration regarding the "span of control" prescribes that an executive should not have more than a limited number of subordinates reporting to him, because he is able to supervise properly only a few. While the number that can be effectively directed varies with circumstances, most administrators in the social services will find that they have their hands full when five or six division chiefs are reporting Administrative Machinery and Personnel %4t5 directly to them, along with a few staff officers and heads of auxiliary services. A combined department which was really unified under central direction would have a dozen or more major operating branches, too many for any chief executive to handle well.4 In addition there is the related problem of what may be termed the "intellectual span of control." This is the difficulty of the chief executive becoming familiar with and keeping in touch with the subject matter of a considerable number of specialized fields within the broad territory of health and welfare. Each branch, tuberculosis control, venereal disease control, generalized public health, child welfare, juvenile delinquency, mental hygiene, public assistance, etc., has its own specialized literature, its own national and international organizations, and its own special-interest groups of professional and lay people. The busy administrator who tries to keep up with developments in each area in other provinces, in the United States, and in foreign countries (as he should, if he is to give effective leadership at home), is overwhelmed by the books, reports, and journals that crowd onto his desk and by invitations to professional conferences, and he is likely to give up the effort in despair and to rely upon the advice of the various specialists on his staff. Of course he should depend upon their help, to a large degree. But without technical knowledge at least comparable to theirs, if not so intensive, he is gravely handicapped in appraising their proposals and mediating between their claims, as he must often do. Naturally, if his basic training has been in health he will give more attention to developments in the health field in the limited time that he has, while if he has a welfare background he will follow welfare affairs; and in each case the other field will be neglected. 5. The budget and the staff of a health and welfare department would be so large as to overshadow by far those of other departments of provincial government, and this would throw a disproportionate responsibility upon the minister by contrast with that assumed by his cabinet colleagues. The British Columbia Estimates for the 4The reader will see, by referring to Chart IV on page 237, that at present there are five main branches of health and welfare under the Department of the Provincial Secretary, plus small institutional divisions and one auxiliary service. But there are six operating divisions grouped under one branch, the Provincial Board of Health, and there are several in the Social Assistance Branch which are, or ought to be, main units. The chief executive, in a thoroughly integrated department, ought to be closely in touch with the heads of all or most of these units as well as with the other branches listed on the chart. If 246 Public Health & Welfare Reorganization fiscal year ending March 31, 1945, show how this has already come to pass in British Columbia on account of the concentration of social services in the Department of the Provincial Secretary. The appropriations of the various departments for the current fiscal year are given below: Department Estimated Expenditure Agriculture $440,961 Attorney-General 2,216,798 Education 4,994,748 Finance 1,873,355 Fisheries 24,950 Labour 154,265 Lands 1,878,022 Mines 286,880 Municipal Affairs 26,890 Provincial Secretary 10,644,261 Public Works 3,404,500 Railways 21,850 Trade and Industry ,. 280,935 Total, All Departments $26,248,415 Public Debt, etc 8,256,810 Total Appropriations $34,505,225 The figures show that the present budget of the Department of the Provincial Secretary is more than twice as large as that of the next one in size, Education, and that it makes up nearly 40 per cent, of all departmental appropriations. Obviously it is a giant among pygmies, which should be broken up if the public business is to be distributed somewhat evenly among departments. 6. The respective fields of health and welfare are each important enough to demand cabinet representation and the undivided attention of a minister. The problems of top management which have been mentioned above press severely upon a minister of a combined department. Since tenure of political office is usually brief he has but little time, at best, to become familiar with the department over which he presides; and a complicated organization like that of the Provincial Secretary is too much for the best of ministers to learn to understand. Therefore the two fields are not likely to Administrative Machinery and Personnel 247 be given adequate representation in a cabinet when one busy and harassed minister must speak for both. Moreover, it is unfair that a department spending 40 per cent, of the total appropriations should be represented by only one vote in a cabinet of six or seven, as is the case in British Columbia. The argument that the number of departments and of cabinet portfolios should not be increased may be accepted, as a general principle. But this is no reason, in British Columbia, for not breaking the Department of the Provincial Secretary into two parts. Some of the puny departments now in existence could be, and should be, consolidated. Thus Fisheries and Mines might be amalgamated with Lands to form a Department of Natural Resources, and Railways might be made a small division in Public Works, while Trade and Industry has a dubious claim to independent existence in its present form. A general departmental reorganization, which is very much needed, should bring about a number of changes to reduce the total number of departments and of portfolios, at the same time that it permitted separate agencies for health and for welfare. 7. Precedent in the United States, and to some extent in Canada, favours two departments rather than one. A few American experiments with combined departments have not been very successful and have been abandoned," except in the state of Maine. In Canada there was a distinct welfare department only in Ontario, prior to 1944. But at this year's spring sessions of the legislatures of four provinces, Alberta, Saskatchewan, Quebec, and Nova Scotia, new welfare departments were authorized. The balance of the argument, it appears, is strongly in favour of two departments rather than one. This conclusion is reinforced by the fact that the Provincial Board of Health is now operating virtually as an autonomous unit within the Department of the Provincial Secretary. The Provincial Health Officer has direct contact with the minister, and the deputy and assistant deputy exercise but little supervision over the public health services. They have their hands full with public assistance, hospitals, the mental hospitals, and the other institutions, the Board of Health is well organized and strongly directed, and it is very natural that they, as laymen, should leave the health programme pretty much to itself. 248 Public Health & Welfare Reorganization It would be recognizing the realities of the present situation to give to the public health services the status of a department and to the health officer the position of deputy minister. Problems Raised by Two Departments But the formation of two departments raises several difficult problems which have been indicated in the arguments for consolidation which were given above. These are the allocation of certain services, notably mental hygiene and medical care, the question of field service, and the co-ordination of health and welfare activities. There are various reasons for grouping the mental hygiene services with public health, as follows: 1. The two programmes are akin in that they both employ medical techniques to a great extent and that the knowledge and skill of their professional personnel arise largely from medical training. Insofar as the health agency has medical institutions under its jurisdiction, notably tuberculosis hospitals, it has problems of institutional management to handle similar to those of the mental hospitals. 2. The integration of mental hygiene and general public health promises to forward the utilization of the local health agencies as instruments for the prevention of mental illness. In both Canada and the United States there is a growing realization of the valuable contribution which the local health departments can make towards preventive work in mental hygiene. 3. There has been developing for some years a broadening concept of public health, which goes beyond concern with physical disability to concern with mental disability. The medical profession generally has begun to become interested in the importance of the emotional factor in illness, and the view is now well accepted that physical and emotional factors are closely interrelated. Therefore a modern programme of preventive medicine must be concerned with mental hygiene. This trend is represented in the United States by the development of mental hygiene divisions within the federal Public Health Service and within many state and local health departments; and in Canada by the planning of the Heagerty Administrative Machinery and Personnel 249 committee for a national health programme which will include federal giants to the provinces to assist them with their mental hygiene work. 4. The extension of free treatment to all victims of mental disease, as proposed by the Heagerty committee, would take mental treatment out of the realm of free service only for the indigent and would put it on the same economic basis as the general public health services, thus extending the clientele of the mental hospitals and clinics to the whole population. 5. In five provinces of Canada, Alberta, Saskatchewan, Manitoba, Ontario, and Nova Scotia, there is a clear pattern of integration of public health with mental hygiene in the same department, which has worked reasonably well. On the other hand, the mental hygiene services have close affinities with welfare, for the following reasons: 1. There has been a traditional association. Charitable care has long been necessary for the "unfit," and prominent among these have been the mentally ill and the mentally deficient. Public assistance has been necessary for a large number of this group outside of institutions; and their maintenance at public expense inside the institutions has generally been required. In part, the mental hospitals of today grew out of the poorhouses of yesterday and when they were established independently they often remained in close association with the institutions for the destitute. The mental hospitals were under the welfare departments of twelve of the American states and territories in 1941, whereas they were under health departments in only four.5 The American Public Welfare Association and other important agencies have commonly listed mental hygiene as part of the welfare field. 2. Although medical training is basic to the leading types of professional work in mental hygiene, as in public health, the psychiatrist, who dominates the professional personnel, is very different in knowledge and in skill from the public health officer. He is concerned primarily with incapacity for normal social 5Based upon U.S. Public Health Service, Reprint No. 2306, from the Public Health Reports, Vol. 56, No. 34, "Distribution of Health Services in the Structure of State Government," Chapter 1, "The Composite Pattern of State Health Services," by Joseph Mountin and Evelyn Flook. 250 Public Health & Welfare Reorganization behaviour on the part of his patients, rather than with physical disability, and he works closely with social workers and community welfare agencies to achieve his objectives of treatment. Since the social worker and the public welfare official are frequently better trained in mental hygiene than public health officers and nurses, the psychiatrist and his co-workers are likely to collaborate with welfare personnel even more easily than with public health workers. Indeed, there is considerable danger of cleavage and lack of understanding between the mental hygiene and the public health groups. 3. Community service, carried on by social workers, is of the utmost importance in the mental hygiene programme. The finding of homes for patients under a boarding-out programme, the supervision of patients on parole, case-work service with families, the preparation.of reports for the psychiatric clinic, collaboration with social agencies, the provision of economic maintenance for patients or their families, and the planning of rehabilitation measures are among the tasks performed by social workers in a good mental hygiene programme. Where it is difficult or impossible to have a specialized staff of social workers for this work, covering a broad territory, the mental clinics and institutions have great need for the assistance which a generalized welfare field service can offer. 4. The care of the mentally deficient has usually been associated with the care of the mentally ill. But it is obvious that a programme for this group involves social rather than health problems, and the welfare department is usually better equipped to deal with these than the health department. The rival arguments are somewhat the same in the case of other programmes which involve medical care administered by medically trained personnel. Superficially it appears that they should be grouped with public health. But their historical association has been with public assistance because they have been directed toward the needy groups in the population. In short, they have been part and parcel of the relief system. However, changes are taking place in the form and the objectives of the medical care programmes, the old lines between preventive and curative medicine are breaking down, the drift towards health insurance promises public medical care for all without reference to economic status, Administrative Machinery and Personnel 251 and the old reasons for associating medical care with welfare are becoming less important. The analysis of preceding chapters has shown that the present systems of medical care for the needy and of hospital grants will no longer be necessary when a broad system of health insurance is set up, so that the problem of distributing these two services between the proposed departments of health and of welfare will solve itself. This leaves practical problems of allocation regarding four programmes—mental hygiene, hospital inspection (which will be needed when health insurance is established, as well as at present), the infirmaries, and services for crippled children. Opinions are likely to differ as to which, if any, of these should be grouped with public health. There are good arguments on both sides and it would be a workable solution to place them either in the health or the welfare departments. But the writer has been led progressively to the view (after holding the contrary opinion for a considerable time) that it would be preferable to group at least three of them, mental hygiene, hospital inspection, and crippled children's services, with health. This would be in accord with the distinct tendency towards a widened concept of public health, it would make a commonsense appeal to the general public, it would mark a clean break from the unhappy pauper background of these services, and it would clear the decks for a new and broad approach to the protection and the advancement of the health of the people of British Columbia. Various readjustments in policy and in attitude on the part of the administrative personnel in the present public health services and in the mental hygiene programme would be needed. But as each group educated the other and as new personnel came to the work of the health department with broader training and interests than in the past, these adjustments should be possible. The case of the infirmaries is different. Medical care is not nearly so important for their patients as for those in hospitals. They are very closely related to public assistance, for they receive, 252 Public Health & Welfare Reorganization and will continue to receive, their inmates largely from the public assistance rolls. They will continue to represent, more than anything else, the residual element of medical relief which cannot be avoided even when there is a full new system of social security, and it seems, therefore, that they should be kept with the welfare services. The problem of field service for the health agencies, if there are two departments, will no doubt pose greater difficulties than if there is a combined department. The existing field service is primarily concerned with welfare administration, and it would naturally be taken over by the welfare department, while the health department would scarcely be justified, in a province like British Columbia, in setting up a province-wide field service of its own. The solution would appear to lie in continued use of the welfare field service by the health agencies, by virtue of a sort of contractual arrangement between the two departments. To avoid the danger that the welfare department would not render service adequately, without some quid pro quo, the health department might contribute through its annual budget part of the costs of the field work. In a vigorous and co-operative welfare department there would be a real desire to help in this way, and there is reason to believe that a mutually satisfactory and advantageous arrangement can be worked out. In addition, the strengthened and improved local welfare departments which have been proposed should be able and willing to serve the health divisions to a considerable extent, thus reducing the demands of the latter upon the provincial field service. If they undertake seriously a family welfare job they will consider it part of their regular duties to perform community service in co-operation with the health agencies. The health department should have its own specialized staff of medical and psychiatric social workers at headquarters offices and at its institutions; and the professional conventions of social work should go far to bring about co-operation between these persons and the general- Administrative Machinery and Personnel 253 ized social workers of the provincial field service and the local welfare agencies. Co-ordination between the activities of the two departments is the third major problem to be faced. If the health department uses the welfare field service, as suggested above, this will make for close and valuable interdepartmental relations. Another useful device, tending to bring about co-operation at the operating level, is one which has already been undertaken to a small extent, whereby public health nurses and welfare field workers are housed in the same office. More formal machinery will be desirable higher up in the administrative hierarchy. Various advisory and consulting committees to the different divisions of each department, such as those that already exist, will be useful, and on most of the health committees there should be representation from the welfare department, and vice versa. Finally, there is a very important place for a formally constituted interdepartmental committee or council, made up of the deputy ministers of health and of welfare, senior officials from each department, and perhaps a few representatives from other related agencies, such as the Health Insurance Commission, the Workmen's Compensation Board, the Department of Education, and the Department of Municipal Affairs. This council should meet frequently to study problems of co-ordination between the two departments and related agencies and to devise ways and means of achieving smooth working relationships, particularly through administrative arrangements within the control of the members. In addition, it would naturally advise the government, through the ministers of the departments represented, upon changes in legislation, regulations, and budgetary provisions that were desirable to improve the whole system of social services. Thus it would be both a planning and a co-ordinating, agency, and it should contribute much to policy formation as well as to administrative efficiency. In summary, the analysis of the preceding pages leads to the conclusion that the Department of the Provincial Secretary should 254 Public Health & Welfare Reorganization be abolished, with its present miscellaneous services being distributed among other departments; and that it should be succeeded by two new departments, one of health and one of welfare, the first of which would consist of the programmes under the Board of Health at present plus the mental hospitals, hospital inspection, and crippled children's services; while the latter would embrace the welfare services now under the Provincial Secretary (including the infirmaries and the inspection and licensing of welfare institutions) along with the provincial jails and adult probation and parole. An interdepartmental council is desirable as a central body to deal with problems of over-all planning and co-ordination. Suggestions follow regarding the internal organization of the new departments. The Department of Health The present organization of the Provincial Board of Health, as the reader will see by referring to Chart II on page 89, is reasonably clear and good. Around this structural nucleus it would not be difficult to build the new department. However, there are some deficiencies in the present structure and there would have to be new units, to include services transferred from the Provincial Secretary's Department and new programmes, so that considerable alteration in organization would be required. Chart V and the text that follows outline a simple reorganization plan. The plan is intended to be tentative and suggestive, to illustrate the characteristics of a well organized department, without pretending to be a perfect pattern. At various points changes in it might be made which would still leave a clean and workable scheme. The present operating divisions of tuberculosis control, venereal disease control, laboratories, vital statistics, and local health services might remain. In addition, there would be needed divisions of mental hygiene (embracing the mental institutions, clinics, and preventive services) and of hospital inspection. If medical care for the needy were not taken over by the health insurance system e-1 £ i*» HgZ Z «3 £> « 256 Public Health & Welfare Reorganization If I it would be logical to set up a large division of medical care to perform this function and to include hospital inspection. This would give seven major operating units, which ought to be enough. The present Division of Public Health Engineering, which is a very small unit, might be placed under Local Health Services; and here, too, might be placed the small new units needed to deal with problems of industrial hygiene* cancer control, and crippled children. Each of these programmes has a certain claim to division status, since it will be, partially at least, a specialized provincial operating service. But each must be closely integrated with the local health agencies and each will be small, so that it seems reasonable, both because of natural affinity and because it is desirable to keep down the number of main divisions, to group them with the other local health services. In addition, there should be several auxiliary services, which might be called branches. At least three appear to be needed, to be concerned respectively with accounting and business management, personnel and training, and public information (including health education). The new department will have the more important institutions now under the Provincial Secretary, the mental hospitals and tuberculosis institutions. There are difficult problems of management connected with these institutions, and the chief of the Accounting and Business Management Branch should be much concerned with these issues. His branch would plan and install uniform accounting systems in the institutions and elsewhere, would deal with problems of physical facilities and supplies for the whole department, would represent the department in dealings with the provincial purchasing commission, would approve vouchers and expense accounts, would take over from the present Collections Office responsibility for the collection of patients' accounts, would deal with the financial aspects of grants to the local agencies, and in general would relieve the senior officers of the department and the institutional business managers of much detail which now harasses them. The branch would also prepare the annual departmental Administrative Machinery and Personnel 257 budget. Only if direction of the function of business management is pulled to the top of the department in this way is the deputy minister likely to have success in getting uniformity of business practice in the various institutions and in controlling expenditures reasonably well. One of the leading administrative weaknesses of the Department of the Provincial Secretary has been the fact that each institution has been able to go its own way, pretty much, with respect to business management, because the deputy minister and even the division chiefs have had no special assistants to deal with these problems and to check carefully on the many points of detail that require attention. It is probable that many economies and improvements in business practice will be discovered if a central business office is established. There is also a place for a small Personnel and Training Branch. The department will be large enough to have substantial problems of recruiting, relations with the Civil Service Commission, personnel relations, and staff development. A personnel and training officer, with one or two assistants, should be able to do much to relieve the deputy minister and other senior officials of problems of this kind and to build up uniform personnel policies and practices throughout the department. The education of the general public in health would be the leading task of the Public Information Branch. Much work of this nature is now being done by the central office of the Board of Health and by the divisions, notably Tuberculosis Control and Venereal Disease Control. The function is sufficiently important to warrant a separate office. The new office might also assume a good deal of responsibility for the preparation and the distribution of annual and special reports. Research and statistics is another auxiliary service which should be represented in the department. However, there is no apparent need for a special office to undertake this work since it can be done by the Division of Vital Statistics. The present division has been a statistical workshop for a number of years, serving various 258 Public Health & Welfare Reorganization m branches of the Department of the Provincial Secretary, and this is a very good precedent for the future. No provision has been made for an assistant deputy minister. This may be necessary, but the help that the deputy will obtain from the various auxiliary service chiefs should make it possible for him to direct the affairs of the department without the aid of an assistant deputy. The reader will have noted that there has been no proposal to separate the institutions from the treatment and preventive services, ■ in the case of mental hygiene and tuberculosis control. This is a policy which has often been followed in the United States and which was seriously proposed in British Columbia in 1943 within the Department of the Provincial Secretary. Indeed, charts were issued giving the impression that reorganization along these lines was under way. Superficially, this approach has a certain appeal. For in some respects it seems logical to group all institutions together because of the common problems of institutional management which they face. But this is integration on the basis of "process" rather than of "purpose," and the former type of integration is generally less desirable than the latter for the formation of major operating units. In this instance it is open to serious objections. The main one is that the separation of the institutional and the community service aspects of a given programme, like tuberculosis control, leads too easily to poor co-ordination between the two. The institutional superintendents and managers tend to retreat into their own world and to lose contact with the community work. The "institutional mind" develops, and it is hard to persuade them to co-operate effectively with the preventive group. In consequence there is likely to develop frustration on both sides. The separation of the two branches of work means also that other advantages of unified direction are lost. The enormous progress in the tuberculosis field since the institutions and the preventive services were integrated in 1935, under common direction, suggests the danger of breaking them apart again. What has been lacking Administrative Machinery and Personnel 259 in British Columbia, to overcome the major problems of institutional management, has been the central office of business administration proposed above. It is desirable that the Minister of Health and his chief officials should have some advice and assistance from persons outside of their organization. The need for an interdepartmental planning and co-ordinating council has already been mentioned. In addition there might well be an advisory council which would offer advice to the minister on broad questions of policy and would act as a link with the community agencies and groups particularly interested in health questions and with the general public. For this council to have good status it should be formally authorized by statute; and members should be appointed by the government to serve for specified terms of years. Representation should be given to such groups as the medical profession, local health agencies, the hospitals, community chests and councils, the Union of British Columbia Municipalities, and labour, business, and agricultural organizations. In addition it would be well to include a few members of the legislature. By virtue of its composition the council would express to the minister a lay point of view regarding health problems. This is needed just as much as the expert advice of the permanent officials. There would be no need, in the new organization, for the Provincial Board of Health. Since this consists at present of the members of the provincial cabinet it is something of an anachronism. It might as well be abolished completely, with the Minister of Health being empowered to make health regulations, subject to approval by the cabinet, which is the essence of the present situation. The addition of the advisory council, however, would bring into the picture a group which could do something valuable which the original board of health was supposed to do—to watch over health conditions in the province from a nonpolitical point of view and to propose effective measures of health protection. Thus the council, in a sense, would take the place of the present board. .1 260 Public Health & Welfare Reorganization The Department of Welfare Chart VI on the next page outlines a possible structure for the new welfare department. As with the proposals regarding a health department, there is intended to be nothing final or definitive about this plan. There are various ways of solving problems of departmental organization and a structure differing considerably from the one that is suggested might prove to be quite satisfactory. As in the case of the health department, two advisory councils are suggested, the Interdepartmental Council on Health and Welfare and the Welfare Advisory Council. This latter council would be made up of persons representing various groups interested in welfare questions as well as the general public interest^ and should be given good status through legislative authorization and tenure appointments for the members. Public understanding and support of the welfare programme needs to be cultivated even more than in the case of health (for public recognition of the need for good health services is better developed), and the members of the council can do much to develop this backing if they themselves understand the programme and are convinced it is sound. Three auxiliary services are proposed, in the form of branches of accounting and business management, personnel and training, and research and statistics. The first of these would supervise the accounting for all operating divisions and would also supervise and audit the accounting of the local public welfare agencies. It would have a very important task to keep the records and to handle the financial aspects (subject to some arrangements for division of labour with the Department of Finance) of the welfare grants to the local authorities. It would also, like the similar branch in the health department, have some supervisory responsibilities regarding institutional management and would prepare the annual departmental budget. The duties of the Personnel and Training Branch are obvious from its title. Responsibility for the training pro- i i <£ m 5 H&q i £2 o *B i i Ph o 1 g | ^ 93 << IB Om 02 £ 1 % Qg £>§ <w 2<S H<5 O t» O 1 ^* «5S 1 o m mOcd ft < 262 Public Health & Welfare Reorganization gramme now under the Field Service of the Provincial Secretary's Department would naturally be transferred to it. The Research and Statistics Branch Would be concerned with the collection, organization, and interpretation of statistics from the operating divisions and from the local welfare agencies, and with various projects of administrative research. There would be an abundance of such jobs to do that would contribute notably to the service and the efficiency of the department. Administrative research on a modest scale is not a luxury but a necessity in a well- managed welfare department, even in a province no larger than British Columbia. In addition to the primary functions of research and statistics it would probably be appropriate (in order to avoid the multiplication of small auxiliary-service offices) to assign to this branch certain other related duties, such as public information, the preparation of annual and special reports (in collaboration with the various divisions), the preparation of forms, and the preparation of manual material for the guidance of personnel in all divisions. The branch would be a centre of information about the work of the whole department, and its chief should be able to assist materially the deputy minister and other senior officers in planning. It is proposed that there be two divisions for public assistance, to be termed respectively the Division of Categorical Aid and the Division of General Assistance. The names are awkward, and if something better could be suggested the writer would be pleased. However, they have the merit of indicating fairly clearly the functions of these divisions. The categorical aid division would have under it old age pensions, mothers' allowances, and the new system of disability allowances which was proposed in Chapter 5. These three programmes have problems of policy and administration sufficiently similar to warrant their being grouped together. If the administration of these schemes is progressively transferred to the local welfare departments, as has been proposed, the categorical aid division will require only a small staff of specialists, who will be concerned primarily with the preparation of rules and Administrative Machinery and Personnel 263 procedures and with the supervision, through the field staff, of the local agencies. The present insistence of the Dominion government upon an old age pensions board makes a separate old age pensions branch virtually necessary at present, but this factor may disappear as Dominion policies on social security are worked out. Under the Division of General Assistance (or the Social Assistance Branch, the present term, which has much to commend it) would come general relief, or social allowances, as it is now called, along with the infirmaries. It seems proper to differentiate this work from that of the categorical aid division because there is* need for considerable flexibility in the general assistance programme and because it may expand and contract in volume very greatly with changes in economic conditions. At present it is not large; but when demobilization comes at the end of the war it may have to be expanded considerably, to meet the needs of employable as well as unemployable persons, so that it will take on many of the responsibilities of the unemployment relief programme of the depression period. Should it be necessary to set up camps and hostels for single men, to organize self-help schemes for the unemployed, to develop subsistence farming, or to encourage local work projects, the planning and part of the administration would be undertaken by this division. It seems reasonable to place the infirmaries under it because of their close association with general assistance. Like the categorical aid unit, this division would be a staff agency to a considerable degree, for it would be concerned largely with planning and policy formation, the actual supervision of the administrative work of the local welfare departments being undertaken by the Division of Local Services. Its staff (apart from the employees of the infirmaries) would not be large; but it should be a staff of quality, whose members are qualified by training and experience to plan, organize, and direct a very good general assistance programme. Within the staff there should be a small group of experienced social workers who would make up a family welfare unit, 264 Public Health & Welfare Reorganization to plan for constructive welfare service and to provide a consulting service for the local agencies. The Division of Child Welfare would have essentially the same functions as those of the present unit. To the Division of Delinquency Control6 would go the provincial jails, the Borstal institution, the industrial schools, and the adult and juvenile probation and parole services. The juvenile institutions and probation and parole for juveniles might be placed under the child welfare division, as has been done frequently in the United States, for juvenile delinquency and child welfare problems are closely related. Social workers commonly favour this approach because they fear that constructive work in dealing with young delinquents is unlikely if the juvenile programme is associated with the frequently backward and repressive adult institutions. This is certainly a danger which must be considered. But if there is enlightened leadership for both branches of the field there seems to be no inherent reason why good work for juveniles cannot be done in an integrated delinquency programme, and there are certain administrative advantages in consolidation. The Division of Vocational Rehabilitation would take general charge of the rehabilitation work suggested in Chapter 5. Among other things, it would dispense grants to, and would supervise the work of, the Canadian National Institute for the Blind, if it were decided to continue delegating provincial responsibility for blind welfare work to this organization. It is possible that it might be desirable to transfer to this division the School for the Deaf and Blind, now operated by the Department of Education. This is a question which merits investigation. The Division of Local Services would absorb the present field service, and to it also might be assigned administration of the Welfare Institutions Licensing Act, distribution of grants to private agencies, and relations with private agencies generally. But its 6This name is far from satisfactory. A possible alternative, "Division of Corrections, " is probably even less desirable. Administrative Machinery and Personnel 265 most important task would be the administration of grants-in-aid to the local authorities and the supervision of their activities. The field service would remain as a distinct unit within the division, but it would change in form materially. As direct administration of public assistance is taken over progressively by the local welfare agencies, in the manner proposed in Chapter 6, the members of the field staff would have a great deal less to do in the way of direct service to clients. Their direct service would come to consist mainly of work for the child welfare, delinquency, and vocational rehabilitation divisions of the department and for the various divisions of the health department, in accordance with such arrangements for interdepartmental co-operation as might be made. As time went on much of this work might also be transferred to the local welfare agencies. But there would grow in importance a new function, that of supervising the local agencies. For this work very competent and experienced staff members would be required. The present system of regional offices might be retained, with the supervisor of each performing a dual function, overseeing the work of his staff members in their direct service to clients and acting as provincial supervisor of the local departments within his district. Through the field service and the regional supervisors there would be channelled both to the provincial field staff and to the local welfare agencies the plans and procedures worked out by the various divisions and branches of the department; and back from the field, through the same channels, would come essential information on operations and requests for instructions and assistance. Thus the field service would continue to play a part of the greatest significance in the whole welfare programme. It would be, literally, the connecting link between the provincial and the local phases of the progranilne, it would do much to hold together the various divisions of the welfare department, and it would also, insofar as it performed service for the health department, be an invaluable co-ordinating agent for health and welfare. The importance of Public Health & Welfare Reorganization making generous provision for the field service, in staff and in budget, cannot be overstressed. As a result of the reorganization of 1942 the Department of the Provincial Secretary now has both a deputy minister and an assistant deputy—and there is good reason for this arrangement under present circumstances. But whether this would be necessary under the plan outlined here is questionable. With responsible officers in charge of each of the six divisions of the department, with competent persons also heading the three auxiliary services, and with detailed administration pulled away from the central office, it will probably be quite possible for a deputy minister to give active and effective direction to the work of the whole department without having an assistant deputy. It might be better for him to obtain the help, should any be necessary, of one or two administrative assistants attached to his office. There is a further question about the jurisdiction of the welfare department which deserves examination. This is the problem of where to place the provincial recreation programme which was discussed in Chapter 5. At present the Pro-Rec scheme is under the Department of Education, and there are various arguments for its remaining there. But on the other hand a broadened recreational programme would have much relation to the various welfare services. Its personnel should be drawn largely from the ranks of social workers who.have had special training in recreation and group work. They would talk the same language as the social workers in the welfare department and would work well with them. It is possible that the welfare department would develop the recreational programme with more enthusiasm and imagination than the educational department, which has difficult problems of classroom instruction on its hands and which has long-standing traditions which might stand somewhat in the way of pioneering in new fields. For these and other reasons there is a case for grouping recreation with welfare. If careful study of the situation were to lead to this Administrative Machinery and Personnel 267 conclusion it would be simple to add a recreational division to the welfare department. Health Insurance Machinery Health insurance promises to be so big and so distinctive an undertaking as to warrant separate organization. Fears that it may be mismanaged are widespread, particularly on the part of the medical profession, and this is reason enough, in itself, to support the idea of its being operated outside of regular departmental channels, by an independent commission, as has been proposed by tKe~ Heagert^^onunxtteeat Ottawa. The present form of the British Columbia Health Insurance Commission has many advantages, for unity of command is pretty well guaranteed by the fact that the chairman is designated as chief executive officer, while questions of policy must be decided by majority vote of the commission as a whole. But it is anomalous that the vice-chairman should be a full-time, paid member of the commission, and therefore the second executive. It would be better if the chief, subject to the approval of the commission, could pick his own second-in-command, rather than to have him appointed by the government, as the present scheme provides. Probably it would also be better if the commission consisted of a few responsible persons, serving only on a part-time basis, with power to appoint the chief executive. In this case the commission's functions should be to exercise control only over matters of major policy, with all administrative authority specifically delegated to the executive. He would then have major responsibility for working out a satisfactory internal organization. Local Organization The problem of local organization is relatively simple. In each administrative district there would be separate departments of health and of welfare, and these would be small agencies, except in the case of the Vancouver area. A simple pattern of organization 268 Public Health & Welfare Reorganization for the local welfare office is for it to have two divisions, one for social service and one for business and office management; and it is common for the health department to have three small divisions, one for public health nursing, one for sanitary inspection, and one for office and business management. Special staff or auxiliary services would not be necessary, although in departments as large as those of the Vancouver area it might be appropriate for the respective directors of health and welfare to have administrative assistants who would do a variety of specialized jobs for them. In order to bring the health and welfare programmes as close to the people as possible and to obtain lay advice and co-operation, it would be desirable to set up advisory committees to each local agency. These would be similarln composition and in function to the advisory councils suggested for the provincial departments. It would be well lor them to include representation from the municipal councils and perhaps the school boards, so that elected officials were brought into close touch with both expert and lay reactions to health and welfare administration. Since their functions would be purely advisory they would have no power to interfere with the control of the municipal councils over the health and welfare agencies. But they should be able to exercise considerable influence over the councils, both to interest them in active support of their health and welfare programmes and to prevent them from adopting the negative and destructive attitudes towards the social services which have been such a handicap to their development in British Columbia. The idea of the interdepartmental co-ordinating committee is also one that might be applied at the local level. In practice the health and welfare agencies would work very closely together and probably no formal co-ordinating committee would be needed in most districts, where the members of the two staffs would see each other daily. But in the Vancouver and Victoria areas it might be desirable to set up some formal machinery to stimulate coordination. Administrative Machinery and Personnel 269 Personnel Policy The problem of personnel is a major issue. More than anything else, perhaps, it is the chief concern of the senior officials who have led the campaign for better health and welfare services in British Columbia during recent years. There has been much success in building up good personnel since 1933. But the battle was only half won up to the outbreak of the war. The war has drained away .many good officials, temporarily at least, new and broadened responsibilities that are in prospect call for more and better trained staff, and the personnel problem promises to be acute in the post-war period. The problem has two aspects, quantitative and qualitative. We have seen already that staffs have been generally too small to provide adequate service and that they must be greatly increased. Present efforts to do so are largely frustrated because of war- induced shortage of personnel of all kinds. With victory and demobilization of the military forces and the war economy the situation will change, and there will be no lack of applicants for health and welfare positions. Thus the quantitative aspect of the problem can be solved; but the qualitative aspect will remain unless vigorous steps are taken to deal with it. The quality of the present staff is not as high as it should be (in spite of great improvement in recent years) for several reasons. In the first place, there are many present employees who have not had proper technical training for the positions which they hold, and who have not learned enough through experience to compensate for this lack of basic training. This is specially true of those in the welfare group, including the former unemployment relief officials, the social workers with only one year of graduate work at the provincial university, and the staffs of the correctional institutions for adults and juveniles. Most of the unemployment relief officers are not sufficiently equipped in the modern techniques of social work, notably social case work; many of the girl social workers are 270 Public Health & Welfare Reorganization deficient in capacity for administration and community organization; and the institutional staff members, in most cases, have had no special preparation at all for their work. The situation is particularly difficult with respect to the key personnel—the supervisors, executives, technical consultants, and general administrators. There is not yet in sight, among the lower grades, enough executive and supervisory material for the higher positions as they fall vacant. This, in the opinion of thoughtful executives in the Department of the Provincial Secretary, is the rock upon which the recently broadened welfare programme may founder; and there are similar, if less acute difficulties, in the health field. Thus the problem of key personnel is of paramount importance to the development of the greatly enlarged social security measures proposed in this book. The second element in the problem of staff quality is simply that there has been a chronic shortage of qualified personnel for most technical positions. It has been difficult to find, in British Columbia, enough public health physicians, sanitary officers, psychiatrists, specialized social workers (e.g. child welfare, psychiatric, and medical), institutional workers, and welfare administrators for the posts that have been available. There has been a more adequate (a.nd at times a quite good) supply of public health and general duty nurses. In the welfare field trained men, who are particularly needed to develop into administrative officers, have been few. The war has only accentuated a shortage situation which has been chronic for years. This shortage problem has two major roots, inadequate provisions for training and lack of sufficient inducements for good young people to enter the public health and welfare services. There has been no medical school and no training for health officers, psychiatrists, or sanitary engineers in British Columbia, and therefore no supply of local graduates to draw upon. The social work course at the university has been weak and has provided only elementary training. This lack of technical education at home, coupled with a general policy of appointing only British Columbia residents to Administrative Machinery and Personnel 271 the public service, has made it virtually impossible to obtain properly qualified personnel for many positions. If the attractions of public service had been greater it is probable that more British Columbians would have taken specialized training in the East or in the United States, to return to their home province. But there has been no general personnel policy on the part of the provincial government designed to attract good personnel. The government has taken the attitude, by and large, that it was a privilege for anyone to have a public job, and that since there were (until the war) far more applicants than vacant positions there was no need to worry about recruiting the best possible candidates. The progressive personnel steps which have been taken have come from the efforts of individual ministers and officials, rather than from the application of any over-all policy. There has been a formal civil service system since 1916, supposedly operated under an independent commission to guarantee impartial administration. But for the last ten years the act has been administered by the Superannuation Commissioner, who has had no real freedom of action, and an amendment of 1929, intended originally to validate some irregular appointments, has had the effect of breaking down almost entirely any protection against political control of the civil service which the act provided. In consequence, appointments, promotions, salary adjustments, and other personnel matters have been settled very largely by the ministers. In short, it has been a patronage system, with friends of the government being appointed to a good many posts. However, this has not been entirely, or even largely, evil. Individual ministers, like the two provincial secretaries of the last ten years, have supported the appointment of qualified staff to technical positions, and many good persons have been brought into the civil service—including some who, although they were essentially political appointees, settled down to become useful civil servants. But however benevolent and considerate this personnel system has been, it has lacked the positive characteristics necessary to 272 Public Health & Welfare Reorganization a liftr recruit the best possible staff. For various groups salaries have been much too low. At present (after some upward adjustments during the war period) about one-third of the positions of the provincial Field Service offer a salary of only $1,200 per annum (with a small wartime cost-of-living bonus) and nearly all of the remainder pay less than $1,800, while the supervisor and the regional office supervisors of this important unit are listed as in receipt of salaries ranging from $2,100 to $2,400. Since college graduation plus a year of graduate training in social work is the desired minimum qualification for junior staff members, it is clear that the reward held out to those who offer this equipment is very slight. The earnings of social workers in both the provincial and local departments have been well below the salaries of groups comparable in educational qualifications, public health nurses and high school teachers—neither of which have been over-paid. The salaries of physicians have also been relatively low—from about $2,400 to $3,600 per annum for most of them in the Provincial Secretary's Department during the 1930's. Since earnings for competent doctors in private practice were generally much larger, it was difficult to attract good young men to the provincial service or to hold them when they were engaged. On the other hand, some relatively good salaries are paid, and there have been various anomalies which have stood in the way of good morale. According to the provincial Estimates for 1944-1945, the Deputy Provincial Secretary is listed at $5,000, while the Provincial Health Officer, technically subordinate to him, receives $5,100 and the Director of Tuberculosis Control, below both the former officials, is paid $5,600 for part-time service. In the case of the mental hospitals there are two officials, the General Superintendent, at $5,720, and the Medical Superintendent of the Ems- dale Hospital, at $5,600, who receive more than their nominal chief, the Deputy Provincial Secretary. These anomalies reflect the fact that market situations^ have made it necessary to pay more to medical men in key positions than to general administrators. Administrative Machinery and Personnel 273 There are various other anomalies in the salary structure of the department, the product of special arrangements and decisions to meet individual cases. The net result is a situation in which some salaries are too low, while others are generous or perhaps too high. Promotions and salary advances, in the past, have been arranged sporadically, according to no fixed rules. These and other characteristics of a casual and undeveloped personnel programme have not represented adequate inducement for competent young people to plan for careers in the public health and welfare services. A Personnel Policy The preceding analysis of the personnel problem points towards three steps that are necessary to solve it—development of attractions for career service, active support of training bqth for employees and potential employees, and gradual displacement of unqualified staff. The first step would be difficult without a broad measure of civil service reform. For whatever was done by the departments of health and welfare might be compromised by the insecurities, uncertainties, inconsistencies, and anomalies inherent in a civil service system always subject to ministerial control on matters of detail as well as of general policy. The civil service act should be amended so as to transfer effective control over appointments to an independent commission. Only if this is done (and only if this step is followed by constant vigilance) will a reasonably stable system of appointment for merit replace the easy-going patronage of recent years. A vigorous and competent commission will find it necessay to define and classify all positions in government service, to fix salaries and other terms of employment commensurate with the importance of each position, to set up rules regarding regular salary increases and promotions, to examine applicants for appointment, to recruit vigorously in order to seek out well- qualified persons, and generally to develop an orderly and constructive set of personnel policies. These basic measures, affecting the 274 Public Health & Welfare Reorganization whole civil service, should go far towards making the health and welfare services more attractive than in the past. Salary readjustments, to mention only one point, will probably be desirable (in terms of present and prospective salary scales for work of comparable importance in British Columbia) to bring the earnings of the deputy ministers of health and welfare well above the $6,000 mark, to set the entering salaries of social workers and public health nurses at about $1,800, to increase the scales of physicians materially, and to adjust upwards a good deal the salaries of the welfare supervisory personnel. The government has recognized tl^e need for general overhaul of the civil service system. The coincidence of a coalition government of Liberals and Conservatives and of a war situation in which there are few job-seekers troubling the politicians has been favourable to reform. In 1942 an interdepartmental committee was appointed to make a reclassification study and to prepare proposals for reorganization of the whole system, and the Provincial Secretary has announced that the government plans action to implement the recommendations arising out of the committee's work.7 Vigorous action on training is the second essential to solve the personnel problem. In-service training, such as is now being conducted for welfare workers and public health nurses, is much to be commended. The mental hospitals have a good record of training nurses for psychiatric work through their nursing school. These various activities should be continued, under the general direction of the personnel branches of the health and welfare departments, and a continuous programme of training for additional groups of employees should be developed. In addition the departments, in collaboration with a reorganized civil service commission, should foster the development of stronger training programmes at the provincial university. The assistance recently given to the social service curriculum through the Depart- 1 Vancouver Sun, Feb. 7, 1944, Administrative Machinery and Personnel 275 ment of the Provincial Secretary is both a good precedent and a good omen for the future. A much stronger programme of social work education at the university is now emerging, which promises for the first time to provide advanced training. There appears to be a strong case for a school of medicine at the university; and it may be that training for public health officers and sanitary officers should be added to the existing programme in public health nursing. But it will be too much to expect advanced training for all the health and welfare professions to be offered within British Columbia. Therefore provision should be made to assist staff members and prospective staff members to visit eastern Canada or the United States for advanced work. This has already been done, to a considerable extent, by means of Rockefeller fellowships for health officers, provincial bursaries for welfare workers, and leaves of absence on full or part pay for doctors in the mental hospitals. These are good precedents for even more generous provisions. It is particularly important that promising younger persons be encouraged and assisted to undertake advanced training, so that the vital problem of key personnel may be solved; and that persons now in the key positions, whose training is inadequate for their responsibilities, be released for study and observation outside of British Columbia. The third essential step in personnel policy is the weeding out of the unfit. With the way open for training to all, either on the job or on leave of absence, the competent employees should be able to build up their qualifications sufficiently to warrant continued tenure and advancement. But some will not have the native ability or adaptability to rise to the new opportunities, and they are likely to interfere seriously with the constructive work of the new departments if they are allowed to retain their positions until retiring age. They should gradually be removed from positions for which they do not qualify; but this should be done most carefully and considerately, in recognition of the service that they have given in good faith and of their legitimate claims for economic security. £276 Public Health & Welfare Reorganization Some can be transferred to other positions in government service for which they are fitted; others, who are close to retiring age, may be given special pensions to tide them over until they become eligible for superannuation grants; still others may be able to make arrangements for alternative empl@yment if they are given ample time to do so; and for a small remaining group the device of the "dismissal wage" might be employed. Such persons might be offered a year's pay or more, spread over a period of two or three years, to assist them in making the transition to different work. The number to be dealt with in this way should be very small; and the costs involved should yield large dividends in the way of better administration, staff morale, and favourable public opinion. These policies should apply to local as well as provincial personnel. There is not much chance of the local health and welfare departments, through their municipal councils, working out adequate personnel policies by themselves, for all of them except the Vancouver agencies will be too small to have specialized personnel officers, and there is scarcely to be expected, on the local level, the degree of knowledge and foresight which is necessary. Therefore the provincial government, through its civil service commission and the personnel branches of the two departments, should both set standards for local personnel and should extend to local employees the same, or similar, opportunities for training as it does to its own staff members. In this connection, it is interesting to note that serious proposals have been made at recent sessions of the Union of British Columbia municipalities for the development of a formal municipal civil service system. The Significance of Organization and Administration The main proposals of Chapters 5 and 6 may be summarized as follows: 1. Operating functions should be redistributed between the provincial government and the local authorities, with the province taking over complete responsibility for juvenile courts, probation. Administrative Machinery and Personnel 277 service, and medical care for the needy; while the administration of old age and blind pensions, mothers' allowances, and of any new categorical aids should be progressively delegated to the local welfare units, under provincial supervision, so as to unify public assistance administration at the local level. 2. Local administration of health and welfare services should be undertaken only by the larger municipalities or by new operating units, to be formed by grouping small municipalities together along with contiguous unorganized territory, preferably in such manner as to make them appropriate for health, welfare, and educational administration; and when these conditions are not met there should be direct provincial administration. ^ 3. The existing system of grants to and charges upon the municipalities should be changed drastically. Municipal charges for hospital patients and inmates of provincial jails should be discontinued. The present grants should be replaced by two, a percentage grant for health and an equalization grant for welfare. A possible formula for this latter grant, which would aim to protect every municipality against unreasonable welfare charges, would be for the province to assume 95 per cent, of all welfare costs in excess of an amount equal to the yield of 4 or 5 mills on local taxable valuation and to contribute a large percentage of administrative expenses. 4. The province should set standards of administration to be observed by the local authorities, including the employment of qualified personnel, and should supervise carefully and sympathetically local operations. 5. The present Department of the Provincial Secretary should be superseded by two new provincial departments, one of health and one of welfare. 6. While there are good arguments for placing the mental hospitals and hospital inspection with either of the proposed departments, the case for grouping them with the present public health services to make up the new department of health appears to be the stronger. 7. The new welfare department should cover public assistance, child welfare, vocational rehabilitation, and delinquency control (including the jails and adult probation and parole, to be transferred from the Attorney-General's Department). 8. Each of the new departments, besides its major operating divisions, should have auxiliary service branches to deal centrally 278 Public Health & Welfare Reorganization with such activities as accounting and business administration, research and statistics, and personnel and training. 9. Arrangements for co-ordinating the work of the two departments may be made by joint use of a field service (to be formally under the welfare department), by setting up an interdepartmental council to advise on common problems, and by interdepartmental representation on various other advisory committees. 10. Each department should have an advisory council of citizens, authorized by statute, to bring a lay point of view to the attention of the ministers and their officials. 11. A separate health insurance agency is desirable.. 12. Separate health and welfare departments, simple in structure, should be set up in each local operating district, and each department should have a lay advisory committee. ' 13. A positive personnel policy designed to attract competent technical employees. to the public health and welfare services, provincial and local, and to hold them, should be developed by the provincial governrnent. This calls for an orderly, non-political civil service system, under an independent commission; for in- service training, the development of better training facilities at the provincial university, and assistance to staff members and potential staff members (particularly personnel for key positions) to obtain professional training in British Columbia or outside the province; and for the gradual weeding out of unqualified persons now in the provincial and local services. This is a formidable list of desirable changes in the structure and the administration of the health and welfare services. To the reader it may appear to represent counsel of perfection, impossible of realization within the political environment of British Columbia. The barriers in the way of action, because of lack of recognition of the importance of the administrative factor by the political authorities, provincial and local, and by the general public, are very real. But this, surely, is no reason for failing to propose policies which the principles of good public management and the experience of other jurisdictions on this continent and in other countries dictate. Most of these changes in organization and administration can and should be made promptly. In many respects they are essential to improvements in the content of the provincial social services. Administrative Machinery and Personnel 279 Better organization and administration promises economies which may be quite considerable, thereby freeing funds for more and better service to beneficiaries. Preceding chapters have shown how poor administration has affected service adversely in the past, Although the situation is now very much better than it was ten years ago it can be still further improved. This is essential if British Columbia is to be given a high rating in health and welfare, not only by comparison with the past and with other provinces, but also in terms of good standards derived from experience elsewhere. The provincial government can make no better contribution to the building of the national system of social security than to clean up relations with the municipalities, to reorganize its departments, to build up personnel, and generally to set its health and welfare house in order, so that it will have the administrative machinery to assume the broader obligations of social security. It is unfortunate that this was not recognized by the provincial Postwar Rehabilitation Council, appointed in 1942, whose two extensive reports have dealt chiefly with questions of veterans' rehabilitation and industrial development. But these are questions upon which the main decisions must be made by the Dominion. The council dealt scarcely at all with problems of the social services, over which British Columbia does have jurisdiction. The administrative proposals have implications that go beyond j the health and welfare services. They involve drastic revisions in local government, and they point the way to its total reorganization. They also call for important modifications to the organizational structure of the provincial government and suggest the, need for complete overhaul of the present departmental system. If these larger problems of public administration were tackled seriously, solution of the health and welfare segments would be much easier. The larger the scope of reorganization the better the results are likely to be for the health and welfare system, as well as for the general government of the province. Piecemeal attacks on the problem, such as some that have been undertaken in the past, are too likely to run up against obstacles that defeat good results. r- PART III East of the Rockies The Prairie Provinces JLHE PREDOMINANTLY RURAL AND agricultural characteristics of the Prairie Provinces must be borne in mind in any discussion of their health and welfare services. Saskatchewan, with 895,992 people according to the 1941 Dominion census, is the most populous, while Alberta, with 796,169, and Manitoba, with 729,744, are nearly the same in population. In 1941, 67 per cent, of the population of Saskatchewan was classified as rural in the census reports, while 61.5 per cent, of those in Alberta and 56 per cent, of those in Manitoba lived in rural areas. There are no large cities except Winnipeg, Manitoba, with a population of 221,960 in 1941. Saskatchewan has only two fair- sized cities, Regina and Saskatoon, the former with a population of 58,245 in 1941 and the latter with 43,027; while the same is true ' in Alberta, where in 1941 Edmonton and Calgary each had populations of about 90,000. The three provinces were hit very hard by economic depression and crop failures in the 1930's, standards of living were seriously curtailed, and governmental agencies were 283 284 Public Health & Welfare Reorganization ii I U forced to make rigid economies. As the health and welfare scene is surveyed in 1943 the effects of inadequate appropriations during the lean years of depression are still very evident. In general the same array of health and welfare services is to be found in the Prairie Provinces as in British Columbia, and patterns of provincial-municipal distribution of functions and responsibilities are also quite similar. But there are some significant differences in organization at the provincial level, notably because of the existence in all three provinces of well-developed departments of health and the poor integration of the welfare services. There are similar difficulties arising from the variable incidence of health and welfare charges upon the municipal authorities, while the problem of the small local administrative unit is much more serious on account of the wide dispersion of population in tiny rural municipalities over great areas. The services and the outstanding problems in each of the three provinces will be sketched briefly in the following pages. ALBERTA In Alberta an extensive system of provincial health services comes under the Department of Public Health, established in 1919, which up to the beginning of 1944 also operated part of the welfare programme. The department has general charge of the administration of the Public Health Act, which includes supervision of the health work of the local authorities. Grants amounting to 50 per cent, of total costs are made to certain rural health units. There are within the department the usual central services of vital statistics, laboratories, and sanitary engineering. It operates and finances a tuberculosis control programme, which offers free diagnosis and treatment at tuberculosis clinics and the Central Alberta Sanatorium. There is also a venereal disease control programme with several free treatment clinics. The mental hygiene services include two major mental institutions, a training The Prairie Provinces 285 school for mental defectives, two auxiliary hospitals, and psychiatric clinics. The department is also concerned with hospitalization of the sick through administering provincial grants to general hospitals (at a basic rate of 45 cents per patient day) and through its administration of the Municipal Hospital Act, which authorizes the establishment and the operation of hospitals by municipalities or groups of municipalities. In addition orthopedic patients admitted to two hospitals are subsidized at the rate of 90 cents per patient day. Direct service to the rural districts, both organized and unorganized, for people who are inadequately served by local agencies is provided by the Public Health Nursing Division of the department, which carries on both preventive and bedside nursing, including midwifery. Associated with this programme is a travelling medical clinic which reaches into rural communities to diagnose and to treat various disabilities at charges adjusted to the means of patients. The department also administers a programme for the victims of poliomyelitis, which includes provisions for hospitalization, free treatment after discharge, and rehabilitation. In 1940 the Cancer Treatment and Prevention Act authorized a provincially, operated cancer scheme, which offers free diagnosis and free X-ray and radium treatment when necessary, as well as free surgical treatment on the recommendation of the diagnostic clinics. A health insurance act passed in 1935 is on the statute books but has never been put into operation. In March, 1944, The Maternity Hospitalization Act was passed to provide for the free hospitalization of maternity patients and their infants, and the administration of this progressive new scheme was assigned to the health department. Up to the spring of 1944 Alberta had a highly centralized child welfare system, operated by the provincial Superintendent of Child Welfare under the Department of Public Health. Although children's aid societies were authorized by law none were in operation, and orphans and neglected children were committed by the 286 Public Health & Welfare Reorganization courts to the superintendent, who operated a province-wide service of placing them in foster-homes, usually on farms. The superintendent also administered the adoption provisions and other items in the child welfare code. Criticism of the system led to a provincial child welfare inquiry in 1943, and this was followed by a new child welfare act in the spring of 1944 which provides for significant changes in the system. The new act brings together provisions regarding neglected and dependent children, juvenile courts, immigrant children, adoptions, the children of unmarried parents, and child welfare organizations. The role assigned to these latter agencies is much less important than that granted to children's aid societies in British Columbia and other provinces, and the courts are instructed to commit children, in case committal seems necessary, to the provincial superintendent. - The most striking changes in the system are those that throw more specific obligations upon the municipalities, notably by requiring each city and town with more than 3,000 people to appoint a child welfare worker and all cities and towns to appoint probation officers. From the mid-depression years until the early part of 1944 provincial relief administration had been under the Bureau of Relief and Public Welfare which, although it was listed in official documents as a branch of the Department of Public Health, operated as a separate agency. The bureau was absorbed in 1944 into the newly created Department of Public Welfare, to which the child welfare services were also assigned. The remnants of the unemployment relief programme of the depression period make up the greater part of the work of the new department. Grants are made to the municipalities amounting to 80 per cent, of their costs of aiding destitute employable residents, but these are naturally very small at present. No grants are made in respect of unemployable persons. The department is also in charge of all relief for the residents of unorganized territory (both employables and unemployables), and of relief and medical care for homeless men and The Prairie Provinces 287 other municipal transients or non-residents. However, the Department of Agriculture has had jurisdiction over land settlement for relief recipients and some other farm relief activities. Two other departments are concerned with the operation of the remaining provincial welfare programmes. The Treasury Department is in charge of the administration of old age and blind pensions and of mothers' allowances. The two provincial jails are operated by the Department of Public Works. There are no provincial training schools for juvenile delinquents, boys or girls. Local Responsibilities Generalized public health service, apart from the specialized and overhead functions performed by the provincial government, is the responsibility of the municipalities. With the assistance of provincial grants they administer and finance unemployment relief for their residents. They are wholly responsible, administratively • and financially, for relief to unemployables and for medical care for both employables and unemployables in receipt of municipal aid. In addition they are required to meet the public ward charges of indigent residents in general hospitals and to pay maintenance charges in respect of children committed by the courts to the care of the provincial Superintendent of Child Welfare. They also pay 25 per cent, of the cost of mothers' allowances and 10 per cent, of the cost of old age pensions granted through provincial machinery to their residents. Their administrative work, in connection with these two forms of public assistance, is limited to taking applications and forwarding them, with recommendations, to the provincial authorities. Appraisal of the System Domination of the organizational picture by the Department of Public Health suggests both the strengths and the weaknesses of the Alberta system. Both provincially and locally the health 288 Public Health & Welfare Reorganization services are much better developed than the welfare services and it i appears that real progress has been made in various sections of the health field. In the provision of free tuberculosis treatment, in venereal disease control, in the development of health units, in cancer control, in the formation of municipal hospitals, and now in its new scheme of maternity hospitalization Alberta's record is good. The formation of the Department of Public Welfare is an important forward step and the concern of the department for the rehabilitation of needy farm settlers is also to be commended. But with due credit for the good work being done at various points it appears that there are numerous problems of inadequate service and of poor administrative machinery in Alberta, particularly in the welfare field. The major problems are outlined below. 1. Inadequate Service There are various gaps and inadequacies in service. The annual reports of the Department of Public Health are quite frank on the weaknesses of both preventive and curative medical work in the rural districts. In the 1940 report it was pointed out that "the death rate for infants under one year of age in rural districts is 55 per cent, higher than the infant death rate in the cities"1 and that this is closely related to insufficient preventive health services in many rural communities. Other sections of the report pointed to the lack of sufficient personnel for venereal disease control, the need for a programme of rehabilitation of tuberculosis patients, serious overcrowding in the mental hospitals, the need for additional psychiatric clinic service, and other problems. Dr. M. R. Bow, the Deputy Minister of Public Health, stated at the conclusion of his report that "the need for the expansion of preventive health services, particularly in our rural and small urban centres, is great and no expenditure will pay larger dividends in ensuring the mental ip. 16. The Prairie Pro 289 and physical fitness of our people."2 Improvements made since these statements were made have not been sufficient to change the situation materially. The lack of training schools for delinquent boys and girls has led to some difficult problems. It has been necessary to detain some unstable juveniles in the mental institutions, while in some cases the courts have had no alternative but to commit young people to the provincial jails. At the other end of the scale, some difficult children who should be in institutions are kept in foster- homes. Organized probation service is very slight and is scarcely specialized at all, usually being provided by police officers. In the absence of children's aid societies child protective work has been very poorly developed. Since curative medical care is mainly the responsibility of the municipalities they provide only a limited poor relief service or nothing at all. Relief standards have varied considerably from Edmonton and Calgary to the smaller municipalities, the disposition of the smaller places having been generally to grant very limited assistance. 2. Distribution of Administrative and Financial Obligations The distribution of operating functions and financial responsibilities between the provincial government and the municipalities is open to much question. The sheer weakness of local administration in many places seems to have led the provincial government to undertake operating functions that would be unnecessary if local finances and local administrative machinery were strong. For example, the provincial public health nursing service and travelling medical clinic provide direct service in some rural areas. In some respects the administration of unemployment relief has been very highly centralized, with decisions on individual municipal cases being made at Edmonton. The degree of supervision of relief 2P. U. 290 Public Health & Welfare Reorganization administration outside the cities has amounted almost to provincial administration. The lack of children's aid societies or other local agencies has been accompanied by a highly centralized administration of child welfare services. On the other hand the municipalities are left to look after the relief of unemployables and general medical care entirely without provincial aid or supervision and they are required to contribute to the costs of old age pensions and mothers' allowances on a percentage basis. The burden upon them financially has not been evenly distributed, so that during the late depression the province was forced to assume total responsibility for the welfare obligations of some municipalities. The distribution of functions has not been sufficiently clear-cut to avoid the chronic problems of overlapping, "passing the buck" on cases, and denial of service to people who fall between stools. Thus in Edmonton the Civic Relief Department (dealing with unemployables) has made provision for the medical care of "municipal cases," while the provincial Bureau of Relief and Public Welfare did the same for transients who were "provincial cases." Both agencies operated small farm camps near the city for indigent persons. During the years of depression and up to August, 1942, there was a third public agency (the Edmonton Special Relief Department) which gave material aid to employable persons who were Edmonton residents. Thus there were three public relief agencies operating in Edmonton during recent years. Inevitably there were difficulties involved in sorting out the responsibilities of each agency and there were differences in policies which led to much dissatisfaction and criticism. 3. Local Administrative Units The great majority of the municipalities of Alberta have been quite unsuitable, because of their small population, to be satis- The Prairie Provinces 291 factory local units of administration. In 1941 there were 7 cities, 53 towns, 145 villages, and 143 municipal districts with general powers of local self-government. But out of this total of 348 municipal units only the four cities of Calgary (88,904), Edmonton (93,817), Lethbridge (14,612), and Medicine Hat (10,571) exceeded 10,000 in population in 1941 and only two of the remaining municipalities had more than 5,000 people.3 The great bulk of the .municipal units, typically the towns and rural .municipalities, have fewer than 3,000 people, while the villages are commonly inhabited by only three or four hundred. In these small places relief, probation service, child welfare, and the taking of old age pensions and mothers' allowances applications must usually be handled by the secretary-treasurer of the municipality, while the general practitioner of the district spends a little of his time as a part-time medical health officer. In the fields of health and education there has been recognition of the unsuitability of these small units. The provincial Department of Public Health has carried on a campaign of education to show the advantage of health units embracing a number of municipalities, and there are now nine of these rural units in operation, each with full-time doctors and nurses. The departmental programme looks forward to the establishment of others, as funds become available, until the whole province is covered. Alberta has undertaken with marked success a bold programme to abolish the small rural school districts, about four miles square, which were inherited from the territorial regime preceding the formation of the province in 1905 and of which there were 3,325 in existence in 1935. Prior to 1935 an attempt had been made to meet the financial problems of the poorer districts by means of equalization grants from the province. But this policy was not sufficient, and in 1934 the legislature appointed a committee to survey problems of rural education. In its report the committee 3Dominion Bureau of Statistics, Eighth Census of Canada, 1941, Bulletin No. Al. 292 Public Health & Welfare Reorganization at pointed to the need for larger school units and this paved the way for legislation in 1935 and 1936 empowering the Minister of Education to consolidate rural school districts into larger areas where it appeared desirable to do so. Backed by these new powers the Department of Education vigorously pushed a programme of consolidation. As a result of this work all the rural school districts but a scattered few were united in forty-nine new school divisions by the end of 1942.4 In a pamphlet5 issued by the department the advantages of consolidation are set forth in some detail. It is claimed that taxation for school purposes within each division has been substantially equalized, whereas formerly school taxes varied greatly from one district to another. There have been improvements in service, incidental to better provision for high school instruction, better libraries, greater use of school facilities, extension of the school year in some districts, and increased supervision. The position of teachers has been improved, because they can be placed more effectively, because their salaries have been paid more promptly and more regularly, and because occasions for friction between them and the school boards have been reduced. Financially, it is claimed, the new policy has been advantageous because the divisional school boards, made up of members of better calibre than those who usually served the small school districts, have been warranted in employing full-time secretaries and superintendents and have provided more business-like administration. In spite of the improvements in quality of service average costs per pupil for each day of attendance were only 28.3 cents in the divisional schools during the year 1939-1940, as compared with 31.8 cents in the rural schools outside the divisions.6 In summary, according to the Department of Education, "the 4Department of Education, Annual Report, 1942, p. 59. 5After Three Years (1940). *Ibid., p. 28. The Prairie Provinces 293 Divisional System . . . has decided advantages over the system of local control. . . . The Divisional System has increased very greatly the opportunities of rural children. At the same time it has succeeded in giving the people of the province a larger return on their educational dollar. "7 The need for larger units for the general purposes of local government has also been recognized in Alberta. For some years •the provincial Department of Municipal Affairs has been urging the amalgamation of rural municipalities. In a pamphlet issued by the department in 19418 it is argued that larger municipal units would permit more efficient operation of local services, would equalize rates of taxation over broad areas, would lead to improvement in the calibre of municipal officials, and would actually reduce costs of administration. Estimates of operating costs for two hypothetical larger units, as compared with the actual costs of the existing municipalities in 1940, show that in the case of the first, with actual expenditures of $11,424, there would be savings of $2,434; and in the case of the second, with actual expenditures of $11,084, the savings would be $1,524. Under existing provisions of legislation the Minister of Municipal Affairs has power to order amalgamations. With these powers at hand the Department succeeded, in 1942, in bringing about the establishment of five new rural municipalities of from 5,000 to 10,000 in population, each made up of three or more former municipal districts. By the end of 1943 the total number of the larger units had increased to 40, replacing 150 of the older rural municipalities. Thus the movement of reorganization is proceeding rapidly. Excellent as this development is, it still does not provide local units large enough in population for good administration in the fields of health, welfare, and education. In spite of these progressive moves on the part of the health, Ubid., p. 32. 8Local Rural Self-Government in the Province of Alberta. Public Health & Welfare Reorganization education, and municipal affairs departments of the provincial government, which give to Alberta the credit of being the most progressive province in Canada in striking at the problem of the small unit of local administration, nothing has been done to establish larger welfare districts. The lack of action on this front obviously stems directly from poor integration of welfare services at the provincial level and a serious lack of vigorous and imaginative leadership in this field. 4. Low Standards of Administration At various points standards of administration have been low, particularly in the welfare services. Even casual study of the provincial system of unemployment relief will show that it has quite generally violated good modern standards of policy and of administration. Apart from the four cities of Calgary, Edmonton, Lethbridge, and Medicine Hat, and from the unorganized portions of the province, administration has been carried out mainly by the secretary-treasurers of the municipalities, giving only part of their time to work for which they lack training and specialized equipment. Food, clothing, and shelter orders have generally been issued to relief recipients, rather than cash, which progressive thinking favours. Although maximum relief allowances have been prescribed by the provincial Bureau of Relief and Public Welfare, minima have not been set, and the bureau has not issued any budgetary scale for the guidance of the local authorities. In consequence the scales of assistance have varied considerably from place to place, and complaints are common that relief has frequently been inadequate. This has led, in some cases, to conditions of child neglect that have made necessary the removal of children from their homes by the provincial Child Welfare Branch; and to some efforts by nonrelief agencies to meet special needs, as in the case of the provincial Public Health Nursing Branch which has made some provision for layettes and other supplies for expectant mothers. The Prairie Provinces 295 Some idea of the nature of relief administration on the local level in Alberta and the other Prairie Provinces is given by the following excerpts from an unpublished study of the McGill University Social Research Series which deals with unemployment and relief in the prairies during the later 1930's:9 The duties of relief officer devolve upon the municipal secretary, who may not have the time to properly handle the relief cases, or he may not have the requisite experience. Voters have become strongly tax conscious in impoverished communities. Being intimately acquainted with relief recipients, they are inclined to adopt an unsympathetic attitude towards those whose present plight can in any way be attributed to lack of thrift or initiative. As a result an ill-informed municipal council which is quite certain it knows how relief should be handled may issue pitifully inadequate assistance as a penalty for personal shortcomings in the hope of keeping taxes down by forcing recipients to leave the municipality. In the course of a discussion on the marked variations in relief policies and procedures to be found from place to place Mr. Duncan says that "no administrator on the spot was able to give authoritative answers to the many problems involved. Interviews with relief officials throughout the region clearly evidenced a lack of agreement among those most closely in touch with the problems involved. For every strongly held opinion of one relief officer on how some relief problem should be handled, another could be found who held the contrary opinion equally strongly. What is worse, local administrators frequently had only the slightest knowledge of the alternative techniques to which they were opposed." The existence of such conditions in Alberta can be attributed largely to the lack of leadership, or the peculiar kind of leadership, offered by the provincial Bureau of Relief and Public Welfare.10 9Albert S. Duncan, The Prairies in Perspective. Quotations made by permission of Dr. L. C. Marsh, editor of the McGill Social Research Series. 10The policies of the bureau are discussed here rather than those of the new Department of Public Welfare, which grew out of it, because there is no evidence as yet that administrative reorganization has led to significant changes in relief policies. 296 Public Health & Welfare Reorganization 1 The bureau has emphasized the upper limits of relief to be granted by the local authorities and has been vigorous in its efforts to reduce the relief rolls. But apparently it has been much less concerned with guaranteeing adequacy of relief and it has done but little to assist local officials in doing a more constructive job. Essentially its supervision has been limited to financial matters, and in this respect it seems to have been very strict. Evidently it has been a law unto itself. It has issued no manual of policies and procedures, so that the administrator and his officials have been free to make arbitrary decisions. The municipalities have complained about this frequently, and so have private agency social workers and other departments of the provincial government, who pointed out to the writer the lack of clear-cut policies emanating from the bureau. The public reports of the bureau are very limited in the amount of information that they contain, and officials informed the writer that it was their policy not to tell the public any more than was strictly necessary. Relief applicants have had no opportunity to appeal decisions made in respect of their claims except through political channels. The bureau has been the exponent of a "hard-boiled relief policy." Its major emphasis has been upon the keeping down of costs rather than upon the alleviation of human need and suffering. Such an administration has no doubt served fairly well the immediate interests of the provincial government in keeping each disbursement on relief to a minimum. But it is doubtful if the policy makes even for governmental economy in the long run, since it does not take account of the hidden social costs of grinding the faces of the poor. And it is abundantly clear that it is totally at variance with modern social welfare thinking which stresses the need to deal sympathetically and understandingly with problems of destitution and to use all possible measures to rehabilitate the indigent and to prevent the emergence of further destitution. The incorporation (or rather the transformation) of the bureau into the new Department of Public Welfare is a step forward. But the The Prairie Provinces 297 promise of the new department will not be realized unless many of the policies and practices of the old agency are discarded for better ones. Another defect in the provincial welfare system is the shortage of field staff for dealing with old age and blind pensions, mothers' allowances, and child welfare problems. Applications for old age and blind pensions and mothers' allowances, are taken by municipal officials and are forwarded to the respective superintendents of these services at Edmonton. The provincial estimates for 1944- 1945 authorize ^ve inspectors for old age pensions and none for mothers' allowances. The latter programme is serviced in part by the old age pension inspectors, while police and other provincial officials in outlying districts make investigations for both programmes at the request of the central offices. It is clear that so small a staff of inspectors cannot perform an adequate job of investigation. It was reported to the writer that the financial interest of the municipalities in these two systems of public assistance led them frequently to recommend very low rates of aid. In the absence of close supervision of the municipal reports or good independent reports the provincial officials who make final decisions can scarcely be in a position to do justice to the claims of applicants. Child welfare cases present much more difficult problems, and the inspectors of the Child Welfare Branch, ten in number for 1944- 1945, according to the Estimates, have found it necessary to make a good many field visits. But the staff has been too small to cover the province properly, and it has been necessary for the branch to rely upon assistance from the Royal Canadian Mounted Police, from local police officers, and from municipal officials. Effective child welfare work, which demands much skill, time, and patience cannot be expected under these circumstances. With two systems of categorical aid in a separate department from general relief and child welfare, there is not much hope of a proper field service being developed, because each department has too small a volume of work to justify blanketing the province with district social workers. 298 Public Health & Welfare Reorganization But if these programmes were grouped together in the public welfare department the way would be clear to organize a field service similar to that of British Columbia. Without adequate field service the continuance of the policy of a centralized child welfare programme is open to question. A possible alternative is the building up of a number of children's aid societies on a district basis, to cover the greater part of the province, as has been done in other provinces, while another alternative, the one to which the new child welfare act points, is the development of child welfare work under municipal auspices. But this approach is not likely to be successful unless it is incorporated into a scheme of building strong local welfare departments in fair-sized districts, so that a social work team, including a child welfare specialist, is organized in each community. 5. The Personnel Problem The lack of trained personnel in the public welfare services of Alberta is striking. In July, 1942, there was not a single member of the Canadian Association of Social Workers, to which the bulk of the trained social workers in Canada belong, in the employ of Alberta public welfare agencies.1 Only in the provincial psychiatric clinics have there been trained workers, two or three having been employed there in recent years. Men, usually of limited educational background, have generally been appointed to relief administration positions both by the provincial government and the municipalities, rather than women, who are much more commonly qualified by disposition and by training for this type of work. A good part of the work of investigation in the unorganized territory of the province in connection with unemployment and poor relief, old age pensions, mothers' pensions, and child welfare work is done by the Royal Canadian Mounted Police, to which the government makes an annual grant of $25,000 for this service. Provincial 11Letter from the Secretary, Toronto, July 24, 1942. The Prairie Provinces 299 officials praise the work of the police, saying that it is done competently, cheaply, and nonpolitically. No doubt this praise is warranted in many respects. But the system is only defensible in the absence of a qualified corps of social workers. It should be obvious that the authoritative approach of the policeman is not the proper one in dealing with frightened, insecure relief applicants, that even the best policeman is usually but poorly qualified to deal with a complicated problem of child welfare, and that the unmarried mother or the woman whose husband has deserted her is not likely to relish the prospect of telling her story of painful personal experience to a uniformed male officer of the law. In the health services, on the other hand, there has been a definite policy of recruiting and appointing technically trained officials, and the quality of personnel is clearly a great deal better. Yet in this area, too, personnel standards might be higher. Salaries are generally low. The writer was informed that it had been difficult to hold competent public health doctors, nurses, psychiatrists, and other technical workers in the public service. An outstanding defect of the salary scale in the Department of Public Health is that the heads of two mental institutions and of the Central Alberta Sanatorium receive somewhat more than the $5,000 salary of their superior officer, the Deputy Minister of Health. The remuneration allowed for this important and able official is very modest; and it is certainly not fair to him nor compatible with effective leadership of the department that subordinates should rank higher in salary. 6. Departmental Organization The welfare services are poorly integrated and organized both at the provincial and local levels; and the internal organization of the provincial health department is open to some question. As we have seen, the provincial public assistance services are distributed between the new Department of Public Welfare and the 300 Public Health & Welfare Reorganization Treasury Department. Child welfare is in the Department of Public Welfare and the provincial jails come under the Department of Public Works. Thus three separate departments or major agencies are concerned with the operation of closely related services which might be grouped, according to good modern thinking, in the welfare department. Under present circumstances little in the way of co-operation can be expected between these separate activities of provincial government, and the way is not clear for a unified public welfare policy for the province being worked out which would integrate and co-ordinate the activities of both provincial and local agencies. The first step towards better organization is obviously the transfer of the categorical aids from the Treasury Department to the new Department of Public Welfare. The welfare agencies in the few cities appear to be poorly organized, while in the small municipalities there are, of course, no welfare departments at all. While the major health services, including mental hygiene and curative medical care, are well integrated in the Department of Public Health, the internal organization of this department is rather undeveloped. The annual report of the department for 1940 lists thirteen divisions or branches, and an organization chart prepared by the department shows*even more. This means that the deputy minister has a large number of officials reporting directly to him, surely more than he can supervise effectively. Accounting is centralized under the secretary of the department, but no provision is made for two other important types of overhead service, research and personnel management. Field service arrangements for the supervision of the local health departments and health units seem to be very limited. No doubt some of these apparent deficiencies can be explained by inadequate appropriations during recent years. It is probable that a careful administrative study, such as the American Public Health Association survey in Mani- The Prairie Provinces 801 toba,12 would bring clearly to the fore such problems as have been mentioned here and would materially assist the deputy minister and his staff in grouping the department more logically into five or six main divisions, with several auxiliary service offices, and in generally improving the administrative structure. With this reform added to the progressive steps already taken under the present leadership Alberta should have a very good system of •administrative machinery in the health field. SASKATCHEWAN Saskatchewan, more than most provinces, has deviated in practice from the doctrine of basic local responsibility for health and welfare services. The doctrine is on the statute books in many places. But the terrible rural depression and destitution of the 1930's, incidental to a deadly combination of low farm prices and drought over great areas, was too much for a weak system of local government made up of nearly 800 small population units. Provincial per capita income fell from the 1928-1929 average of $478 to $135 in 1933.13 Recurrent drought led to widespread crop failures even in the years when the rest of Canada was recovering from depression, so that in the winter of 1937-1938 two-thirds of the rural population were destitute and almost half the total population was on relief. Rural tax collections broke down almost completely, the rural municipalities collecting in 1937 only 8.5 per cent, of the total arrears and current tax levies outstanding.1 Under these circumstances not only unemployment and farm relief but also health services and other functions of local government had to be supported financially by the provincial and the Dominion governments, and inevitably a good share of administrate p. 318ff. 13Rowell-Sirois Commission, Report, Book I, p. 150. 1 Saskatchewan Department of Municipal Affairs, Annual Report, 1940-41, p. 11. 302 Public Health & Welfare Reorganization tive control was also taken over by these superior authorities. While economic conditions have greatly improved during the war, the effects of the depression years are still apparent. One of these results was the assumption by the province of an unusually high degree of responsibility in the fields of health and welfare. The provincial government, through the Department of Public Health which was established in 1923, carries on the public health activities usual at the provincial level and in addition renders a number of additional services that reach down to people in their homes. The department exercises general supervision over local public health activities, collects vital statistics, operates a laboratory service, oversees sanitary conditions throughout the province, and administers grants to general hospitals at the rate of 50 cents per day for all patients treated. It also provides free treatment for venereal disease patients through four full-time clinics, one part- time clinic, and arrangements with private physicians, operates a trachoma programme involving direct service to patients, and conducts a public health nursing service which does general community and school work in the rural districts. Maternity grants up to $25 are paid to needy expectant mothers. The department operates two mental hospitals, at North Battleford and at Weyburn (where a school for mental defectives is connected with the institution) and a psychopathic ward at the Regina General Hospital. It also administers a programme of medical services for relief recipients. During the year 1940 this involved not only the provision of medical services for relief recipients who were "provincial cases" (persons lacking municipal residence, those living in unorganized districts, and settlers being rehabilitated in new areas) but also special grants to doctors, dentists, nurses, and hospitals in various parts of the province to assist them in performing their usual work for private patients. Expenditures on this extensive medical care programme in 1940 were approximately $464,000/5 15Saskatchewan Department of Public Health, Annual Report, 1940, p. 16. The Prairie Provinces 303 Outside the department are two important health programmes, tuberculosis control and cancer control. The former is administered by a semi-official association, the Saskatchewan Anti- Tuberculosis League, which operates three sanatoria and clinical services and carries on case-finding and educational activities. The province contributes one dollar per day for all patients in the institutions and the municipalities meet the greater part of the remaining expenses. The Saskatchewan Cancer Commission, authorized by legislation adopted in 1930, operates cancer clinics in Regina and Saskatoon which give direct service to patients referred by their attending physicians. A new Cancer Control Act adopted in April, 1944, authorizes free treatment for all cancer patients at provincial expense. After experimenting with a provincially administered general relief programme through the Saskatchewan Relief Commission from 1931 to 1934, Saskatchewan turned back the operation of direct relief for local residents to the municipalities, at the same time offering them financial aid and supervision through the Relief Branch of the Department of Municipal Affairs. The amount of financial aid has varied in accordance with changes in Dominion policy regarding assistance to the province and in accordance with the varying financial needs of the local authorities. From 1934 to 1939 (except in the fiscal year 1935-1936) the federal government assumed all relief costs in severe drought areas throughout the province. All through the depression years the provincial government made many special arrangements whereby it deviated from a general policy of percentage grants to the municipalities by carrying the local as well as the provincial share of direct relief charges for those communities that were particularly depressed. In the summer of 1942 the general policy of assistance was for the province to assume 70 per cent, of relief costs (covering aid to both employables and unemployables) in those municipalities which could make a valid claim for assistance. Thus the grants were not routinely made to all local authorities. Each one was required to submit 304 Public Health & Welfare Reorganization clear evidence that it needed assistance before grants were authorized, to be paid for a limited time and in any event not beyond the following March 31, the end of the fiscal year, when reconsideration was required. In 1942 grants were made only to the cities and to a limited number of the other municipalities. But in May, 1943, this system was replaced by a flat 50 per cent, grant to all municipalities for direct relief. Thus the informal equalization system of the depression period (which had given rise to some awkward problems of administration and policy) was superseded by a system which, simpler in its characteristics, lacks some of the advantages of the preceding scheme. The Relief Branch (incorporated since April, 1944, in the new Department of Reconstruction, Labour and Public Welfare) issues regulations in some detail regarding relief policies and procedures. It has maintained a substantial field staff to supervise the municipal authorities and has exercised control particularly through the device of having a field man sit with local representatives on municipal relief committees. It has also been responsible for all forms of assistance to single homeless men and other nonresidents of the municipalities and has maintained offices to meet their needs in several of the cities. The branch has followed the unusual, but very laudable, practice of using municipal machinery in part for the administration of the provincial programme, and has made small payments to municipal secretary-treasurers to reward them for their co-operation in this work. The resettlement of farm families forced out of drought areas and the assistance of voluntary settlers in new districts, mainly in the northern part of the province, has been a very important part of the Saskatchewan relief programme. In 1935 a separate agency, the Northern Settlers Re-establishment Branch, was set up in the Department of Municipal Affairs to administer this programme. Rehabilitation in a new environment by means of loans, assistance in obtaining livestock, feed, and seed, and in breaking new land and erecting buildings, together with temporary The Prairie Provinces 305 relief pending the attainment of self-support has been the policy of this agency rather than continued maintenance by means of a dole. By 1940 some 6,000 families had been assisted under this scheme. Mothers' allowances and child welfare services are operated by the provincial Bureau of Child Protection, which was an independent agency reporting to the Minister of Highways prior to its incorporation in the new Department of Reconstruction, Labour, and Public Welfare in the spring of 1944. The bureau also oversees the operation of the provincial Juvenile Delinquents Act and exercises some supervision over the work of the Boys' Industrial School. However, this school comes also under two other departments, Public Works, which looks after physical facilities, and Education, which controls the educational programme. There are four children's aid societies in the cities of Regina, Saskatoon, Moose Jaw, and Prince Albert, three of which have shelters for children requiring care. In other parts of the province service for neglected children is provided wholly by the bureau. Work in the field is performed by a field staff operating out of district offices, thirteen in number in 1942. The field staff is closely integrated with field representatives of the Old Age Pensions Branch, who work out of the same district offices. Thus there is, in effect, a unified field service which handles old age pensions, mothers' allowances, child welfare, and juvenile probation problems. The Old Age Pensions Branch was an entirely separate and independent agency, until it was incorporated in the new Department of Reconstruction, Labour and Public Welfare in 1944. The Department of Public Works is concerned with the health and welfare services through its responsibility for the operation of three provincial jails and the provincial Home for the Infirm, which accommodates about ninety old people. It is in direct charge of the maintenance of physical facilities at all provincial institutions, including the-menta! hospitals. 306 v*; Public Health & Welfare Reorganization Local Responsibilities Relief of both employable and unemployable residents is administered by the municipalities, with the assistance of financial grants from the province. They are responsible also for the basic public health services and for medical care to needy persons, subject to such assistance from the province as has been mentioned. They are assessed, in proportion to their taxable valuations, to meet something over half the costs of maintaining patients in the sanatoria of the Saskatchewan Anti-Tuberculosis League. They are required to meet a large part of the costs of indigent residents in receipt of care in general hospitals and to pay fees for services rendered to residents at provincial cancer clinics. The costs of maintaining neglected children removed from their homes by court order are chargeable to them. To discharge these functions Regina and Saskatoon and a few other cities have set up health departments and relief departments with full-time officials. But in the small towns and villages and rural municipalities there are no such departments, health and welfare duties being performed by part-time health officers or other part-time officials or by the municipal secretary-treasurer. In one respect local initiative in the health field is unusually well developed. The sheer lack of hospital and other medical facilities in the rural districts has led to the establishment of the "municipal hospital" and "municipal doctor" systems. Out of 90 general hospitals aided by provincial government grants in 1940, 9 were owned and operated by separate municipalities and 23 were "union hospitals" established by groups of municipalities.16 Besides setting up hospitals which are financed from government grants, municipal contributions in respect of indigent patients, and fees from patients, many municipalities have taken advantage of legislation which permits them to arrange, either through their own hospitals or otherwise, for the hospital care of all residents, ™Ibid., p. 56. The Prairie Provinces 307 IF r with the costs being defrayed out of taxation. This is a form of hospital insurance for all members of a community, and in 1940, 61 rural municipalities and 14 towns and villages had such schemes in operation.17 A still larger number had set up municipal doctor schemes. These plans date from legislation enacted in 1916 permitting municipalities to subsidize physicians in rural areas. Present legislation authorizes rural municipalities, towns, and villages, with the approval of their ratepayers, to employ physicians to provide medical care for all residents and to levy taxes to meet the necessary costs. Supervision of contracts with physicians and general direction of the programme is exercised by the Health Services Board established under the provincial Department of Public Health. In 1941 plans were in operation in 97 rural municipalities and 64 towns and villages, covering 203,000 people, or nearly a quarter of the population.18 With this background of experience it is easy to understand why Saskatchewan should be particularly interested in state health insurance, or even in state medicine. While a federal health insurance scheme was still in the discussion stage at Ottawa, the -^Saskatchewan legislature enacted a health insurance measure in ►Vlie spring of 1944. It is designed to provide medical benefits for ^all residents of the province and is to be administered by a commission to be appointed by the government. Essentially it is an enabling act, permitting the government to work out an agreement with the Dominion to participate in a national scheme, which has few Retails on important points of policy and which is significant chiefly as a gesture of co-operation with the Dominion. Progressive Characteristics From the foregoing account of major services it will be seen that Saskatchewan has some unique and progressive achievements 17R. O. Davison, "Rural Medical Care in Saskatchewan", Medical Care, April, 1941, p. 130. ™Ibid., p. 129, 308 Public Health & Welfare Reorganization i to its credit. The tuberculosis control programme is generally recognized to have been an outstanding success. The municipal doctor and municipal hospital systems represent bold and imaginative efforts to solve the problem of medical care in thinly populated rural districts. The plan of an integrated field service to deal with old age pensions, mothers' allowances, and child welfare services has many advantages in a province of scattered population. The efforts to rehabilitate settlers on new land in the northern part of the province are to be commended, even if some questions can be raised about their success. The Relief Branch of the Department of Municipal Affairs (now incorporated in Reconstruction, Labour and Public Welfare) has been progressive in recognizing the varying needs of municipalities for financial assistance and in working co-operatively with them, through its field staff, to assist them in meeting administrative problems. The cancer, trachoma, and maternity grant programmes are all praiseworthy positive steps to meet urgent needs. Leading Problems But on the other side of the ledger is a considerable array of problems in the field of health and welfare, many of which are recognized by forward-looking people in the province. 1. Gaps and Inadequacies There are several outstanding gaps and a number of the programmes now in operation are not giving adequate service. There is no training school for delinquent girls nor are there public psychiatric and child guidance clinics. There is much need for a provincial training school for mental defectives. There is no provision for adult probation and parole. There are no rural health units and it appears that public health service in the rural districts is very much underdeveloped. Probably this is an important reason for the infant mortality rate being much higher; The Prairie Provinces 309 in the country than in the eight cities.19 While the municipal doctors generally perform public health functions in their communities they reach only about one-quarter of the population and in any event they are not adequately equipped to do a good job of preventive medicine. To meet this situation the provincial government, in its Submission to the Royal Commission on Dominion- Provincial Relations in 1937, stated that the province might be organized in eight health districts, each with trained public health personnel, who would supervise and assist the municipal doctors in preventive medicine activities.20 Other needs pointed out in the submission were a new mental hospital with a capacity of 1,200 beds (to relieve serious overcrowding in the mental institutions), two cancer hospitals with a capacity of 30 beds each, a home for incurables with a capacity of 200 beds, and the general extension of curative medical services with financial support from the province. The mothers' allowances scheme is defective in that it does not provide grants sufficient to maintain many of the widows with dependent children, at least in the cities and towns. The present scale (the result of increases in 1942 and 1943) allows for $12.50 per month for a mother with one child, $17.50 for two children, $22.50 for three children, and $4.00 additional for each subsequent child. Where municipal relief has been extended with reasonable freedom it has been customary to supplement these small grants with relief allowances, so that the families concerned have been in receipt of aid from two sources. But in many cases this has not been done, so that frequently widows with small children have been forced into undesirable work or living arrangements in order to maintain their families. Another weakness in public assistance which came to the fore during the war years, when a good many municipalities were denied provincial relief grants, is that these 19This differential" is shown in the section on infant mortality, Department of Public Health, Annual Report, 1940. 2op. 282. 310 Public Health & Welfare Reorganization communities cut out relief for their residents altogether or reduced it to very little. No longer in receipt of provincial aid, they were substantially free from provincial supervision, and they could disregard the claims of their destitute residents if they so desired. The new system of flat-rate grants of 50 per cent, of relief costs, initiated in 1943 and payable to all municipalities, was designed, among, other things, to solve the problem of municipal denial of relief to the needy. These gaps and deficiencies in service are understandable in the light of the extraordinarily severe financial plight of the province and the municipalities during the 1930's. But there is not the same excuse for a number of serious defects in organization and administration which are very apparent. ii 2. Provincial-Local Relations The distribution of administrative and financial responsibilities between the province and the local governments calls for reexamination and the working out of more satisfactory policies than those of the present. The provincial government, as in Alberta, is providing more direct service in the form of public health nursing and medical care than would be necessary if local programmes were strengthened. The system of provincial grants for relief and medical care is the legacy of depression emergency policies and is open to a number of objections. The new system of flat percentage grants for relief has the merit of applying to all municipalities. But such a system, as we saw in the case of British Columbia, cannot be effective in equalizing the relief burdens from municipality to municipality. On the other hand, this objective was achieved, to some extent, by means of the preceding policy of granting aid only to those municipalities which could establish a good claim for it. Working from this precedent a more formal and more workable system of variable grants to the local authorities might be devised which would give them reasonable assurance that The Prairie Provinces 311 in future (always assuming no recurrence on a great scale of drought conditions, which would again make emergency measures necessary) they could make adequate financial provision for the health and welfare services which they administer. If this is not done the logic of the situation will call for a still further transfer of administrative and financial responsibilities to the provincial level. 3. Small Local Units The problem of the small local unit of government is particularly acute in Saskatchewan. In 1942 there were 784 self- governing municipalities, consisting of 8 cities, 82 towns, 392 villages, and 302 rural municipalities.21 Only the eight cities and one rural municipality had more than 5,000 population. The villages were composed typically of 200 to 300 people, the towns of 500 to 600 people, and the rural municipalities of 2,000 to 3,000.22 Unlike the situation in Alberta, not much has been done to develop larger units of administration. A few rural school districts have been consolidated into larger areas. In 1929 one rural health unit was established in the Gravelbourg district, with assistance from the Rockefeller Foundation, but this was discontinued a few years later on account of lack of funds. The twenty-three union hospital schemes represent the most important attempt to organize social services on the basis of larger districts. Provincial officials with whom the writer discussed the problem were not very optimistic about developing bigger local units, partly on account of the technical problems involved in widely dispersed population and partly on account of local political resistance to change. No doubt these are important factors. But it has been shown that they can be overcome in other provinces, notably Alberta, so that they 21In addition there are local improvement districts, where taxes are levied for some of the ordinary purposes of local government with administration being conducted by the Department of Municipal Affairs. 22Based upon population figures in the Annual Report, 1940-41, Department of Municipal Affairs. 312 Public Health & Welfare Reorganization should not be insurmountable in Saskatchewan. If a serious attack is not made on the problem of the small unit it is not likely that the people of the province will gain the advantage of well- administered local health and welfare services, and this will greatly strengthen the case for the further transfer of administrative responsibilities to the provincial authorities. 4. Integration and Organization Structurally the outstanding weakness at the provincial level, up to the beginning of 1944, was the poor integration of the welfare services. These were divided among four separate departments and agencies, the Department of Municipal Affairs, the Bureau of Child Protection, the Old Age Pensions Branch, and the Department of Public Works, while the Department of Public Health also had a finger in the pie through administering maternity grants and certain other aids to destitute persons and the Department of Education had major responsibility for the operation of the Boys' Industrial School. The delinquency services were badly scattered between Public Works (operation of jails), Education (the Boys' Industrial School), and Bureau of Child Protection (some supervision of the Boys' Industrial School and of the juvenile probation system). Under these circumstances there could not be expected an over-all view of welfare problems on the part of the provincial government or good central direction of the welfare programmes that were in effect. At the spring session of the legislature in 1944 an act was passed to establish the Department of Reconstruction, Labour, and Public Welfare. In the new department were grouped general relief, the categorical aids, and child welfare, as well as simple labour services and the administration of certain "reconstruction" activities. The integration of public assistance and child welfare is a most valuable achievement. But it may be questioned whether the labour and reconstruction services belong in the new department The Prairie Provinces 313 whose main job is certainly public welfare. If the delinquency services could be transferred to the department, it would be a good unit for welfare administration and the problem of welfare integration at the provincial level would be largely solved. The provincial health functions are well grouped in the Department of Public Health, with the exception of the tuberculosis control and cancer control programmes. In theory a strong case could be made for their inclusion in the department but both programmes seem to work well independently and to be closely co-ordinated with the department, so that their independence presents no serious difficulties at present. The department is very much concerned with curative as well as with preventive medicine, as its administration of grants to hospitals, the municipal hospital and municipal doctor systems, and relief medical services shows. Presumably it is experience with such a programme that led Dr. R. O. Davison, the Deputy Minister of Public Health, to state, in 1940, that "an assumption has persisted for many years that there is an artificial dividing line between the two fields of the practice of medicine: that is, the preventive and curative. Personally, I am unable to define that line."23 So far as the writer can judge the union of the two types of work in the department is fairly satisfactory and it would not be appropriate to disturb it. Indeed, the system has interesting possibilities of disseminating a preventive-medicine point of view throughout medical practice generally if the hopes of the department to use the municipal doctor system more fully as a medium for public health work in the rural districts can be realized. Of course, the curative programme will be supplanted by health insurance when it is established and will be removed from direct departmental administration to the health insurance commission which has been authorized. Cursory observation of the department suggests that, as in Alberta, internal organization might be tightened* up and that arrangements for the supervision of local health services might be greatly strengthened. 23Canadian Public Health Journal, October, 1940, p. 459. 814 Public Health & Welfare Reorganization 5. Weak Administration In the welfare field there is much evidence of poor administration. As in most parts of Canada the operation of the local relief services has been on a low plane. Case loads in public assistance and child welfare have been much too high for visitors and investigators to do adequate work with and for their clients. A survey by the Canadian Welfare Council in 1937 in Saskatoon disclosed that the untrained male investigators of the Civic Relief Department were carrying case loads of over 400 per person and were unable to visit their clients more frequently than every three months. By contrast, the survey report states that "a minimum standard which has been found to pay in larger relief departments, in the bare terms of relief expenditure alone, is monthly visiting of all families under care, and a case load not exceeding 125 per visitor."24 The same problem affects the provincial field staff administering the special types of assistance. Premier W. J. Patterson states that, at the end of 1942, "There are approximately 13,000 old age pensioners and 3,000 mothers' allowance cases. . . . There are 13 full time old age pension and mothers' allowance inspectors who are assisted during the winter months by some four to six other inspectors. The maximum total number of old age pension and mothers' allowance cases under one inspector is approximately 1,700. . . . Inspectors may have (in addition) a limited number of child welfare cases."25 Such case loads were far above the levels that would permit efficient work. Serious criticisms of the administration of child welfare and juvenile delinquency services were made to the provincial government in a brief submitted on March 6, 1942, by the Community Council of Saskatoon in support of a request for an impartial survey of the whole situation. The brief contains twenty specific complaints, a number of which are supported by evidence in the 24A Study of Community Welfare Services in Saskatoon, p. 8. See Chapter 5, p. 176. 25Letter, December 12, 1942. The Prairie Provinces 315 Canadian Welfare Council survey of the Saskatoon situation which has been mentioned above. Among the complaints are the lack of personnel standards for child protection workers engaged by the provincial government and the children's aid societies; the scattering of responsibility for juvenile delinquency services among several government agencies; the placement of neglected and dependent children in boarding or adoption homes without prior investigation of these homes by competent persons; the placing of children from families where parents are on relief or are ill in children's aid shelters rather than in boarding homes; inadequate supervision and after-care of children placed in homes; and the keeping of many children in shelters beyond the three months' limit specified in the Child Welfare Act. A major reason for some of these problems is apparently the low standard of work of the children's aid societies and the failure of the Bureau of Child Protection to supervise their personnel and their activities adequately. In justice to the bureau it should be noted that its appropriations and staff have been very limited, while political obstacles to effective supervision have always been present.26 There is also criticism in the province, among informed people, regarding dull and unenlightened administration of the Boys' Industrial School and the provincial jails and incompetent and inadequate juvenile probation work by children's aid society officials and police. 6. The Personnel Situation Undoubtedly the roots of many of these difficulties are in the untrained personnel of the public welfare agencies and the lack of good personnel policy. In the summer of 1942 there was not, so 26Premier W. J. Patterson, in a letter of December 12, 1942, commenting on the foregoing statements (which had been submitted to him for criticism), denies the accusation that children are placed in boarding or adoption homes without proper investigation, and explains that if, in some cases, children are kept longer than three months in shelters it is because the children are subnormal, deformed, or suffering from congenital disease, so that they cannot be placed in normal homes "and they must be institutionalized in some way or another." ,316 Public Health & Welfare Reorganization i: far as the writer could discover, a single professionally trained social worker engaged in welfare administration, provincial or local. Nor were any efforts being made to build up trained staff by sending staff members away for professional training. It was obvious that the welfare services of the province were being operated by persons who, however capable and conscientious some of them might be, were generally not equipped with the necessary knowledge and skill to render high-grade administrative service and to assist their political superiors in the formulation of sound policies. Recently the government has recognized the need for better personnel, and has taken some steps to remedy the situation. In 1943 a trained welfare administrator was appointed as chief assistant to the Commissioner of Child Protection. Moreover the bureau has made arrangements for members of the staff to obtain leave for purposes of social work training.27 These are useful moves, but they represent only the beginning of a positive personnel policy in the welfare field. In the health field personnel is much better, although even here there is a shortage of well-trained specialists, such as public health doctors and nurses. The lack of good provincial policy on salary classification is suggested by the fact that the position of Deputy Minister of Public Health, held at present by one of the leading public health men in Canada, carried in 1942-1943 a salary of only $4,500 (plus $750 for chairmanship of the Health Services Board), much below the salaries of the heads of the Battleford mental hospital, the Anti-Tuberculosis League, and the Cancer Commission. Personnel standards for the local health agencies are not prescribed by the provincial government. These personnel problems are intimately related to the fact that the provincial government does not have an independent civil service system. Appointments, salaries, promotions, and other personnel matters have been handled under what is essentially a 27Letter from Premier W. J. Patterson, February 1, 1944. The Prairie Provinces 317 benevolent system of political patronage. Such a system permits the recruiting of some good people, particularly to do work where technical training is recognized to be necessary, as in the case of physicians and engineers. And it must be said that the government has retained in office appointees qf previous administrations, such as the Commissioner of Child Protection, in the belief that they were capable. But a system of the kind does not generate the positive personnel policy that is required to attract to the public service competent officials in all branches of work and to hold them there. MANITOBA More than the other Prairie Provinces, Manitoba has been aware of the existence of serious problems of health and welfare administration and has made valiant efforts to solve them, even in the dark days of the depression when public finances were in desperate shape. The visitor to the provincial parliament buildings and the civic offices of Winnipeg gains the distinct impression that an earnest effort has been made by political leaders and public officials to provide good government in many areas of public affairs, including health and welfare. This impression is confirmed by study of the public documents that are available. The influence of a number of able and public spirited citizens of Winnipeg, a city that is unusually enlightened and progressive, is clearly apparent in the political life of the province. Courageous and intelligent leadership has given to Manitoba a better-than-average system of public health and welfare services. Yet in this province, too, there remain to be solved many problems of organization and administration, partly because of the setbacks to orderly community life which were suffered during the depression years of the 1930's. One of the leading indications of a progressive approach in Manitoba has been the willingness of the public authorities to invite careful examination of their services by qualified and objective investigators and to seek suggestions for improvement. The 318 Public Health & Welfare Reorganization Canadian Council on Child and Family Welfare made a careful survey of child welfare problems in 1928-1929 at the request of the provincial government. Ten years later civic government in Winnipeg was subjected to exhaustive.scrutiny by a Royal Commission headed by Mr. H. Carl Goldenberg. In 1941, at the request of the Minister of Health and Public Welfare, the field staff of the American Public Health Association, headed by Dr. Carl E. Buck, surveyed the health programmes of the provincial government and the city of Winnipeg. These and other reports provide information which makes it more easy to criticize and appraise the health and welfare services of Manitoba than of other provinces which, if they were subjected to similar analysis, would probably not show up nearly so well. Provincial Functions The health and welfare activities of the provincial government come largely under the Department of Health and Public Welfare, which was established in 1928. The department performs the usual provincial public health functions, including the general oversight of the local health services. It is empowered, under the provisions of legislation adopted in 1942, to order the grouping of municipalities in full-time health districts with not less than 10,000 population, and is actively committed to the formation of such districts generally throughout the province. Grants amounting to 50 per cent, of costs are made to three local health units outside of Winnipeg. The department operates laboratories, venereal disease clinics, and a public health nursing service, and performs services of sanitation, vital statistics, industrial hygiene, maternal and child hygiene, and health education. Two mental hospitals (one at Brandon and one at Selkirk), the Psychopathic Hospital at Winnipeg, the Manitoba School for Mental Defectives, and mental hygiene clinics also come under the department. It administers grants to general hospitals at the rate of 40 cents for each public ward patient day, assumes the financial responsibility for the The Prairie Provinces 319 hospitalization of indigent patients from unorganized portions of the province, makes grants to the St. Boniface Home for the Aged and Infirm, and exercises general supervision over the system of municipal doctors, of whom there were sixteen in 1941. The department is directly concerned with tuberculosis control through the work of its public health nurses and through the operation of a central tuberculosis registry. Otherwise the tuberculosis programme is handled by a semi-official organization, the Manitoba Sanatorium Board, which operates two sanatoria, a central tuberculosis clinic at Winnipeg, and travelling clinics, and which is financed by a general government grant of 50 cents per patient day of institutional care, by municipal contributions, and by donations from private sources. There is also a cancer programme under a semi-official agency to which the provincial government makes grants. The welfare work of the department consists mainly in the administration of mothers' allowances and child welfare services, which are grouped in the "Section of Public Welfare." This unit has a small field staff of social workers which does a generalized job on mothers' allowances and child welfare cases throughout the province. Mothers' allowances applications are made to the municipal authorities in the first instance, and are then investigated by the provincial field staff before being referred to an unpaid board appointed by the government, the Child Welfare Board, which makes final decisions. Child welfare work in the municipally organized portions of the province is performed largely by five children's aid societies organized on a district basis and supervised by the Child Welfare Division. However, the adoption programme is handled directly by the provincial agency. In addition the Department of Health and Public Welfare administers relief to unemployables in unorganized territory, makes grants to charitable institutions (on the advice of a statutory body, the Welfare Supervision Board), and supervises and licenses child-caring institutions 320 Public Health & Welfare Reorganization and homes, maternity homes, and homes for the aged and infirm through its public health nursing service. The departmental chart of organization in the annual report for 1940 showed eleven operating divisions of varying degrees of importance, together with two central service offices concerned respectively with accounting and the administration of the estates of the mentally incompetent, all reporting to the deputy minister. The 1941 report of the American Public Health Association28 recommended the reorganization of the department into six sections, to be entitled respectively "Administration," "Environmental Sanitation," "Preventive Medical Service," "Psychiatry and Hospitalization," "Local Health and Welfare Service," and "Public Welfare," and by the end of 1942 this plan of organization had been adopted.29 But in spite of its name the Department of Health and Public Welfare handles only a portion of the provincial welfare services. All during the years of depression and through the war years unemployment relief administration has been under the Department of Public Works. After the cessation of Dominion unemployment relief grants to the provinces, in April, 1941, the province continued to make grants to its municipalities, amounting in the fiscal year 1941-1942 to 60 per cent, of total expenditures and in the fiscal year 1942-1943 to 50 per cent. However, an exception to this rule was made in the case of Winnjpeg, which for the fiscal year 1942-1943 received a lump sum grant of $213,000. Unlike the policy in British Columbia and Saskatchewan, these grants are designed to cover aid to employable persons and their dependents only, and no assistance is given with respect to unemployables. The provincial authorities have laid down rather specific rules and regulations to guide the administrative work of the municipal 28Public Health in Manitoba, 1941. In the following pages this will be referred to as the "Buck report." 29Department of Health and Public Welfare, Annual Report, 1941-1942, p. 215. The Prairie Provinces 321 officials, and in the case of the Greater Winnipeg area these have been compiled in a printed manual. Besides making grants to the municipalities the provincial government has performed a number of unemployment relief functions directly. It administers relief to the residents of unorganized territory and to transients lacking municipal residence. During the depression years it operated a complete programme for single hpmeless men, including those with and without municipal residence. Central dining halls for these men were operated in Winnipeg and Brandon and also a camp hostel, at Camp Grassmere, which was continued during the war period as a refuge for physically unfit and aging men. Associated with this programme for single men, under the Single Men's Commission appointed in 1932, have been" programmes of youth training and latterly of training for war industry. Another related agency, the Rural Rehabilitation Commission, has directed a programme of land settlement for the benefit of needy families. The Greater Winnipeg Unemployment Advisory Board, established in 1932, has performed valuable advisory and standard-setting functions for the government and the municipalities in the Winnipeg area and has also undertaken administrative work, including the operation, until recently, of a central clothing depot from which both provincial and municipal relief recipients in the Greater Winnipeg area obtained clothing, with the costs being charged to the responsible authorities. These three commissions were closely related to the Unemployment Relief Branch of the Department of Public Works, partly because the deputy minister was a member of each. While their functions were technically advisory, in the main, they exercised great influence, so that the relief programme was somewhat decentralized. With the decline in the need for relief during the war, only the remnants of the extensive programme of the depression period remain, still under the Department of Public Works. Old age pensions are administered by another independent agency, the Workmen's Compensation Board. Applications are 322 Public Health & Welfare Reorganization made first to the municipal authorities, which investigate and forward the applications to the board, with recommendations. The board, which makes final decisions, has no field staff to make investigations, but is given some assistance by the Royal Canadian Mounted Police and at times "obtain reports from a private company engaged in investigation work."30 The delinquency services are administered by the Department of the Attorney-General, with the exception of the Manitoba Home for Boys at Carman (a training school for delinquent boys) which comes under the Department of Education. There are five small provincial jails and two detention homes for juvenile offenders. The juvenile court system is particularly interesting because it is operated and financed almost wholly by the provincial government, with only slight participation by the municipal authorities. There are three juvenile court districts, each under a juvenile court judge who may be assisted by deputy judges, and each with full-time probation officers. The judge of the Winnipeg district juvenile court gives full-time service, but the judges of the other two districts (Brandon and Dauphin) serve only part-time, acting also as magistrates. The Local Services The municipalities are responsible for the usual local public health activities and for the administration of poor relief and unemployment relief for their own residents. In addition they are required to contribute, at a basic rate of $1.50 per patient day, towards the costs of hospital care for indigent residents; at 50 cents per day towards the maintenance of inmates of the provincial school for the mental defectives; and, at 50 cents per day for ambulatory patients and one dollar for bed-ridden patients, towards the care of inmates at the St. Boniface Home for the Aged and Infirm. In the case of tuberculosis patients receiving institutional 30Letter from the Assistant to the Old Age Pensions Commissioner, July 24,1942. The Prairie Provinces 323 treatment under the direction of the Manitoba Sanatorium Board the four cities of Brandon, Winnipeg, Portage la Prairie, and St. Boniface pay $1.80 per day for their residents, while the provincial government levies against the remaining municipalities, on the basis of equalized assessments, a social service tax that is designed to yield a fixed grant ($145,000 in 1942) for the Sanatorium Board. Through the social service tax the municipalities are also assessed 123^ per cent, of the cost of the provincially administered old age pensions. Local departmental organization is scarcely developed at all except in the urban communities. In Winnipeg there is a well developed health department and there are three other full-time health units outside the city, the four units serving 39 per cent, of the population of the province in 1941.31 Since 1940 Winnipeg has had a department of public welfare, the result of the amalgamation of two previously existing agencies, the Social Welfare Commission, which administered aid to unemployable groups, and the Unemployment Relief Branch of civic government. Otherwise there are relief or welfare departments only in the suburban municipalities around Winnipeg and in four or five other cities and towns. In the rural districts the public health work is done mainly by part-time health officers and the welfare work by municipal secretary-treasurers. Some Strong Points The Manitoba system has a number of very good characteristics. The provincial health services are well integrated in one department, and have had vigorous leadership in recent years from an able and progressive deputy minister and from sympathetic and intelligent ministers. Unemployment relief administration has been much better than in most provinces, both provincially and locally. Considerable leadership from the provincial government, standardi- 3 American Public Health Association, op. cit., p. 7. 324 Public Health & Welfare Reorganization zation of policies and procedures in the Greater Winnipeg area, a well developed programme of medical relief in Winnipeg, the formation of the Winnipeg public welfare department, a province- wide policy of work relief on constructive projects to as great an extent as funds permitted, and the provincial programmes for the care of single men and for rural rehabilitation are items of relief policy that deserve commendation. The juvenile delinquency programme has been quite progressive. Sincere efforts have been made to recruit trained personnel for the public health services and for some branches of public welfare, notably child welfare, mothers'" allowances, and juvenile delinquency. Manitoba has a number of trained social workers in its public welfare agencies. Apparently "politics" has been kept out of the administration of the public services to an unusual degree. Major Problems 1. Inadequate Service But on the other hand there is a substantial array of defects to be noted. There is much evidence of inadequate service, partly on account of the very limited appropriations for health and welfare which were available during the years of depression. The Buck report and the recent reports of the Department of Health and Public Welfare both cite many illustrations of insufficient health service, particularly in the rural districts. For instance, in the 1940 report of the department it was stated that less than 20 per cent, of the municipalities outside of Winnipeg had public health nurses or health inspectors, that in many places there was little or no sanitary supervision over restaurants, food handling, milk and water, that school medical services were seriously underdeveloped, and that part-time health officers were not properly performing public health duties. The mental hospitals are seriously overcrowded, with persons being denied admission who should have institutional care, and there is need for substantial extension of the The Prairie Provinces 325 mental clinic programme. At the end of 1942 there was a waiting list of about 200 persons for admission to the Manitoba School for Mentally Defective Persons, and there was need for "from two hundred to two hundred fifty (additional) beds ... at the earliest possible moment."32 The parole system for prisoners released from the jails is casual and unimpressive. The provision of curative medical care for public assistance recipients outside of Winnipeg is generally very limited. Vocational rehabilitation is quite undeveloped. There is no family court or other court concerned with domestic problems. 2. Provincial-Municipal Relations The problem of inadequate service in rural districts arises in large part from the failure of the provincial government to work out satisfactory permanent policies regarding the distribution of administrative and financial responsibilities between the province and its municipalities. In order to compensate somewhat for the weakness of the local agencies the province has undertaken to perform directly a number -of functions, particularly in rural communities, that are frequently administered locally. This is strongly criticized in the Buck report, which advocates the building up of strong local health agencies and the withdrawal of the province from direct services such as public health nursing, venereal disease control, and tuberculosis control, with these activities to be undertaken locally under provincial supervision. The disadvantages of the provincial public health nurses rendering certain direct services throughout the province, as has been done recently, are illustrated by an analysis in the Buck report of the working time of a group known as the "roving nurses" which shows that they lived up to their title by spending 35 per cent, of their working time in travel because of the broad expanse of territory they covered.33 In the health field steps are being taken to deal with these problems, for 82Department of Health and Public Welfare, Annual Report, 1941-42, p. 217. ™0p. dt., p. 73. 326 Public Health & Welfare Reorganization the provincial government is committed to the strengthening of the local health services along the general lines recommended in the Buck report. But in the welfare field similar problems exist, and clear policies have not yet been formulated to meet them. On the side of finance there is the chronic problem of the varying capacities of the municipalities to bear health and welfare charges. The great range of difference in the tax-raising abilities of the municipalities is suggested by the fact that the taxable assessments of school districts (smaller than municipalities) vary from as little as $2,000 per teacher to $352,000 per teacher, the wealthy district thus having a tax base for educational purposes 176 times greater than the poorest district.34 The present system of provincial grants in aid of unemployment relief and of full-time health units at the rate of 50 per cent, and the scheme of uniform per-patient-day charges in respect of municipal residents in hospitals and provincial institutions do not spread equitably the main burdens of health and welfare among the local taxpayers. As in other provinces, many municipalities were unable to meet their obligations during the depression years. It is illogical, unfair, and undesirable for administrative reasons that no provincial grants should be made in respect of municipal relief to unemployables. Some system of variable grants to the municipalities, covering all of their health and welfare obligations, is clearly needed. The desirability of this approach has been recognized in the system of assessing against municipal taxpayers part of the costs of old age pensions and of maintaining patients in tuberculosis sanatoria. But it may be questioned whether there is any justification for these levies, since the municipal authorities have little or nothing to do with the administration of either scheme and since their financial contributions are not specifically in respect of their own residents but are pooled in general provincial funds. An excellent precedent for a system of variable grants in the 34Hon. Ivan Schultz, "Equalization Grants for Weak School Districts," The Manitoba School Journal, May, 1942, p. 9. The Prairie Provinces 327 health and welfare field has been set by the provincial Department of Education, with its recently adopted scheme of equalization grants towards school districts. According to this plan the revenue of all school districts is to be brought up to at least $950 per school room per year, the amount considered necessary for a minimum standard of service. This is to be achieved by continuing a provincial grant of $200 per room which has been in effect for some time, by requiring local school district taxation of at least 12 mills on taxable valuation in organized territory and 15 mills in unorganized territory, and by providing provincial grants to make up the difference between the yield from these sources and the minimum standard of $950 wherever any deficiency exists. Thus the rates of taxation for school purposes will be substantially equalized throughout the province while every school district will be assured of the minimum revenues essential for proper operation of the schools, but provincial grants will vary sharply from district to district in accordance with needs for assistance.35 3. Small Units Like other provinces, Manitoba is plagued by the problem of the small municipal unit. There are 173 municipalities, but outside of Winnipeg and 5 suburban communities in the Winnipeg area there were only 14 municipalities in 1941 which had more than 5,000 inhabitants. More than half of the people of the province live in municipal districts too small to permit the efficient administration of local health and welfare services. The Buck report strongly recommended the grouping of the small municipalities in full-time health districts, a policy to which the provincial government is now committed. In the educational field there has been some progress in building up consolidated school districts. But apart from the significant work of the Greater 35This interesting and significant scheme is well described in an extensive article by the Minister of Education, Hon. Ivan Schultz, op. cit. 328 Public Health <fc Welfare Reorganization Winnipeg Unemployment Advisory Board in co-ordinating unemployment relief policies and procedures in the Winnipeg area and the development of children's aid societies on a broad district basis, nothing has been done to establish larger welfare units. The Winnipeg district presents special problems of local organization and administration, and the possibility of developing in this area metropolitan departments of health and welfare is well worth consideration. 4. Departmental Organization At the provincial level there are several important problems of administrative organization. As it has been pointed out, there has been substantial reorganization of the Department of Health and Public Welfare along the lines recommended in the Buck report. The recommendations regarding the health services, calling for the logical grouping of public health, mental hygiene, and curative medicine programmes within the health department, seem to be essentially sound. But those on welfare reorganization, notably the retention of child welfare and mothers' allowances in a welfare branch of the department, are very much open to criticism. Evidently this proposal was made because the Buck survey was limited to the programmes under the jurisdiction of the Department of Health and Public Welfare. This led, inevitably, to lack of consideration of the welfare services outside the scope of the department and to a too narrow view of the welfare field. This points to the central weakness in the organization of the provincial Welfare services—that they are scattered among three governmental departments and one outside agency, the Workmen's Compensation Board. The Department of Health and Public Welfare lives up to its name only very partially. It is rather a health department dog with a welfare tail. Lack of integration goes far to explain the fact that there has been much less provincial leadership, supervision of local programmes, and co-ordination of provincial and local activities in welfare than in health. There is J The Prairie Provinces 329 overlapping between the investigation work of the field staff of the Child Welfare Divisisn and the limited investigation activities of the Workmen's Compensation Board in connection with old age pensions. The Unemployment Relief Branch of the Department of Public Works administers aid for employable persons in unorganized territory, thus performing functions similar to those of the Social Assistance Branch of the Department of Health and Public Welfare. And at various other points there is evidence of overlapping of activities and poor co-ordination. If these several agencies concerned with public welfare were integrated in one department a provincial field service might be organized that would serve all of them much more economically and efficiently than they are served at present. Integration of the public assistance and child welfare services is the most urgent measure of administrative reform that is needed, and if this were achieved they might be grouped with the health services in the Department of Health and Public Welfare. In this case the Boy's Industrial School could be transferred from the Department of Education to the Department of the Attorney-General in order to group all the delinquency services together. But there are various objections to a combined department of health and welfare, as has been pointed out in Chapter 7, and it is probable that much the best solution would be to establish a new department of public welfare, to be made up of the child welfare and public assistance services now in Health and Public Welfare, unemployment relief, old age pensions, and the delinquency services. In this case some of the other functions now performed by the health department should also be transferred to the new department, notably the making of grants to charitable institutions and homes for the aged and infirm. These latter duties, now undertaken by public health nurses, could be performed better by social workers operating out of a welfare agency. In the new department it would be advisable, among other things, to co-ordinate the delinquency services more effectively than they are at present by placing all of them under the 330 Public Health & Welfare Reorganization jurisdiction of a competent official and by developing a unified probation and parole service for the province under the direction of a chief officer. With strong and well organized departments of health and welfare there would be little justification for several administrative or semi-administrative boards and commissions that now exist. The Buck report suggests that the Child Welfare Board be stripped of its administrative functions (passing upon applications for mothers' allowances), and that it be amalgamated with the Welfare Supervision Board to perform only advisory duties. This is a good suggestion, which is valid also for the Greater Winnipeg Unemployment Advisory Board and the Rural Rehabilitation Commission. Although these bodies have all performed valuable services they would be unnecessary as administrative agencies if there were a good provincial welfare department. At the local level there is much to be done in the way of improving departmental organization. In every community there should be separate health and welfare departments, organized on a district basis. The American Public Health Association survey of 1941 pointed out a number of serious weaknesses in public health organization in Winnipeg36 and made recommendations for improvement, some of which have been adopted. Winnipeg's new public welfare department (1940) gives the city far better welfare machinery than ever before, but according to reports from well- informed persons the internal organization of this agency will stand further improvement. 5. Unsatisfactory Administration In view of the weaknesses in organization and finance that have been mentioned it is not surprising to find a good deal of evidence of unsatisfactory administration, particularly in the welfare field. Constructive policies to deal with prisoners in the provincial jails SQPublic Health Activities in Winnipeg, 1941. p. 46ff. The Prairie Provinces 331 might be very much extended. Limited field investigation of old age pensions applications through the mounted police and a private investigating agency does not represent good practice. This is also true of the investigation of applications for social assistance in unorganized territory, which is handled largely by the tax collectors of the Department of Education. While more has been done than in most provinces to develop standards of local administration and to supervise the activities of local agencies there is still much room for extending and for strengthening the supervisory and standard- setting functions of the provincial government in both the health and the welfare areas. This is illustrated by the hospitalization policy, which has been criticized as much too generous in the Buck report. "Generally speaking," says the report, "the province is conservative in its expenditures for preventive medicine and public health, and lavish in providing free hospital care. . . . One might predict that public . . . payments for hospital care could be reduced by as much as 25 per cent, if the technique of admitting were tightened up and the definition of 'emergency' confined to its literal meaning. From the standpoint of the Department of Health and Public Welfare alone this would mean an annual saving of $150,000. "37 The Department of Health and Public Welfare has surveyed the hospital problem further since the Buck report was prepared, and is taking steps to control the situation more effectively. Another illustration of inadequate supervision and leadership on the part of the provincial government comes from the child welfare field. In 1942 the child welfare services of Winnipeg were surveyed by the Canadian Welfare Council,38 and it was discovered that both the children's aid societies and other agencies were guilty of some very bad practices. Two basic weaknesses were noted: (a) The absence of an adequate service of child placing in family homes, the overwhelming preponderance of institutional care, and 37Op. cit., pp. 90-91. 38Report of Child Care and Protection Survey of Winnipeg. IS 332 Public Health & Welfare Reorganization the absence of proper correlation of function between these two types of care. (b) The inadequate standards of personnel and the almost total lack of trained leadership and staff.39 If the provincial child welfare division had exercised effective supervision over the local child welfare services, these conditions should not have been in existence. Although Manitoba is ahead of most provinces in efforts to develop competent personnel in its public health and welfare services much more remains to be done. Dr. Buck's reports are full of references to weaknesses in the personnel policies of the health agencies. For instance, it is stated in the special report on Winnipeg that about 70 per cent, of the nurses employed by five public health nursing agencies in the city that were surveyed had had no special training in public health, that provisions for in- service training and supervision were inadequate, that salary scales were very low, and that many nurses were too old for effective service.40 Salary scales in the provincial health department were seriously criticized as much too low to attract and to hold competent personnel. Dr. Buck points out that a convention has existed to the effect that the deputy minister should not receive a salary higher than that of his political superior, the minister. But "this means that the deputy minister cannot receive a salary in any way commensurate with the training and experience required for the position or with the responsibilities which he is expected to assume. Further, the salary of the deputy minister depresses the salaries of other personnel in the department. . . . Salaries of professionally trained people are shamefully low."41 Dr. Buck proceeds to make a number of personnel recommendations including general increase in salary scales, special provisions for the training ™Ibid., p. 2. *°Op. cit, p. 24 ff. Since the report was issued steps have been taken in Winnipeg to improve personnel standards and practices. *l0p. cit, pp. 27-28. The Prairie Provinces 833 of staff, improvements in supervision of staff, and various other measures to increase the attractiveness of public service. Such criticisms are even more valid for the welfare services, for personnel problems are distinctly more acute in this field. With occasional exceptions, there have been no trained social workers engaged in relief administration. The jails are totally without trained staff. The old age pensions scheme has been administered by untrained personnel. There is a serious lack of strong executive material in the welfare field, as was discovered in Winnipeg in 1940, when efforts were made to find a competent director for the newly formed city department of public welfare. In the absence of a suitable candidate in Manitoba a search was made, without success, for an outsider. Without vigorous direction by a professionally qualified executive the department has not measured up to the high hopes of its progressive sponsors on the city council and in the community. An important step to solve the welfare personnel problem was taken in 1943, when a school of social work was established at the University of Manitoba. The provincial government showed its interest by making a special contribution of funds toward the new enterprise. Some Highlights Several points stand out in this review of the health and welfare services of the three Prairie Provinces. In all of them a clear pattern of health organization has emerged, with public health, mental hygiene, and curative medicine grouped together in provincial health departments, and this seems to be quite satisfactory. But local health work in the rural districts is woefully weak. A good many deficiencies in the health field have been brought to light in Manitoba by the Buck report, but there are certainly weaknesses that are just as serious or worse in the other two provinces, and they would undoubtedly profit from similar objective surveys. In all three provinces the problem of the small local 834 Public Health & Welfare Reorganization administrative unit is acute because of their predominantly rural populations. The financial position of many of these rural units is not strong enough to support adequate health and welfare programmes. And in the three provinces personnel problems are serious, particularly in the welfare field. Even more important than these points is the great weakness in welfare organization and administration. Health is far better developed than welfare across the prairies, and provincial health departments, under competent deputy ministers, have given a good deal of leadership. But nothing at all comparable has been done on the welfare side. There is urgent need in all the provinces for better integration of the welfare services at the provincial level and for placing them under the direction of highly qualified officials. If only this could be done solution of many of the other welfare problems that have been mentioned might be expected to follow. For no competent public welfare director would tolerate for long the disorganization, the inefficient administration, and the bad social practice that are now all too common in the welfare field throughout the prairies. As this is written the most hopeful sign for the future is that there is widespread recognition, in all three provinces, of the need for better health and welfare programmes. Alberta and Saskatchewan, as we have seen, made significant changes in their systems in 1944, notably by establishing departments of welfare, and in both provinces there have been official committees recently to investigate problems of the social services. Manitoba, having profited greatly from the Buck report, has arranged for a comprehensive welfare survey by the American Public Welfare Association—a good precedent for the other two provinces to follow. Health and welfare are on the march across the prairies! Jlhere are significant differ- ences between the health and welfare machinery of Ontario and of the western provinces. Ontario has a more mature system than those to be found in the West. One finds here more institutions, public and private, the legacy of the institutional era of the nineteenth century. Local government is stronger, on account of larger and older population units. Counties share with cities, towns, villages, and townships administrative and financial responsibilities for the social services. The local authorities are somewhat more concerned with direct administration than in the West. The role of the provincial government, more than in the provinces that have been surveyed thus far, is to supervise and to assist financially municipal and private agencies. The provincial services are more neatly organized. The evil financial effects of the depression years upon the social services are much less in evidence. Yet in many respects the same problems of organization and administration are also to be found here, in the wealthiest and most populous of the Canadian provinces. As this is written, in mid-1944, important changes are in process, 335 336 Public Health & Welfare Reorganization so that it is difficult to give an account of the health and welfare system that will be good for very long. After a provincial election in 1943 and the assumption of office by the new Progressive- Conservative government, sweeping reforms in health and welfare were initiated, under the minister who assumed both portfolios, Hon. Dr. R. P. Vivian. At the spring session of 1944 the legislature enacted measures to authorize various changes and voted funds for broad extensions of service. Since there has not been time, as yet, for the new schemes to be fully put into operation, the system in existence at the end of 1943 will be described first and the prospective modifications to it will then be sketched. Provincial Functions The provincial health activities, including public health, grants to general hospitals, and the operation -of mental hygiene services, are almost all grouped in the Department of Health. Besides exercising general supervision over the public health services of the municipal boards of health, the department operates some programmes directly and makes grants to the local authorities to assist them in operating others. There is a provincial system of laboratories and the department has well developed divisions of sanitary engineering, industrial hygiene, maternal and child hygiene, venereal disease control, and public health nursing. In 1938 the Sanatoria for Consumptives Act relieved the municipalities of substantially all charges for tuberculosis patients in institutions, these being assumed by the provincial government, and authorized a highly centralized system of tuberculosis control. There are no provincial sanatoria, but to five city and county hospitals and to a number of privately operated institutions the provincial Division of Tuberculosis Prevention makes grants at the rate of $2,075 per patient day. In addition the division operates six travelling tuberculosis clinics, supervises and co-ordinates the clinical and other tuberculosis control work carried on by general Ontario 337 hospitals and local boards of health, supervises the sanatoria, and makes grants to municipal authorities to compensate them for the costs of pneumothorax treatment given to non-institutional tuberculosis patients under the direction of the local boards of health. The division also oversees the other types of after-care for patients discharged from sanatoria which are provided by the local health authorities. The venereal disease programme is a joint provincial-local scheme under the direction of the provincial Division of Venereal Disease Control. There are twenty free treatment clinics, usually located in hospitals, where the medical and nursing staffs, nominated by the local boards of health, are paid in large part by the province. The province distributes certain drugs free to co-operating local boards of health, hospitals, and physicians, pays 25 cents for each treatment given in the local clinics, and meets 75 per cent, of the costs of service to patients from municipalities which have no free clinics. The Department of Health has been authorized for some time to make grants to local health units, but in 1943 was giving such aid (amounting to 50 per cent, of costs up to $15,000 per annum) only to one rural unit. It also makes grants of 20 to 30 per cent, of costs towards school dental clinics and contributes toward the expenses of a crippled children's programme operated by the Ontario Society for Crippled Children. It distributes insulin free to diabetic patients unable to purchase it (with 75 per cent, of the costs assumed by the province and 25 per cent, by the municipalities), sponsors seven cancer centres, supervises nursing education, and performs a number of other miscellaneous public health services. The Division of Medical Statistics collects and analyses statistical data from the various branches of the department and from other sources, but the usual work of a vital statistics division comes under the Registrar-General's Branch of the Department of the Provincial Secretary. Another major function of the department is to supervise and to 338 Public Health & Welfare Reorganization make grants to general hospitals, convalescent institutions, and homes for incurables. The basic rate of aid for general hospitals is 60 cents per patient day for public ward patients, while the basic rates are lower for the other types of institutions. In the Hospitals Division of the department are grouped sixteen mental hospitals (including the Orillia training school for the feebleminded and the Toronto Psychiatric Hospital) and other mental hygiene services. The department has a well developed system of mental health clinics which has been in operation since 1930. In 1943 there were five of these clinics, which operate in close connection with certain of the hospitals. Since 1933 the department has followed a progressive policy of boarding in private homes patients suitable for this type of care. By the end of the fiscal year 1942 (March 31), 559 patients, or 3.6 per cent, of the total number under care, were handled in this way.1 In addition, 6.2 per cent, of the patient population were on probation. These policies of extramural care and supervision have undoubtedly contributed to the virtual stabilization of institutional population which has been achieved in the last few years, a record that is unusual in the Canadian provinces. Ontario's Department of Public Welfare, established in 1931 on the recommendation of the Royal Commission on Public Welfare of 1930, was the only one of its kind in Canada until Alberta, Saskatchewan, Quebec, and Nova Scotia organized departments in 1944. In it are grouped the public assistance and child welfare services. Until recently unemployment relief has been the major concern of the department, on account of the great amounts of Dominion and provincial relief grants which it was disbursing to the municipal authorities. The remnants of the large organization required to administer this programme continue to exist as the Unemployment Relief Branch. However, the name is no longer very appropriate, since grants towards relief for employable persons 1Hospitals Division, Department of Health, Annual Report upon the Ontario Hospitals, 1942, p. 24. Ontario 339 ceased in 1941. Since then grants covering 50 per cent, of costs have been made only in respect of unemployables. The department has supervised rather closely municipal compliance with provincial regulations through field staff reviewing fair-sized samples of case records in local offices and also making some home investigations, as well as by auditing financial records. The regulations have prescribed upper limits of relief allowances for purposes of determining the amounts to be granted to the municipalities, but minimum scales have not been set. A province-wide system of medical care for public assistance recipients has grown out of the unemployment relief programme. Beginning in 1934, the provincial government made an arrangement with the Ontario Medical Association whereby relief recipients might call on the physicians of their choice for medical care. The doctors are paid from pooled funds derived from provincial and municipal contributions monthly in respect of every relief recipient, originally at the rate of 25 cents per person, but now at 56 cents. The scheme is administered through central and district committees of the Ontario Medical Association. In the summer of 1942 arrangements were made to extend the scheme to the recipients of old age and blind pensions and mothers' allowances. Payment of contributions to the Ontario Medical Association and very limited supervision of the plan are responsibilities of the Department of Public Welfare.2 Old age and blind pensions and mothers' allowances are grouped together in what is essentially one branch of the department, although each scheme is directed by a separate commission of three members. A former minister of health was the chairman of both commissions for a time, but there is now a chairman for each commission. Applications for assistance are made in the first instance to the municipal authorities and are passed upon by local boards of five persons, three appointed by the province and two by the municipality, before being forwarded with recommendations to 2The plan is described in some detail in L. C. Marsh, et al., Health and Unemployment (McGill Social Research Series, No. 7, 1938). 340 Public Health & Welfare Reorganization ft! the provincial commissions. There follows further investigation by the provincial field service, which serves both commissions, before final decisions are made. The Children's Aid Branch of the Department of Public Welfare is in charge of the administration of child welfare legislation. Its most notable work in recent years has been the strengthening of the system of children's aid societies, dating back to 1893, of which there were fifty-two in 1942, organized mainly on a county basis. Grants are made towards the salaries of the local superintendents, and a small field staff supervises the work of the societies. The Department of Public Welfare also administers small grants to county and city houses of refuge, and to orphanages, infants' homes, and other minor institutions. To some extent standards for these institutions are prescribed and their work is supervised. The Soldiers' Aid Commission, established at the end of the last war to render certain welfare services to ex-soldiers and their dependents, now carries on functions of minor importance essentially as a branch of the department. The provincial delinquency services are mainly in the Department of the Provincial Secretary. There are three major jails and ten small district jails (the latter in northern Ontario) which are operated by the government. Modern training schools for delinquent boys and girls were established in recent years respectively at Bowmanville and at Gait, but during the war these plants have been taken over by the military authorities and the schools have had temporary and unsatisfactory quarters. Grants are also made by the department to several other institutions operated under private auspices, including the Catholic Church, to which delinquent boys and girls may be committed. Operating under the department is a Board of Parole, which is empowered to order the release on parole of prisoners given indeterminate sentences to the provincial jails. There is a staff of full-time parole officers, but most of the supervision of paroled prisoners is carried on by the provincial police. Ontario 341 The Department of the Attorney-General is empowered to appoint juvenile court judges and probation officers. By 1937, eighteen juvenile courts had been established, covering 52 per cent, of the population.3 Ontario is the only province in Canada with a full-fledged adult probation system. Adult probation officers, appointed and paid by the province, serve the courts of the county of York and the cities of Toronto, Ottawa, and Hamilton, but the system has not been extended to other communities. Municipal Responsibilities The Ontario municipal system is more complicated than those of the western provinces. In southern Ontario there are thirty- eight counties, as well as basic municipal units consisting of cities, towns, villages, and townships within county boundaries. The major operating functions of the counties are highways and bridges, secondary education, and the administration of justice. The 22 cities and 7 "separated towns" of the southern part of the province are quite independent of the counties, performing all the ordinary municipal functions, but the remaining 670 towns, villages, and townships share the responsibilities and powers of local government with the counties in which they are situated. In northern Ontario local government activities in 203 populated areas are carried on by municipal units, while the provincial government administers directly the affairs of citizens living in great expanses of unorganized territory.4 In addition to the local Units that have been mentioned there is a complex system of school authorities, 6,617 in number at the end of 1940.5 The basic local units (cities, towns, villages, and townships) operate generalized public health programmes through boards of health and medical officers of health. As we have seen, they share 3Royal Commission to Investigate the Penal System, Report (1938), p. 183. 4The numbers of municipal units given above are taken from Department of Municipal Affairs, Annual Report of Municipal Statistics, 1942, p. v. 5Report of the Minister of Education, 1940, p. 119. 342 Public Health & Welfare Reorganization responsibility with the provincial government, administratively and financially, for the operation of the venereal disease control programme. In the field of tuberculosis control they perform some case-finding and clinical services and they are responsible for the, after-care of patients discharged from sanatoria. The Sanatoria for Consumptives Act of 1938 requires the local boards of health to meet, for indigent patients released from sanatoria, the expenses of transportation to their homes, of maintenance grants covering the "necessaries of life," and of certain special treatments which they may require. In the case of municipalities other than cities and separated towns, these costs are divided equally with the counties in which they are situated. I General relief is another important function of the basic municipal units, and in this the counties have had no part, administratively or financially. To a very limited extent, through appointing two members to the local boards dealing with applications and through providing some clerical assistance, the municipalities take part in the administration of old age and blind pensions and mothers' allowances. However, they are concerned directly with a substantial institutional programme, through their obligation under provincial statute for the maintenance of houses of refuge for the benefit of indigent persons requiring institutional care. Counties, cities, and separated towns are required to maintain such institutions, either separately or jointly. They also operate common jails, of which there were 37 in the province in 1942 (35 county and 2 city),6 to which offenders sentenced to short terms (commonly three months or less) are committed. The municipalities are further concerned with delinquency services because the cities, separated towns, and counties in which juvenile courts have been established are responsible for meeting the costs of judges and probation officers as well as for the operation of detention facilities for juvenile offenders. 6Annual Report upon the Prisons and Reformatories of Ontario, 1942, p. 25. Ontario 343 In addition to complete or partial financial responsibility for the programmes which they administer, the municipal authorities are required to assume charges for a number of other services. They meet part of the costs of the medical relief scheme operated by the Ontario Medical Association. They contribute, at a basic rate of $1.75 per day, towards the maintenance of indigent patients in general hospitals,and they make payments also for indigent patients in convalescent and incurable institutions. They are required to pay (through the counties) the maintenance costs of children committed by the courts to the care of children's aid societies. They pay small amounts to the provincial government for the maintenance of indigent residents in the mental, hospitals and they are charged for the care and treatment given to their residents at the Toronto Psychiatric Hospital. They are liable also for certain other charges in respect of care given to indigent or delinquent persons. In the case of the municipalities other than cities and separated towns a number of these social service costs are divided between them and their respective Counties. Departmental organization is fairly well developed in the cities, but is very slight in the towns and villages and the rural communities. Toronto, Hamilton, Ottawa, London, Windsor, and other cities have well developed health departments. There was only one rural health unit in 1943 covering the three counties of Stormont, Dundas, and Glengarry, which was established in 1940. Elsewhere public health work in the small towns and rural communities has been carried on usually by part-time medical officers of health, with or without the assistance of public health nurses and sanitary inspectors. The leading cities also have welfare or relief departments, most of them having been organized to deal with relief problems during the depression years. However, the welfare departments of Hamilton, Ottawa, Windsor, York Township and a few^other urban communities date back well beyond the depression of the 1930's. In Toronto a modern department of public welfare, 844 Public Health & Welfare Reorganization integrating the major welfare activities of the city, was established in 1931 on the recommendation of the Civic Unemployment Relief Committee of that year. But in the smaller cities and towns and in the rural townships there is little or nothing in the way of formal organization to deal with welfare problems, municipal officials performing welfare duties along with other types of work. The Reforms of 1944 Following a survey of welfare problems in the spring of 1944, by Miss Charlotte Whitton, formerly Executive Director of the Canadian Welfare Council, the provincial government made provision for important changes in the system. The legislature also passed the Municipal Health Services Act to authorize schemes of medical care for residents of municipalities whose electors, by majority vote, chose to be covered. The act contemplates local financing, from property or personal taxes or a combination of both, to be supplemented by provincial aid to an amount which is not specified. The actual administration of service is to be undertaken by a provincial agency to be established, the Ontario Municipal Health Services Board, and details, both major and minor, are left undefined, to be prescribed in regulations. The act is a brief enabling measure authorizing a health insurance system which makes no reference to Dominion plans or proposals on the subject. Thus Ontario becomes the fourth province (the others being British Columbia, Alberta, and Saskatchewan) to place health insurance legislation on its statute books in advance of federal action. More important in immediate results will no doubt be an amendment to the Public Health Act, which was also adopted at the spring session of the legislature in 1944, and a sharp increase in appropriations for public health. The amendment broadens previous provisions for the establishment of local health units, notably by bringing school medical services more clearly within their scope. A fund of $150,000 was voted for special health Ontario 345 services in unorganized territory and for grants to health units, and it was announced that a vigorous effort would be made to encourage, by means of grants, the formation of units throughout the province. Plans call for grants amounting to 25 to 50 per cent, of total budgets in organized municipalities, rising in some cases to 100 per cent, of costs in unorganized territory. Community units with minimum population of 30,000 to 35,000 are contemplated, with cities which meet the population requirements being accepted as administrative districts and smaller municipalities being required to join with others to form new districts. Besides strengthening the local health services the programme calls for extension and reorganization of the work of the provincial Department of Health. A new Public Health Administration Branch has been established to direct and supervise the local services. Steps are being taken to decentralize the direct service rendered by the department, by means of the establishment of regional administrative districts each serving from 150,000 to 200,000 people. Each regional centre will offer laboratory, sanitary engineering, tuberculosis prevention, industrial hygiene, and other services, entirely at provincial expense. The system of mental hygiene clinics is also to be reorganized on the same regional basis, so that the number of clinics is to be increased to about twenty. Since the staffing of the expanded health programme was recognized as a central problem, a special appropriation of $42,000 was made for the training of personnel, including grants to students and to training centres, and the School of Hygiene of the University of Toronto has agreed to undertake training responsibilities.7 The Merits of the System Without taking into account the progressive measures which have just been adopted, the Ontario system of health and welfare 7The foregoing section on health plans is based mainly upon information contained in a letter from Dr. B. T. McGhie, Deputy Minister of Health, April 17,1944. 846 Public Health & Welfare Reorganization has had a number of strong points. The mental hygiene programme has been the best in Canada, on account of competent direction and administration, more adequate physical facilities than in other provinces, an extensive system of mental health clinics, a progressive scheme of parole and boarding-home care, and other characteristics. Both the tuberculosis and venereal disease schemes have been greatly extended and strengthened in the last few years, and there has been other good work in public health at both the provincial and the local levels. During recent years strong children's aid societies have been developed throughout the province under vigorous provincial leadership, and an outstanding job has been done in building up an excellent system of child welfare services. The medical relief scheme, recently extended to recipients of old age and blind pensions and mothers' allowances, puts Ontario far ahead of other provinces in the provision of medical care for needy persons. In the provision of training school facilities for juvenile delinquents and of adult and juvenile probation and parole services, Ontario is in advance of sister provinces. The health and welfare services are grouped much better at the provincial level than in most provinces and in the cities local organization is also relatively superior. In the fields of public health, delinquency control, and child welfare the authorities have given valuable leadership to the activities of municipal agencies and private groups. Some Outstanding Problems 1. Gaps and Inadequacies But important problems are not lacking in Ontario. The first of these is insufficient service of one kind or another. Juvenile courts cover little more than half of the population and effective juvenile probation service a good deal less. The adult probation programme operates only in York County and in the cities of Toronto, Hamilton, and Ottawa, Up to the present there has been only one Ontario 347 rural health unit, and a great part of the population in small towns and villages and rural communities lacks the advantage of full-time public health service. The present provincial policy of making no grants to the municipalities in respect of relief for employable persons has led the local authorities generally to deny relief to this group. While this is not important at present on account of the unusual wartime demands for labour, the policy is- one that is bound to do some injustice in individual cases and that is all too likely to carry over into a period when unemployment again becomes serious. No such rigid policy is socially defensible. The provincial government appears to have made less provision throughout the depression years for transient homeless men and other municipal non-residents than the western provinces, and there is no adequate machinery to deal with the problems of these groups should they become serious again. During the depression standards of relief varied a good deal from place to place, and all the reports that are available suggest that allowances were usually inadequate to maintain needy families at a socially desirable level of health and efficiency.8 In 1941, a committee of three experts appointed by the city council, Dr. F. F. Tisdall, Dr. Alice Willard, and Miss Marjorie Bell, investigated the adequacy of relief food allowances in Toronto, The committee concluded that, as of October, 1941, "the present relief allowance is not sufficient to permit families to secure food adequate for health. "9 For example, the minimum cost of adequate diets for a family of two adults with three children four to twelve years of age was set by the committee at $10.00 per week; but the city relief schedule only permitted a grant of $6.42.10 The minimum allow- 8See H. M. Cassidy, Unemployment and Relief in Ontario* 1929-1932 (1932), chap. 7; L. C. Marsh, et. al., Health and Unemployment (1938), chap. 20; and A. E. Grauer, Public Assistance and Social Insurance (Rowell-Sirois Commission Studies, 1940), pp. 23 ff. 9City of Toronto, Report on Study of Relief Food Allowances and Costs (November, 1941), p. 3. ™Ibid., p. 30. Public Health & Welfare Reorganization ances calculated by the committee were far above the maxima authorized by the provincial government for purposes of the 50 per cent, grant towards relief costs. These maxima, in the summer of 1942, were the amounts recommended in the "Campbell Report" of 193211 plus 50 per cent, to allow for advances in living costs. For a family of five this maximum allowance was $7.50 per week. Since Toronto relief scales have been much more generous than those of most Ontario municipalities and since the majority of the municipalities have not been making grants up to the maximum amounts authorized by the provincial government, it appears that food allowances throughout the province have been generally too low. Grants for shelter, clothing, fuel, and other items have been much less adequate, on the whole, than those for food. A leading characteristic of depression relief policy in Ontario was well stated by the Welfare Council of Toronto in a brief presented to the Rowell-Sirois Commission in April, 1938: "The whole matter is regarded as a burden upon the taxpayers which, almost at all costs, must be kept down to the smallest possible amount. The desire to economize seems to find its easiest field in the relief of the poor; we suggest that there is no field in which false economy is more dangerous or in which evasion of responsibility for the sake of economy has more disastrous long-run effects." Unhappily, the statement applies also to relief policy throughout the whole country. During the war period complaints about the inadequacy of public assistance grants mounted on account of increased living costs, and there have been various adjustments. Prolonged agitation by the Toronto Welfare Council and other groups led to the adoption in Toronto, in 1943, of the Tisdall-Willard-Bell standards, which represented an advance well beyond the amount of the increase in living costs. The provincial government has increased substanti- nReport of ~the Advisory Committee on Direct Relief to the Provincial Government of Ontario. Ontario 349 ally the mothers' allowances scales and the old age and blind pensions. Limited information suggests that relief scales are still much too low in most communities outside of Toronto, while the categorical aid grants are more satisfactory. 2. Distribution of Functions and Finances . Assuming solution of the problems of finance and of small local units which are discussed below, the present distribution of operating functions between the provincial government and the municipal authorities is reasonable, except at a few points. The outstanding instance of the local authorities operating services which might better be undertaken by the province is that of the city and county jails. Far better results could almost certainly be obtained if these were taken over by the province, to be made part of an integrated provincial system of correctional institutions, as was proposed by the Royal Commission on Public Welfare of 1930. There is probably a similar case for provincial operation of the present city and county refuges and juvenile detention homes, at least in the case of those in the smaller population units, which are not likely to provide enough inmates at any time to justify the operation of satisfactory institutions of the kind. On the other hand, much of the administration of the categorical aids might be delegated to the local authorities, as in British Columbia. From the account of provincial-municipal financial relationships which has been given in the preceding pages it is apparent that these are unusually complex. Municipally operated services are aided by seven or eight different types of grants from the province, but the municipalities contribute to the costs of some provincially operated services, notably mental hospitals and the training schools for delinquent boys and girls. In addition both the province and the local authorities make grants to various private and semi-private organizations, such as the children's aid societies and the hospitals. In some instances, but not in others, the local share of these social Public Health & Welfare Reorganization service costs is divided between the counties and the basic municipal units. There is little rhyme or reason in this complicated system. Why should the municipalities contribute to the costs of the juvenile training schools when the province makes substantial grants to assist them with general relief? Why should the province make grants in respect of patients in houses of refuge but not towards the salaries of probation officers or the maintenance of indigent patients released from tuberculosis sanatoria? Why should the county assume the costs of children committed to the care of children's aid societies while the local share of the much larger item of general relief is charged altogether against the constituent municipalities? It is apparent that these various arrangements have grown up one by one and that they do not add up to a logical scheme of distribution of financial responsibilities for health and welfare. A careful survey of the problem would probably show that the system might be greatly simplified, with the number of separate grant and payment items being cut down, and that this would lead to economies in accounting and in other administrative work. Since municipal charges for persons who are given care or treatment in various types of institutions or material aid in their own homes are prescribed in a number of different statutes of the provincial government, there must be residence rules in connection with each scheme to determine specifically the persons for whom the local authorities are chargeable. The residence provisions of the different statutes differ considerably in detail, so that a person who "belongs" to one municipality for one purpose may not belong for another. There is an obvious need, both in the interests of the beneficiaries and of simplified administration, for such a codification of these different sets of residence provisions, more than ten in number, as has been provided in British Columbia by the Residence and Responsibility Act.12 12See chap. 4,j>p. 120-122. Ontario 351 The financial resources of the Ontario municipalities differ enormously, but the existing system of distributing the burden of health and welfare charges among them does not recognize this fact. Assessed valuations for local property taxation varied in 1940 from a low figure of $67 per capita of population in a rural township (Bangor) to high figures of about $2,000 or $2,500 in a few wealthy villages and to an extreme figure of $19,115 in the tiny industrial town of Ojibway. In municipalities with more than 5,000 people, where a much smaller range of variation would be expected, the low figure was $188 in Eastview and the high figure $1,665 in Tisdale.13 Since these are local assessment figures and since assessment policies and procedures differ from place to place, they give only a rough indication of variations in tax-paying capacity. During the depression years the provincial government assumed full responsibility for relief costs in a number of weak municipalities which were unable to meet all of their obligations, but apart from this nothing has been done to equalize the burdens of health and welfare charges upon the municipal units.14 In the field of education, on the other hand, there has been recognition of the need for a system of equalization grants. Provincial aid for education is complicated, involving several different types of payments. The most important of these are the grants in aid of elementary public schools, which vary in accordance with the tax resources of the local school districts. Grants towards secondary education also vary, to some extent, with local needs. The net result of the system is for government funds to be directed largely towards the assistance of rural school districts, where tax- paying capacity is typically much less than in the cities. Yet in spite of this variable grant policy great differences in the extent and the quality of educational service, in expenditures per pupil,^ and in taxation for educational purposes, continue to exist between the 13Department of Municipal Affairs, Annual Report of Municipal Statistics, 1940. 14However, the new system of health unit grants which is now planned contemplates equalization provisions. 352 Public Health & Welfare Reorganization different school districts, for government aid, amounting only to 14 per cent, of total school expenditures in 1939,15 has not been large enough to exert a significant equalizing influence. A writer who has discussed the question with great competence concludes his analysis as follows: "Equalization of educational opportunity and of the burden of educational support are highly desirable. They do not exist in Ontario."16 The statement is even more applicable to the health and welfare situation. 3. Local Units Out of 902 local municipalities, 92 had more than 5,000 population in 1942,17 and in these communities there was concentrated about two-thirds of the total population residing within municipal boundaries. Although the problem of the small local administrative unit is less serious than in the western provinces the fact that about a third of the municipal population resides in the 810 municipalities with less than 5,000 people shows that it also exists in Ontario. The need for larger administrative units has been recognized by the present government in formulating the new plans for health and welfare which were described above. However, the existence of the county system has mitigated to some extent the disadvantages of small local municipalities. County assumption of some health and welfare charges has spread the burden of costs over a larger area than if these were all carried by the local municipalities, and thus has lessened somewhat the range of variation'in the incidence of these burdens. The counties are more satisfactory units for operating houses of refuge and jails than the small municipalities. They seem to have served well as the districts for children's aid societies. Since all of the counties 15Report of the Minister of Education, 1940, p. 111. 16Maxwell A. Cameron, The Financing of Education in Ontario (Bulletin No. 7 of the Department of Educational Research, University of Toronto, 1937), p. 161. 17Department of Municipal Affairs, Annual Report of Municipal Statistics, 1942, p. 8. Ontario 353 exceed 5,000 in population, and since all but two have more than 15,000 people, most of them are large enough to be satisfactory administrative units for health and welfare. It would seem that the existing county system might be used largely as the framework for a new system of local administrative areas. A special problem of local organization is presented by the cluster of urban communities surrounding the city of Toronto and, to a less extent, the cities of Ottawa and Hamilton. The Toronto metropolitan area is made up of the city and twelve suburban municipalities. It is probable that distinct advantages would be derived from the organization of a metropolitan health agency to serve this area, as has been done for the 'Vancouver district, and that a similar case could be made for a metropolitan welfare department. These problems of health and welfare organization shade into the larger problem of municipal reorganization for all purposes in metropolitan areas. In one instance vigorous action has been taken to deal with such difficulties, when the border cities were amalgamated in 1934 to form the new city of Windsor. The provincial Department of Education has been actively encouraging the formation of larger school districts for a number of years, partly through offering certain "inducement grants." Legislation authorizing consolidation of small school districts dates from 1927. The union of over 900 small school sections into about 100 township school districts in the two years ending June, 1942,18 suggests that this policy is achieving considerable results. Yet there remain some 6,000 different school authorities! It is not strange, therefore, that Dr. Maxwell A. Cameron concludes his study on the financing of education in Ontario with "the profound conviction that a larger administrative unit is the most pressing need of education in Ontario. "19 It is also one of the most pressing needs in the allied fields of health and welfare. 18As reported to the writer by Dr. G. F. Rogers, Deputy Minister of Education, June 29, 1942. ™0p. cit, p. 170. 354 Public Health <§c Welfare Reorganization 4. Departmental Organization The provincial Department of Health is a relatively strong and well organized agency, directed by competent permanent officials, and the major health services are well integrated in it. It has been much improved, in 1944, by the addition of the new Public Health Administration Branch, which will oversee the local health services, and the proposed decentralization of its direct service activities, on a regional basis, should strengthen it further. But a few questions may be raised regarding the department. It would be strengthened by the addition of a vital statistics branch, which might be achieved by transferring the collection of vital statistics from the Department of the Provincial Secretary. So long as the department handles the administration of general hospital grants and the supervision of hospitals a case can also be made for transferring to it the medical relief scheme which now comes under the Department of Public Welfare. Whether they are under the departments of health or of welfare these two programmes should be grouped together. Health insurance, of course, either in the form contemplated in the new Medical Services Act or in the form of a joint Dominion-provincial plan, will call for the abolition or the drastic revision of the present hospital and medical relief plans and for an integrated attack upon these problems. On the other hand, direction by the health department of the local programme of maintenance grants for patients released from tuberculosis sanatoria is to be questioned. This is essentially a public assistance job which, other things being equal, would more effectively be performed by local welfare agencies under the supervision of the provincial welfare department. The annual report of the provincial Division on Tuberculosis Prevention for 1940 acknowledges that "this work by the central office entails a considerable amount of time-consuming investigation and correspondence as well as other activities common in a welfare office."20 The fact that such a 20Department of Health, Annual Report, 1940, p. 126. Ontario 355 clear-cut public assistance job was placed in the hands of the health authorities, provincial and local, when the progressive Sanatoria for Consumptives Act was adopted in 1938, suggests that the public health men who formulated the scheme had but little confidence in the local welfare machinery. Hasty appraisal of the internal organization and administration of the department suggests that it has too many operating branches. The departmental Estimates for 1944-1945 list eleven major divisions of public health work, in addition to offices that administer general hospital grants and the mental institutions. In a department so much concerned with the social problems of the sick and the handicapped there might well be medical social work and psychiatric social work units to provide technical service for the whole agency. It would seem also that so large an organization, with an annual budget of about $13,500,000 and a large staff, should have a personnel unit. Full advantage has not been taken of the integration of public assistance and child welfare in the Department of Public Welfare. The several different branches appear to operate more or less independently of one another. No attempt has been made to build up a unified field service except for the purpose of serving the Old Age and Blind Pensions and the Mothers' Allowances commissions. Three other field programmes are carried on, those in connection with child welfare, relief administration, and the supervision of houses of refuge. While a completely integrated field staff for the department would not necessarily be the right solution, it seems probable that much might be done to pull together these several field activities. District offices for field agents might be advisable. Greater integration of field work might lead to considerable savings in travelling expenses. Another weakness of the department is that it lacks overhead offices, serving all branches, to be concerned with research and statistics, accounting and business management, and personnel. The department is further hampered through having under it 356 Public Health & Welfare Reorganization three administrative boards, the Old Age and Blind Pensions Commission, the Mothers' Allowances Commission, and the Soldiers' Aid Commission, all established by statute. The first two commissions are not really independent, for they are appointed and their duties are prescribed by government order-in-council. Thus there is no justification for them on the ground that they are impartial agencies, acting as trustees for the performance of important public duties. On the other hand, they may be positive detriments to good organization and administration, since in the past they have had certain political influence, so that they could stand in the way of straight-line administrative control and co-ordination over all branches of the department by the minister and the deputy minister. A former minister of health has been the head of these two commissions, and this fact alone suggests the difficulty that the deputy minister, a permanent civil servant, must have had in exercising control over old age and blind pensions and mothers' allowances during the period up to 1943, "when the chairman's political party was in office. These commissions might well be abolished, to be replaced by a departmental branch carrying on the ordinary business of administration and a statutory board made up of outstanding citizens, serving for little or no pay, which would perform advisory functions and would hear appeals from the decisions of departmental officials regarding applications for aid. The Soldiers' Aid Commission performs unimportant functions, and it too might be replaced by an advisory body, with its administrative duties being taken over by other branches or by a small special unit of the department. Excepting through its progressive Children's Aid Branch, the department has done but little to give constructive leadership in public welfare throughout the province. During most of the depression period the Unemployment Relief Branch was charged with the administration of a harsh and repressive policy of keeping relief costs to a minimum; a policy which it apparently carried out with a good deal of efficiency. Only through the field staff of this branch has the department had much contact with the local welfare Ontario 357 departments. Under these circumstances it is not surprising that not much has been done to assist the local authorities in building strong and progressive welfare agencies. The provincial department should have a competent field staff that renders a positive service of assistance and guidance to the local agencies with reference to all phases of their welfare activities. Division of the provincial delinquency services between the departments of the Provincial Secretary and the Attorney-General is open to much question. At the least, they should be integrated under the Provincial Secretary. In a province the size of Ontario, with a substantial institutional programme for delinquents, there is a case to be made for a separate department in charge of this work. But on the other hand there are disadvantages in the separation of the delinquency services from the related welfare activities. It is particularly desirable that juvenile probation and the institutional care of juvenile delinquents should be closely related to the child welfare services. Therefore there is much to be said for transferring all the delinquency services to the Department of Public Welfare as was recommended by the Royal Commission on Public Welfare of 1930. The question is one that deserves careful study. Health organization on the local level appears to range from fairly good in Toronto and other cities to very poor in the bulk of the small communities. School medical services and generalized public health should be integrated. These are problems which the new health unit policies should go far to solve. As it has been suggested above, it is not appropriate for the medical officers of health to administer the public assistance grants made to patients released from tuberculosis sanatoria. In the welfare field the need for reorganization locally is probably much greater. Even in Toronto, which has had a large welfare department for some ten years, there has been much criticism of the agency, and the City Council has called upon the Public Administration Service of Chicago to make an administrative survey. Social 358 Public Health & Welfare Reorganization ii work observers have also been very critical of the internal organization and the policies of the welfare agencies in Ottawa and other cities; and there is little or no formal organization for public welfare in the bulk of the smaller communities and rural districts. In the absence of detailed information on the situation in most Ontario municipalities, it is difficult to make valid generalizations. However, a survey by the Canadian Welfare Council of a progressive city of 14,000 people suggests the existence of organizational weaknesses that must be very common.21 Relief administration was under the Relief Officer, hospitalization problems and admissions to the County House of Refuge were handled through the mayor's office, civic obligations for children committed to the care of children's aid societies and to reformatory institutions received some attention from the city clerk or from financial officers of the city, public grants to charitable agencies were made by the council without reference to the Relief Officer, and various other welfare problems were handled rather casually. All of these activities, the Canadian Welfare Council report proposed, should come under a reorganized civic welfare department. The local boards which pass upon applications for old age and blind pensions and mothers' allowances are quite separate from the local welfare agencies. There seems to be no need for this. Strong welfare departments should be able to do a better job of dealing with these applications than the present boards, which have little or no paid assistance, whether the making of the final decision remains with the provincial government or is delegated to the local authorities. 5. Standards of Administration Standards of administration seem to have been relatively good in the fields of public health, mental hygiene, and child welfare, except for public health work in the rural communities. But in the areas of public assistance and delinquency control poor adminis- 2i The Welfare Services of the City of Gait, 1938-39. Ontario 359 tration and antiquated practices are all too common. One indication of this is that the case loads of public assistance workers, both provincial and local, have commonly been far higher than good practice decrees. For example, in 1938 one relief officer in Gait was carrying the responsibility for the distribution of relief to about 218 cases monthly,22 at least twice as many as a competent social worker should be asked to handle. It was reported to the writer in the summer of 1942 that provincial visitors dealing with old age and blind pensions and mothers' allowances were carrying as many as 1,200 cases, a burden that would make really adequate service impossible. The prevalence during the depression years (and the situation has not changed materially since then) of antiquated poor law methods of doling out relief is well expressed in a brief presented by the Toronto Welfare Council to the Royal Commission on Dominion- Provincial Relations in April, 1938, as follows: For the most part relief is given in kind or in vouchers exchangeable in stores, less often in cash. In the matter of clothing there is no settled policy. In some localities no allowance is made for this obvious need; in some a very small cash grant is given; in some the relief is given in kind. In the latter case the method illustrates one general defect of public relief as now administered. The task is regarded as one of meeting the obvious necessities of a homogeneous class of needy persons. Individual differences of need and individual sensibilities are apt to be forgotten. The value of self- respect and family respect is often neglected. The brief goes on to point out the great lack, in relief administration, of measures of rehabilitation and of personal service designed to lift recipients out of the dependent class and so to lessen the burden of community support of the destitute. The evidence at hand suggests strongly that in the great majority of the local public assistance agencies of Ontario there has been but little application of good principles of administration. 22Ibid., p. 50. 360 Public Health & Welfare Reorganization The operation of the local jails has been seriously criticized by observers. They were condemned unreservedly by the Royal Commission on Public Welfare of 1930, which said that "they are inferior in nearly every sense of the word. They . . . are as likely to promote offences as to prevent them."23 In 1938 the Royal Commission to Investigate the Penal System reported that the local jails in Canada (including those of Ontario) were practically all "erected many years ago and, from the point of view of reformation, classification, segregation, or providing useful employment, they are entirely inadequate."24 Whether such sweeping statements would be applicable today is uncertain because of lack of evidence. The Department of the Provincial Secretary has made real efforts to improve the jails during recent years and apparently has achieved some success. But the intrinsic difficulties of making good institutions out of a number of small jails, each with short-stay prisoners, are very great. According to all reports conditions are very much better in the provincial penal institutions for adults. But these, too, however well managed they may be in certain respects, should be directed more than at present towards the training and the reformation of offenders. 6. The Personnel Problem As in other provinces the weaknesses in policy and in administration which have been pointed out are intimately related to the problem of poor personnel. As we have seen, the public health, mental hygiene, and child welfare programmes are comparatively well managed. These are the services that are generally directed and staffed by professionally trained personnel—public health physicians and nurses, psychiatrists, and social workers. In these branches of health and welfare the employing authorities have wisely drawn upon the graduates of the training schools of the ^Report, p. 77. ^Report, p. 16. Ontario 361 province, notably the School of Medicine, the School of Hygiene, and the School of Social Work of the University of Toronto, to build up their staffs. But in the weaker branches of service, public assistance and delinquency, there has been a serious lack of such a personnel policy, and the net result is that the administrative work in these fields has been predominantly in the hands of unqualified staff. By and large there has been no serious effort to recruit trained social workers for relief administration, except that after 1934 a number were drawn into the service of the Department of Public Welfare during a brief period of reorganization. But some of the appointments were unwise because young social workers were asked to perform administrative duties for which they were not equipped, the reform movement soon receded, and a number of the social workers who remained found their conditions of work increasingly uncongenial, so that one by one they retired, baffled and discouraged. During the last few years the provincial government has employed few trained social workers in its public assistance services, nor has it set such personnel standards for the local welfare departments. However, a few of these, including Toronto, London, and Windsor, have improved their personnel without aid from the province and are now staffed, partly at least, with trained workers. In Toronto and some other places there are probation officers who have had specialized training for their work, while competent teachers and institutional workers have held positions on the staffs of the provincial juvenile training schools. But there has been no consistent province-wide policy of obtaining professional personnel for the delinquency services. Political control over appointments appears to have stood seriously in the way of good personnel policies in the provincial agencies. On every hand, both from informed outsiders and from responsible officials of the provincial government, the visitor in 1942 heard of the baneful effects of a patronage system that was, apparently, a good deal less benevolent than in the western 362 Public Health & Welfare Reorganization provinces. In the summer of 1942 the writer found much evidence of discouragement and poor morale among the more competent civil servants on account of the great importance of politics in personnel matters. The situation was particularly difficult in the fields of public assistance and delinquency control, where the political authorities saw no need for technically trained staff as they did in the fields of public health and mental hygiene. The province has no independent civil service agency; and without this it will probably be very hard to correct the problems that have been described. However, an excellent example of what can be done to improve personnel standards, even in a highly political environment, is afforded by the work of the Children's Aid Branch of the Department of Public Welfare. In 1934, when the present superintendent was appointed, there were trained social workers only in three children's aid societies, those of Toronto, Hamilton, and Ottawa. A policy was adopted of grading the societies in accordance with their standards of work and of offering grants towards the salaries of the superintendents which increased in amount as the society attained a higher grade. This led progressively to the replacement of many of the superintendents, so that in 1942 only fifteen of the original group were left and twenty-one of those in charge of the fifty-two societies in the province were professionally trained for their work. At the same time a consistent policy of encouraging the appointment of qualified staff members was followed, so that by the summer of 1942 there were trained social workers in all but seventeen of the societies, making up approximately 75 per cent, of the total staff members holding social work positions.25 One of the leading recommendations of the Royal Commission on Public Welfare of 1930 was that professional social workers should be employed in public welfare; and the Royal Commission to Investigate the Penal System urged most strongly the use of 25Data provided by Children's'Aid Branch, June 25, 1942. Ontario 363 trained personnel in the delinquency services. It is apparent that these personnel proposals have been followed only to a limited extent in Ontario. Conclusion From this analysis we may conclude that the outstanding needs in Ontario are for a reorganized and revitalized provincial welfare department, for simplification of provincial-municipal financial relationships and a system of grants that recognizes the great differences in municipal needs for assistance, for reorganized local health and welfare units, and for a positive personnel policy designed to attract trained and competent persons into provincial and local services. Vigorous provincial leadership in the fields of public assistance and delinquency control is much to be desired. Ontario is fortunate in that it has both the economic resources and the key personnel necessary to develop a first-class system of health and welfare services, so that in this province there is less excuse for serious deficiencies than in the Prairie Provinces or the Maritimes. Already the provincial government has taken significant steps to solve major problems in the health field; and plans are being drafted for similar action in the field of welfare. Quebec i, _N QUEBEC WE FIND A PATTERN of organization for health and welfare that is unique in Canada. It is a pattern compounded of two elements—private charity, mainly under Catholic auspices, and state responsibility for social welfare. There is still, in responsible and authoritative French-Canadian circles, more confidence in private charity than in state responsibility. This point of view was clearly expressed by Prof. Esdras Minville, Director of L'Ecole des Hautes Etudes Commerciales of Montreal, in one of the monographs prepared for the Royal Commission on Dominion-Provincial Relations, as follows: "In the province of Quebec, the organization of social welfare is in the hands of private initiative, and Catholics are generally agreed that it must so remain. Let the state intervene to make up the deficiency, to complete, but never to displace or dominate."1 This is rather a statement of what leading French Catholics would like than a description of the actual situation. For, as Prof. 1Labour Legislation and Social Services in the Province of Quebec (Appendix No. 5 to the Commission's Report, 1939), p. 97. 364 Quebec 365 Minville points out in his study, the older system of private charity proved unable to deal, unassisted, with the heavy burden of social needs that emerged at the conclusion of the last war; and the Public Charities Act was passed by the provincial government in 1921 to provide for public subsidies towards charitable institutions and agencies. In the 1930's the great volume of destitution incidental to economic depression led to the adoption of a provincial-municipal unemployment relief programme and of provincially operated systems of old age pensions and mothers' allowances, as well as to the substantial expansion of public health measures. Thus the new element in the system, state responsibility, has increased greatly in importance during recent years. There have been additional changes in 1944, to be described below, which involve further assumption of responsibility by the state, and still further developments of this nature are in early prospect. Thus the two elements, old and new, are in somewhat uneasy association, if not in actual conflict. In principle Quebec may cling to the old system, but in practice it has been necessary to accept ever more of the new. The difficulty of blending the two elements into a consistent whole goes far to explain the deficiencies in the health and welfare services of the province that will appear in the following pages. The system prevailing at the end of 1943 will be described first, to be followed by brief comment on important changes which were authorized in the spring of 1944 and which are now in process. Provincial Functions Organizationally, the provincial scene was dominated up to 1944 by the Department of Health and Social Welfare, in which were grouped the usual public health services, administration of grants to and supervision of mental hospitals, and administration of the Public Charities Act. The latter scheme, because it represents the leading effort in Quebec to reconcile the principles of private charity and state responsibility, will be described first. 866 Public Health & Welfare Reorganization The act is designed to provide a sound financial basis for the operation of private (mainly religious) charitable institutions and agencies of various sorts. In principle each of three partners, the private agency, the municipality, and the provincial government, bears one-third of the costs of the care given to needy persons by the agency. Charitable institutions must be approved for grants by the Bureau of Public Charities of the Department of Health and Social Welfare. They then become eligible to receive subsidies from the government at the rate of two-thirds of an arbitrarily determined daily cost allowance for each inmate or client. The municipal share of the grants, in respect of persons who under the law are local residents, is later collected by the government. Varying daily allowances are set by the Bureau of Public Charities as the basis for grants to ten classes of institutions: general hospitals, special hospitals for convalescent and chronic patients, refuges for the aged, orphanages, maternity hospitals, creches, day nurseries, crippled children's institutions, epileptic hospitals, and tuberculosis sanatoria. Institutions with special needs may be given additional assistance in the form of loans and advances, and special grants and subsidies are also payable to certain agencies providing non- institutional care. Public funds for * the programme are raised partially by means of earmarked taxes collected by the provincial government and the municipalities, notably a 5-per-cent. tax on restaurant meals and some amusement taxes. In addition the provincial government contributes $1,000,000 annually from the earnings of the Quebec Liquor Commission. In the fiscal year 1940-1941 some 200 institutions and agencies received grants to the amount of $6,759,677.2 The Bureau of Public Charities exercises only slight supervision over the subsidized agencies. It is empowered to obtain from them certain reports and it has in law some power of control by virtue of its authority to approve institutions for grants and to 2Quebec Statistical Year Book, 1941, p. 214. Quebec 367 set the daily cost allowances upon which the grants are based. But it is not specifically authorized to prescribe standards of operation as a condition of aid. Indeed, the law definitely protects Catholic institutions against provincial control by virtue of the following provisions: "In the application of . . . regulations under the act, as in the operation of this act, whenever religious communities of the Catholic faith are concerned, the rights of the bishop over such communities, as well as their religious, moral, and disciplinary interests, shall in no way be prejudiced"; and "every contract made with a charitable institution directed by a religious community of the Roman Catholic faith must be approved by the Ordinary of the diocese in which such community is situated."3 A further indication of the limited provincial authority is the fact that in case of dispute regarding the responsibility of a given municipality to make contributions in respect of any person it is the courts, not the bureau, which settle the case. There is a somewhat similar system for the care of mental patients. There are seven mental institutions in the province which are listed, in Dominion and provincial official reports, as "provincial" or "public" institutions. But only one of these, the Bordeaux institution for the criminally insane, is actually operated by the provincial government. The others are administered by private agencies (all of them Catholic religious bodies except the corporation of the Protestant Hospital for the Insane at Verdun) under contract with the government. They are financed by per- diem payments in respect of patients, half from the province and half from the municipalities of origin. However, the government has more control over the mental hospitals than over the institutions which come under the Public Charities Act, for it is empowered to appoint the medical superintendents and also, in the case of three hospitals, certain other medical officers. The superintendents are authorized to make rules and regulations regarding internal manage- 3S.R.Q., 1941, c. 187, s. 20, 21. 368 Public Health & Welfare Reorganization ::lSr ment, subject to the approval of the government. In practice, supervision of the hospitals by the Mental Hospitals Branch of the Department of Health and Social Welfare appears to be quite limited, the branch acting chiefly as an accounting office. Alongside of these systems of state-private collaboration in institutional care is a centralized public programme of preventive medicine. Since 1926 a system of county health units has been established which now covers the greater part of rural Quebec. By 1942 there were fifty- seven rural units serving sixty-nine out of seventy-six counties and these, together with certain urban health departments, gave full-time public health service to 87.3 per cent, of the population.4 The units are staffed by physicians, nurses, sanitary inspectors, and clerical personnel who are appointed and paid and whose activities are directed by the provincial health department. The programme is financed by the proceeds of county taxation, at the rate of lj^ cents per $100 of assessed valuation (2 cents in the case of cities or towns over 4,000 in population which are served by a health unit), and by provincial funds to cover the remaining costs. In the fiscal year 1941-1942 the province met $448,868 out of total costs of $567,034, or about 79 per cent.5 Montreal and some other cities have independent health departments which are outside the county unit system. The provincial department is empowered to establish units in all parts of the province, and this authority is being used progressively with the object of complete coverage in the near future. In the department there are also divisions of tuberculosis and venereal disease control. The tuberculosis division co-ordinates tuberculosis control work within the province, maintains a central record system of known cases, operates a number of stationary and travelling diagnostic and treatment clinics, directs and advises the physicians and the public health nurses of the local health agencies information provided by Department of Health and Social Welfare, July, 1942. *lbid. Quebec 369 in their anti-tuberculosis work, and endeavours to bring about effective utilization of beds in the sanatoria. Since 1929 the division has operated the Grancher system of removing children from tuberculous families and placing them at governmental expense in country foster-homes to protect them against infection. This scheme, which by 1941 had served some 2,000 children, is a notable variation from the Public Charities Act pattern of care by private organizations with governmental financial assistance. The department also operates an extensive venereal disease programme, including free clinics and treatment centres (of which there were eighty in 1941),6 distribution of drugs to private physicians, and compulsory reports by physicians on cases coming to their attention. In addition there are divisions concerned with laboratory service, industrial hygiene, sanitary engineering, vital statistics, epidemiology, nutrition, and publicity. All of these branches appear to be relatively well developed. In view of the substantial uniformity of organization and practice on the local level it is possible for these provincial divisions to work effectively in co-operation with the local health agencies. Penal and delinquency institutions in the province (apart from the federal St. Vincent de Paul penitentiary) are of three classes: prisons, reformatory schools, and industrial schools. There are twenty-eight prisons which are operated by the provincial Attorney- General's Department, all of them small institutions except one in the Montreal district and one at Quebec. However, the pattern of public-private collaboration reappears in the case of the reformatory schools and the industrial schools. These are managed by private organizations, mainly religious bodies, under contract with the government, with their funds derived chiefly from equal provincial and municipal payments in respect of the juveniles committed to their care. There are three reformatory schools to which delinquents from ten to sixteen years of age are ^Quebec Statistical Year Book, 1941, p. 107. 370 Public Health & Welfare Reorganization M committed. Six industrial schools care for children under fourteen years of age "who are without shelter or exposed to undesirable conditions" and "also receive children less than twelve years of age who have been condemned, at the request of their parents, owing to their bad and vicious habits or lack of discipline. The detention is ordered by a justice of the peace, a magistrate, a sheriff, or a prothonotary. "7 Juvenile courts have been established only in Montreal and Quebec City, the salaries of the judges being paid by the provincial government. The courts are under the jurisdiction of the Department of the Attorney-General, while the juvenile delinquency institutions are under the Provincial Secretary's Department. When we turn to public assistance we find publicly operated and financed programmes more similar to those of the other provinces than the institutional schemes that have been described. From the beginning of the 1930's the provincial government accepted Dominion grants-in-aid toward unemployment relief and passed on financial assistance to its municipalities to enable them to issue direct relief to the unemployed or to operate work relief programmes. After granting assistance according to various formulae, the province was assuming 40 per cent, of the costs of municipally administered direct relief in the last two years of the programme, the fiscal years 1939-1941, with 40 per cent, coming from Dominion grants and 20 per cent, being paid by the municipal authorities. Provincial grants ceased, except for a few special arrangements, when Dominion aid was discontinued as of March 31, 1941. However, all municipalities were not aided during the 1930's nor did the assisted municipalities all receive aid on the same percentage basis. During the fiscal years ending 1935 to 1941 the number of municipalities in receipt of assistance was not more than 152, out of a total of nearly 1,500, in any one year.8 In the case of some communities the Dominion and provincial grants covered up to 99 per cent, of "?Ibid., p. 210. ^General Report of the Minister of Public Worksi 1941, p. 90. Quebec 371 all expenditures, while in a number of defaulting municipalities under the administrative supervision of the Quebec Municipal Commission the Dominion and the province met all costs. During the ten years of the relief programme total expenditures were approximately $240,000,000, of which the province contributed about 51 per cent., the Dominion 28 per cent., and the municipal authorities 21 per cent.9 Administration of the provincial phase of this programme was mainly carried on by an unemployment relief division originally established in the Department of Public Works, transferred in 1936 to the Department of Municipal Affairs, Lands and Forests, then shifted to the Department of Labour, and eventually, in 1939, turned into an independent agency, the Bureau of Economic Reconstruction—which, in 1943, was virtually abolished. The unemployment relief division did but little to prescribe standards of service by the municipal authorities and evidently exercised only a very limited supervision over their activities, although in some cases/it took over their administrative work completely. All during the depression period there was provincial administration of relief for needy settlers in colonization areas, and this is still being carried on under a separate provincial agency, the Department of Colonization. In 1936 Quebec adopted an old age pension act and in 1937 there followed legislation to authorize blind pensions and aid to needy mothers. These three schemes are administered, under the Department of Labour, by separate commissions, one for old age pensions and blind pensions and the other for aid to needy mothers. However, the two commissions have the same chairman and are served by the same administrative staff, so that they really make up one operating bureau. Apart from the Dominion grants toward old age pensions and blind pensions the province bears all the expenses of these schemes, and it meets all the costs 9Based on figures in ^he General Report of the Minister of Public Works, 1941, p."l02{ 37£ Public Health & Welfare Reorganization of mothers' allowances. Applications and investigations are handled through a staff of inspectors scattered throughout the province. Changes in 1944 Radical changes in the provincial system were made in the spring of 1944, as a result of investigations begun in 1941, when the government appointed the Commission of Inquiry into Hospitals. In 1943 this body recommended, among other things, the establishment of a commission to work out the details of a health insurance system. The legislature responded by establishing the Quebec Health Insurance Commission. Later this commission was asked to inquire also into problems of child welfare. To this work it addressed itself promptly, and in its first report, issued in the spring of 1944, it proposed child protection legislation similar to that of Ontario and other provinces, separate provincial departments of health and welfare, and a number of other reforms. With unusual speed the provincial legislature adopted the first two recommendations. The new Children's Protection Act authorizes a system of "child protection societies " essentially the same in function and in powers as those of Ontario, British Columbia, and other provinces. They are to be chartered and supervised by the government, working through the "Child Protection Superior Council" (an advisory body) and the Superintendent of Child Protection. Neglected children may be committed by the courts to the societies, or to the superintendent, and the costs of the child's maintenance are to be shared equally by the province and the municipality in which the child was domiciled. The legislature also authorized a system of family courts which would replace the existing juvenile courts of Montreal and Quebec City and would deal, among other things* with all child protection cases. Finally, the legislature established! separate ministries of health and welfare. As this is written administrative steps are being taken to put the new policies into Quebec 373 effect. These developments represent a major breach in the Public Charities system which has prevailed for more than twenty years, for the important category of neglected children is pulled out of it entirely. Municipal Activities The system of local government in Quebec is more similar to that of Ontario than to those of the western provinces for it includes seventy-six counties as well as basic municipal units. In 1940 there were 134 urban municipalities, of which 26 were cities and 108 towns; and 1,365 rural municipalities, consisting of villages, townships, parishes, or parts or combinations of such units. Except in the case of special arrangements (as under the law regarding the formation of county health units, to which cities or towns may belong) the urban municipalities operate quite independently of the counties. But the counties perform limited services of general concern to the rural municipalities within their boundaries, and the county councils are made up of the elected heads of their constituent municipalities. From what has been said already it will appear that the municipalities of Quebec have operating responsibilities for health and welfare which are distinctly less than those of the municipal bodies of Ontario and the West. There is a legal obligation upon them to make provision for basic public health services; but since this obligation can be discharged now through the county health units, which are operated virtually as branches of the provincial health department, the role of strictly municipal health programmes is progressively becoming more limited. Only in Montreal and Quebec City and a few other cities are there full-fledged local health departments apart from the county health units. In those towns and rural municipalities not yet covered by county units there are various arrangements, as in other parts of Canada, for the performance of elementary public health functions by part-time health officers. 374 Public Health & Welfare Reorganization Local welfare organization is even more undeveloped, outside of Montreal. During the years of depression there were some 900 municipalities that received no unemployment relief grants from the provincial government;10 and in these, presumably, no attempt was made to issue home relief to destitute persons. In other places in receipt of grants the municipal authorities commonly arranged for private organizations, notably the St. Vincent de Paul Society with its parish branches, to administer direct relief. Only in Montreal, Quebec, Verdun and a few other larger cities were municipal welfare or relief departments established. While the municipalities are permitted to offer home relief under the municipal law of the province, there is no legal obligation upon them to do so, and their relief activities virtually ceased when Dominion and provincial unemployment relief grants were discontinued in 1941. During the depression years many local governments had given assistance in the home to unemployables as well as to employables, but with the cessation of the grants this form of relief seems also to have been generally discontinued. Even in Montreal, where the problem of the unemployable group has been particularly acute, indigent relief was cut out in 1940, on the ground that private agencies should be able to meet all such needs. While their operating activities in public health and welfare are quite small, the municipal authorities have heavy financial obligations. As we have seen, they contribute towards the costs of maintaining the sick, the orphans, the mentally ill, the feeble-minded, neglected children, juvenile delinquents, and other groups in institutions of one kind or another, and they also meet part of the costs of the county health units. There is a good deal of administrative work involved in the admission of patients to institutions and the determination of municipal financial obligations with respect to these persons. Such work now takes up a 1 information from Quebec Board of Economic Reconstruction, July 24, 1942. Quebec 875 large part of the time of the few local welfare departments that exist, such as the Department of Social Welfare of the City of Montreal. Merits of the System Quebec's outstanding health and welfare achievement in recent years has been the development of the county health units. In 1026 only 30.6 per cent, of the population, in Montreal and four other cities in the Montreal area, had the advantages of full-time public health service by qualified doctors and other personnel, while today nearly, 90 per cent, of the population is covered. Thus Quebec has taken a leading position in Canada in the development of adequate local public health service. Clearly such progress could not have been made without vigorous and intelligent leadership from the provincial health department. The department is also to be commended for its progressive tuberculosis and venereal disease control programmes, for its scheme of placing children from tuberculous families in country foster homes, and for other aspects of its work. These marked advances in public health have been accompanied by sharp decreases in the mortality rates during recent years. From 1926 to 1940 the general mortality rate dropped from 14.2 to 10.1 per 1,000 of population; the infant death rate from 142.0 to 70.3 per 1,000 births; the tuberculosis rate from 125.2 to 76.2 per 100,000 of population; the diphtheria rate from 14.0 to 7.1; and the typhoid rate from 9.0 to 4.0.n This excellent record must be due in large part to the public health programme. The Public Charities Act is an ingenious device for preserving the values of church and other private charitable effort in an age when it can no longer carry heavy financial burdens without public support. It has been estimated that the work of the religious and other institutions (carried on largely by members of religious orders who serve for little or no pay) represents service to the value 18Figures from Department of Health and Social Welfare, July, 1942. 876 Public Health & Welfare Reorganization of about $10,000,000 per year, which otherwise would have to be contributed by the taxpayers.12 Perhaps the system also does something to stimulate a better quality of private health and welfare service than would exist if public programmes were better developed. This may help to explain the fact that the private social services of Montreal, for the English-speaking population, are in many ways stronger than in any other Canadian city. Leading Problems I. Gaps and Inadequate Service On the other hand, there is an array of problems in Quebec similar to those to be found in the other provinces, together with some special problems incidental to the unique role played by private charity. In the first place, there are serious gaps in service, while certain types of service are very inadequate. As it has been pointed out, there is virtually no provision of general relief by the municipal authorities at the present time. In the summer of 1942 private welfare officials of Montreal informed the writer that the policy of the city in refusing aid to unemployable applicants threw a burden upon the private agencies which they could meet only with great difficulty. Even during the period of unemployment relief there was never full acceptance of public responsibility by the City of Montreal, with the result that many persons, such as technical non-residents, deserted women with children, and various categories of unemployables were ineligible for public assistance. The results of this policy are described as follows by the Unemployment Study Committee of the Montreal Branch of the Canadian Association of Social Workers in a report prepared in March, 1938. This unsatisfactory practice of denying relief to these people has caused great distress among the needy and tremendous confusion to social agencies and the general public. Immediately there grew up a large body of single individuals and family groups 12Esdras Minville, op. cit., p. 49. Quebec 877 who had nowhere to turn for help. Private social agencies, churches, missions, refuges, and even private individuals were assailed from all sides, . . . begging increased, health was impaired, furniture and household goods were seized as families were evicted, and still the need was not met. Some of the most urgent cases were assisted by a few of the relief-giving private social agencies, but the problem was beyond their scope and the agencies became heavily indebted with little hope of reimbursement from municipal funds. It was obvious that private social agencies could not hope to deal with the problem. Relief allowances during the depression years were generally inadequate, according to various reports that have been made. Prof. L. C. Marsh concludes that in 1936 "by the most conservative comparison . . . Montreal food allowances were fifteen per cent. deficient."13 In 1941 the Montreal Department of Social Welfare introduced a new policy of limiting relief grants to any one recipient, irrespective of number of dependents, to $12 per week; and this cut the grants to large families far below a subsistence level. The situation was probably worse in most of the smaller cities and towns than in Montreal during the depression years, both because of lower scales of assistance and because of more stringent eligibility rules. By 1938 most of the smaller places which had been issuing direct relief abolished it entirely, substituting municipal work programmes instead.14 This policy, of course, made no provision for those unable to work on the rough municipal projects. One of the major reasons for the ineligibility of destitute persons for relief during the depression years was the system of local residence rules that grew up. The provincial government issued no regulations on this subject and each municipality was free to formulate its own rules. Montreal and various other places established a basic three-year rule and the regulation was common that a person lost residence when he left a given community or lzHealth and Unemployment (1938), p. 168. 14Esdras Minville, op. cit., p. 80. 878 Public Health & Welfare Reorganization shortly afterwards. In consequence many people became ineligible for aid both in the places where they lived at any given time and in the places where they had formerly resided. In addition to this confused and inequitable combination of municipal regulations regarding relief recipients, there are several different sets of residence rules to determine municipal responsibility for social service charges under the Public Charities Act and other schemes. The net result is a complex of residence rules affecting different classes of persons which lacks uniformity,15 which is very unfair in its incidence upon individuals and upon some municipalities, which leads to many disputes between municipal units, and which must be expensive to administer. Thorough review of the whole system would almost certainly show that it could be greatly simplified to the advantage of every interest concerned, the provincial government, the municipal authorities, the private institutions, and the recipients of social services. Another outstanding gap in the public welfare system of the province has been the lack of constructive provision for neglected and dependent children—which is now to be remedied by the children's protection agencies authorized by the Children's Protection Act of 1944. The subsidized private agencies have offered a great deal of institutional care. But there has been no general system of public or semi-public agencies like the children's aid societies of other provinces, to protect children in weak families, to arrange foster-home care, or to deal with problems of adoption.16 In the absence of such service many children who, in other provinces, would be living in family homes, have been placed in institutions. An unusually large number have been treated as young delinquents. As of December 31, 1939, there were 2,051 children in the industrial 15See Canadian Welfare Council, Residence and Settlement Legislation in Canada (1939), pp. 20-23. 16However, in 1937, the Societe d'Adoption et de Protection de VEnfance was organized in Montreal to perform such functions, and it has been subsidized under the Public Charities Act. Similar child-caring agencies have been organized recently at Quebec City, Three Rivers, and Sherbrooke. Quebec 379 schools of the Province and 926 in the reformatory schools, a total of 2,977,17 while the total number in all Canadian institutions for juvenile delinquents was 4,880.18 Thus Quebec, with about 30 per cent, of the population of Canada, had more than 60 per cent, of the delinquent children in institutions. In Ontario, whose population is somewhat greater than that of Quebec, the number of young delinquents in provincial training schools was 615 at the end of 1939.19 Out of the 2,051 children in the Quebec industrial schools at the end of 1939, 73 were less than six years of age and about half were less than ten years of age. Such conditions are not in accord with good standards of child care, which call for a policy of keeping the child with his own family or placing him in a foster-home unless there are very strong reasons for institutional placement.20 Adequate provisions for medical care for the needy (apart from hospitalization) are also lacking. During the depression years_ Montreal had a broad medical care scheme in operation, but Quebec and other cities did not, and their policy was much more the rule than that of Montreal.21 There has been no juvenile probation service except in connection with the juvenile courts of Montreal and 17Quebec Statistical Year Book, 1941, pp. 207, 210. 18Canada Year Book, 1941, p. 942. 19Annual Report on the Ontario Training Schools, 1941, p. 44. 20The Quebec Social Insurance Commission appointed by the provincial government in 1930 (the Montpetit commission), stressed this point and advocated the formation of children's aid societies to undertake protective work and child placement on a selective, individualized basis. The Health Insurance Commission of 1944 reiterated the argument in its first report, stating that "it is astonishing to find that the state of affairs pointed out by the Montpetit report seems still to exist: a very small percentage of the children in public institutions are orphans, fatherless and motherless. The dislocation of families which this fact implies is heart-rending. . . . Besides, the institutions are now overburdened . . . the representatives of the institutions have unanimously deplored to the Commission their inability to meet the ever more pressing requirements, through lack of space in their buildings, small- ness of their means, or numerical insufficiency of their domestic staff." (P. 9.) 21A prominent provincial health official expressed the view to the writer that if adequate medical care could be provided in the rural districts to supplement existin * public health services the infant mortality rate of the Province could soon be cut in half. 380 Public Health & Welfare Reorganization u Quebec City. Adult probation and parole services are non-existent. Psychiatric clinic service is available only at Montreal and Quebec, under the auspices of the local health departments and co-operating universities. Prof. Esdras Minville, in his report for the Rowell- Sirois Commission in 1939, stated that there was an estimated shortage of about 1,000 beds for tuberculosis patients and that many beds for mental patients were also needed.22 The mothers' allowances scheme, while a very great step forward, provides grants too small for the numerous large families in need of assistance (more than a third of them with four children or more in the fiscal year 1940-1941),23 for the maximum grant is only $50 per month. Such families are commonly given supplementary assistance by private agencies in Montreal. Thus in many respects the public health and welfare services of the province are deficient and it does not appear that the deficiencies are all made good by the private organizations, extensive as are their programmes. 2. Weakness of the Public Subsidy System There are serious problems associated with the system of subsidizing private organizations. For one thing, the policy encourages institutional care. The number of inmates of homes for the aged, orphanages, and other charitable institutions is much higher in Quebec, in relation to population, than in Ontario and the western provinces. Since the subsidized private organizations receive grants on a per-diem inmate basis they have no economic motive to refuse applications for admission if they have space available or to discharge inmates. Even if they have the desire to limit institutional care they do not have the facilities to do so, for each organization operates independently, without the close 220p. dt, pp. 90-91. 2SReport on the Old Age Pensions Act . . . and the Needy Mothers' Assistance Act, 1941, p. 43. Quebec 381 relations with agencies serving people in their own homes or in foster-homes which are essential to the reduction of the institutional rolls. Fundamental objections to welfare institutions were admirably stated nearly a century ago by Dr. Samuel Gridley Howe, the great social reformer of Massachusetts, as follows: The more I reflect upon the subject the more I see objections in principle and practice to asylums. What right have we to pack off the poor, the old, the blind into asylums? They are of us, our brothers, our sisters—they belong in families; they are deprived of the dearest relations of life in being put away in masses in asylums. Asylums are generally the offspring of a low order of feeling; their chief recommendation is often that they do cheaply what we ought to think of only as doing well.24 Dr. Howe's point of view has come to be generally accepted by modern authorities on social welfare in the English-speaking portions of Canada and the United States, both Catholic and Protestant. Therefore to point out the disadvantages of the predominantly Catholic institutional programme of Quebec is not to criticize Catholic social doctrine. There is also an undue stress on institutional care in the Maritime Provinces, where there are strong Protestant majorities, and Protestant Ontario probably keeps many people in houses of refuge who might better be maintained in family homes. In all of these cases undue institutionalization is more an example of old social welfare practices that were common a century ago lingering on than it is a reflection of differing views among religious groups. Another objection to the subsidy system as it now operates is that it does not provide adequately for co-ordination of the efforts of the various assisted organizations. In the case of the mental hospitals, for example, there are no central arrangements for the classification of patients and their transfer from one institu- 24Quoted in Edith Abbott, Some American Pioneers in Social Welfare (1937), p. 96. Modern experience shows they usually are expensive, rather than cheap. 382 Public Health & Welfare Reorganization tion to another. Mental hospital statistics are not reported directly to the provincial government, which must obtain them from the reports of the Dominion Bureau of Statistics. There is no central machinery for the development and the implementing of general policies on admissions and discharges, methods of treatment, buildings and equipment, training and appointment of personnel, or after-care of patients. The system is not favourable to the development of psychiatric clinics and boarding-home programmes province-wide in their application, such as have been so successful in Ontario. Many part-time doctors are employed in the various hospitals, and they work independently of those in other institutions, without the professional stimulus which comes from the frequent contacts between members of a large organization. In short, the system does not give the province an integrated mental hygiene programme. Similar criticisms may be made of the subsidy system in connection with the institutions for juvenile delinquents, general and special hospitals, and other branches of the institutional programme. Lack of uniformity in the nature and the quality of the service given by institutions of the same general class is another problem. In many cases the written contracts between the government and the assisted organization simply require them to continue giving such care "as has been customary," without any specifications regarding diets, room standards, ratio of staff to inmates, or other such items. The government does not publish detailed reports on the operation of the assisted institutions and the writer has no specific information on the quality of their work, except that this differs materially from agency to agency. The subsidy system does not make specific provision for the meeting of capital charges, particularly to cover the construction of new facilities. The private organizations have been unable to finance new buildings and equipment in many instances and have appealed to the provincial government for help. This has been given frequently in the form of loans, advances, or special capital Quebec 383 grants. But since there is no formal policy on the subject, set down clearly in law and regulations, there has been a tendency for provincial ministers to settle individual claims separately with political considerations very much in mind. Closely related to this problem is the fact that the various subsidized institutions of a given class press frequently for increased grants or for transfer one by one to a category in which the grants are higher. With many decisions to be made regarding specific claims, either by a class of institutions or by single institutions, and with ministerial authority to settle these questions finally, it is inevitable that political pressures play a large part in administration. The power of the government to make special grants for operating purposes, over and above the regular subsidies, is an additional factor that invites political intervention. There are also certain other difficulties of the system. Grants at fixed rates may be reasonable for some institutions but are not adequate for others. There has been considerable trouble over the determination of municipal responsibility for charges in respect of certain persons, on account of residence rules that are not sufficiently clear and detailed and the lack of provincial machinery for making proper investigations and settling disputes. Either on account of financial incapacity or unwillingness to pay, many municipalities have failed to contribute their share of the grants, and the government has had difficulty in making collections, partly because of political objections to using its legal powers to force payment. In the summer of 1942 the writer was informed by provincial officials that arrears were about $2,000,000. From this brief review it appears that all is not well with the subsidy system in Quebec. This is recognized to a substantial extent by responsible opinion in the province and various suggestions have been made for reform of the system. The Quebec Social Insurance Commission recommended in 1932 a number of changes in policy, including greater provision for grants to organizations providing service in the home rather than in institutions. 384 Public Health & Welfare Reorganization The government has given some thought to replacing the municipal charges based upon payments in respect of individuals by a general tax to be collected by the municipalities and paid in to the Public Charities Fund. Generally, experience with public aid to private charities has not been favourable in English-speaking Canada and the United States, and the weight of informed opinion is against the system unless it is very carefully surrounded with safeguards against abuse. A leading American writer on the subject states that "if appropriations are to be made they should, according to the authorities mentioned, be specific payments for specific services safeguarded by (1) inspection of the agency, (2) reporting and auditing of accounts, (3) control of admissions and discharges, (4) setting the same rate of payment for the same class of dependents, and (5) development of public institutions as rapidly as possible to care for public wards."25 In the past there has been considerable reluctance in Quebec to accept such criteria. Prof. Minville, for example, is unwilling to entrust complete control to the government, although he admits the desirability of greater central direction. He thinks that "the Church must keep the guiding hand" over the institutions insofar as moral and spiritual matters are concerned; while the social workers practising their profession within the institutions are obviously not qualified to exercise general control. Hence he concludes that "there is thus only one possible formula: loyal co-operation between the three forms of authority. And that, at present, is the prevailing state of affairs."26 Unhappily this position leads virtually to a denial of the possibility of reform. More direction by the provincial government is essential if the more serious deficiencies of the system are to be 25Arlien Johnson, Public Policy and Private Charities (1931), p. 4. 260p. cit., p. 71. The services of the Catholic institutions and their peculiar value, from the French Catholic point of view, are described in Arthur Saint-Pierre, VCEuvre des Congregations religieuses de charite dans la province de Quebec (1930). Quebec 385 overcome. Such direction need not mean domination. There are many steps that might be taken to obtain co-ordination, greater uniformity of standards, non-political administration of grants, simplification and clarification of residence rules, and other improvements that would not infringe seriously on the autonomy of the private organizations and that would, indeed, relieve them of many troubles. Specifications on minimum standards of equipment and service, central arrangements regarding classification of inmates and transfer from one institution to another, limitation of the number of day's stay for which grants are payable, and provincial technical service to assist the institutional managers are among the possible measures that might be undertaken. And there is much to be said for the appointment of a non-partisan board to make decisions on grants. Such items should contribute substantially towards a more satisfactory formula for state-private collaboration in social welfare than the one which exists at present. The foregoing analysis of the Public Charities problem derives support from the recent report of the Quebec Commission of Inquiry into Hospitals which was appointed in 1941. In a summary of the commission's findings which appears in The Dominion Labour Gazette, January, 1944 (p. 14), it is stated: The Commission submitted that the system . . . was inadequate under present conditions. The burden on the institutions was becoming increasingly difficult to bear. . . . An undue burden was also being placed on the municipalities with the increase in the number of indigent patients . . . and a particularly undesirable aspect . . . was that the poorest municipalities were those in which there was the greatest need for hospitalization. Moreover, the means test to which the patient was subjected was always humiliating and frequently delayed urgent treatment. The main criticism, however, went further than this . . . the existing system had contributed nothing to the maintenance or improvement of the health of the people . . . since its purpose was purely to provide hospitalization for indigent persons . . . there was an "urgent need for the state to interpose more fully in matters of the general health." 386 Public Health & Welfare Reorganization 3. The Local Financial Burden In Quebec, as elsewhere, many complaints are made by the municipal authorities about the financial burden of the health and welfare services. During* the years of depression many were financially unable to meet their percentage share of the costs of direct relief or work relief schemes authorized by the provincial government. Both the percentage-grant system in the case of unemployment relief and the per-person charges of the subsidy system fail to take into account the varying financial resources of the local authorities. The provincial report on Municipal Statistics, 1940, shows that in that year about 11 per cent, of the total expenditures of the 1,365 rural municipalities were for "insane and public charities," but analysis of the figures shows that the proportion of total expenditures devoted to this item varied from little or nothing in some places to more than 50 per cent, in a few. Whether the total burden is too great or not, it is quite evident that present arrangements do not spread it equitably among the municipal units. There has been some recognition of this problem by the provincial government. The most notable example of a constructive approach is to be found in the scheme of financing the health units, with the province bearing about four-fifths of the total costs and the municipalities being required to contribute only limited amounts based upon their assessed valuations. This is a scheme which makes for genuine equalization of the financial burden of public health. Through giving some municipalities more assistance with respect to unemployment relief than others and through excusing some from making payments under the Public Charities Act, as it is empowered to do, the province has also recognized the claims of the poorest municipalities. But these have only been limited and casual measures that do not go very far towards dealing with a serious problem. What is obviously needed is complete reform of the financial arrangements in connection with the subsidy system, as well as the provision of grants towards municipal general relief, Quebec 387 to make up a total programme of municipal contributions in accordance with capacity to pay. 4. Local Administrative Units There are many small municipalities in Quebec, as in other provinces, which have too little population to be satisfactory administrative units for health and welfare purposes. In 1941 all of the 1,365 rural municipalities had fewer than 5,000 inhabitants, their populations typically ranging from 500 to 1,500. However, all but one of the 26 cities and 17 out of 108 towns had more than 5,000 people, and these larger places included nearly half of the total population of the province.27 At present the problem of the small administrative unit is less important in Quebec than in other provinces on account of the limited operating responsibilities of the municipalities. But if, as they should, they were to make some provision for general relief, there would be a solid core of social welfare activities to which present administration in connection with admission of residents to private institutions, the financial transactions incidental to the grant system, the co-ordination of community activities in the welfare field, and other work might be added. The rural municipalities are much too small to perform such functions efficiently. In Quebec, therefore, as in other provinces, there is much to be said for establishing welfare districts that include a number of municipalities. The county system might be used as the basis of such a programme, as has been done already in the case of the health units. All but 13 of the 76 counties exceed 10,000 in population, and the great majority of them would probably be large enough to constitute satisfactory areas of welfare administration. 5. Departmental Organization The provincial public health services have been well grouped in the Department of^Healthrand Social" Welfare. But the welfare 27Based upon figures in Quebec, Statistical Year Book, 1941, pp. 64-68. 388 Public Health & Welfare Reorganization 12 services have been badly scattered, mental hospital grants and administration of the Public Charities Act being under the health department, pensions for the aged and the blind and grants to needy mothers under the Department of Labour, the remnants of unemployment relief under the Board of Economic Reconstruction, prisons, the inspection of jails, and juvenile courts under the Attorney-General's Department, grants to reformatory and industrial schools under the Department of the Provincial Secretary, and relief to settlers in colonization areas under the Department of Colonization. Under these circumstances unity and consistency in policy and vigorous leadership by the provincial government in the welfare field could not be expected. As Prof. Minville has said, "in the Province of Quebec, notwithstanding a few partial efforts for co-ordination, the organization of social welfare is still remarkable for its scattered condition."28 The outstanding need is obviously the'better grouping of the welfare services. If general relief, and perhaps relief to the settlers in colonization areas, were grouped with old age and blind pensions and mothers' allowances the home relief services would be pulled together. These public assistance programmes, together with the Bureau of Public Charities, would make up a substantial provincial welfare department. In such a department the new bureau of child protection should be placed. The delinquency services should also be pulled together, preferably to be placed in the welfare department, although it would be much better for them to be under either the Provincial Secretary or the Attorney-General than divided between the two, as at present. The mental hospital programme might remain under the health department. As we have seen, a new department of welfare has just been authorized. Information is not available, as this is written, regarding its component parts. The Quebec Health Insurance Commission has recommended that it be given responsibility for the 280p. cit., p. 96. Quebec 389 administration of old age and blind pensions, mothers' allowances, child protection legislation, the Child Protection Tuberculosis Act, and that part of the Public Charities scheme which relates to institutions other than hospitals, "this implying a division of the public charities fund between the Departments of Health and Social Welfare."29 One further point regarding administrative machinery at the provincial level deserves brief comment. As in Ontario, two separate, although closely related, commissions are in charge of the administration of old age and blind pensions and mothers' allowances, under a provincial department. The criticisms that have been made against the Ontario plan in the preceding chapter are also applicable to this situation. The machinery is unnecessarily cumbersome, and it would seem better to provide for straight- line departmental administration, with the commissions being retained only to perform advisory and appeal functions. On the local level the administrative machinery for public health is relatively well developed on account of the existence of health departments in Montreal, Quebec, and other cities and the broad coverage of the county health units. But outside of Montreal and a few other places there are virtually no local welfare departments. There will be enough for specialized public welfare agencies to do if the municipalities make provision for some general relief and if welfare districts are formed in the rural areas. A vigorous and progressive provincial department would encourage the development of local welfare departments just as the health department has sponsored the creation of county health units. 6. The Personnel Problem The Department of Health and Social Welfare has followed a consistent policy for a number of years of recruiting professionally trained public health physicians, nurses, and other personnel. ^Report, p. 13. 390 Public Health & Welfare Reorganization Besides drawing upon the graduates of training courses at the Quebec universities, the department has encouraged young doctors to study at schools of public health outside the province, such as those at Johns Hopkins University, Harvard University, and the University of Toronto, and has then offered them positions. As a consequence of these policies the public health personnel, both provincial and local, seems to be unusually well qualified. But so much cannot be said of the welfare services. The provincial government has made no attempt to recruit personnel with special training for the major public assistance programmes which it operates. During the days of unemployment relief the same was true of the municipalities. The inspectors dealing with applications for old age and blind pensions and mothers' allowances are chiefly men, although some women are employed for the mothers' allowances work in Montreal and Quebec City. The salary scale of inspectors in the summer of 1942, according to information given the writer by provincial officials, ranged between $600 and $1,500. Apparently appointments to these posts have been frankly on a political basis. Thus there are very few trained social workers in the employ of public agencies. The provincial government has not laid down personnel standards for the organizations to which it makes grants. However, in a number of these, both French and English, there are trained social workers. There are social work training programmes in Montreal at McGill University and at the University of Montreal from which the private agencies in the Montreal area are able to recruit staff, and recently Laval University has established a curriculum in social work. Clearly there is a great need for the development of more adequate personnel policies in the welfare field. This was recognized by the Health Insurance Commission of 1944, which pointed out the need for expert social workers and advocated government support of university training programmes, bursaries to trainees, and other measures to develop competent staff. Quebec Conclusion 391 In conclusion it seems appropriate to refer again to what was said at the beginning of this chapter—that in the health and welfare system of Quebec there are two elements that are in uneasy association, an old element of private charity and a new element of state responsibility for social welfare. The Public Charities Act represents an attempt to reconcile the two elements that has been only partially successful, and this formula calls for revision. Increasingly the new element has grown in importance. It has brought with it a brilliant achievement in_the field of public health, leading to an amazing decrease in the hazards to health and life during recent years. But acceptance of the new element has been slower in the welfare field, indispensable public services such as general relief and child protection have been lacking, and there is serious administrative confusion. There is urgent need for integration of the welfare services of the provincial government and for provincial leadership in the public welfare field comparable to that which has been provided in public health. Such leadership need not mean the displacement of the older element of private charity. On the other hand, the traditional system might be retained in its essentials to perform certain institutional and other work with greater uniformity in standards and co-ordination being achieved than at present. It is encouraging to note the acceptance of this view, in large measure, by the recent provincial commissions on hospitals and on health insurance, and the prompt adoption by the government of some of their recommendations. Apparently the ice has been broken, and the health and welfare system of Quebec is in a process of transition, out of which will emerge a pattern more similar to that of the other provinces than in the past. 11 The Maritimes THREE MARITIME PROVINCES have more than their fair share of social problems, while their economic resources for dealing with them are less than those of other parts of Canada. Their economies are based mainly upon the extractive industries of agriculture, forestry, mining, and fishing, their natural resources have long been exploited, they have had to sell cheap in world markets and buy dear in the tariff-protected Canadian market, and their young people have been migrating for many decades to other parts of Canada and to the United States. In consequence they have relatively small populations. According to the Dominion census of 1941, the population of New Brunswick was 453,377, that of Nova Scotia was 577,962, and that of Prince Edward Island was 95,047. During the 1920's they stood far below the other main divisions of Canada in per-capita national income; while in the 1930's they were practically on the same low plane as the drought-ridden Prairie Provinces. In 1936 their average per-capita income was only a little over $200, as compared with a national average of $384/ Hampered by their economic 1W. A. Mackintosh, The Economic Background of Dominion-Provincial Relations, Rowell-Sirois Commission Studies (Ottawa: 1939), p. 71. 392 The Maritimes 393 disabilities and politically preoccupied with the problem of overcoming them, they have been less inclined to develop new social services than Ontario and the West and have continued to rely to a large extent upon old poor law policies and practices dating back to Colonial days. Yet the growing pressure of social problems and changes in thinking on social issues have combined to bring about some important advances in recent years, notably in public health and child welfare. Besides the need for improving and developing further the social services of all three provinces there are important problems of administrative reorganization incidental to the integration of old and new activities. NEW BRUNSWICK Since the ancient poor law doctrine of local responsibility is so much in evidence in the public health and welfare provisions of New Brunswick, it will be well to describe local government organization at the outset. The province is divided into fifteen counties, whose councils levy taxes and carry on the main functions of local government in the rural districts. The rural areas are further divided into 152 parishes, which have administrative and financial responsibilities for poor relief. In addition there are three cities (Saint John, Fredericton, and Moncton), twenty towns, and three villages, which share the usual powers and responsibilities of local government with the counties in which they are situated— except in the case of Fredericton, which is quite independent of its county. Besides these municipal units there are many school districts. Thus there is a simple structure of local government, made up of relatively few units apart from the school districts and the parishes. Public Assistance The rural parishes and the cities and towns are responsible for the relief of the poor, under the provisions of a statute of the newly created province of New Brunswick in 1786 which has been amended I 394 Public Health & Welfare Reorganization very little since its first enactment. This law was a colonial draft of the Elizabethan poor law, dating from 1601, which then prevailed in England and which had also been copied in the New England colonies from which so many of the Loyalist settlers in New Brunswick had come. In each parish three overseers of the poor are appointed by the county councils; and in the cities and towns commissioners of the poor are appointed by the city and town councils. The overseers and commissioners are charged with responsibility for the administration of poor relief (including home relief, hospitalization and medical care, and institutional care) to those persons within their jurisdiction. Eligibility for assistance is determined by settlement rules which prescribe, basically, three years of residence in parish, city, or town. The costs of relief are charged against the taxpayers of the responsible unit (parish, city, or town), and the councils (the county councils in the case of the parishes) are required to levy the necessary taxes on the request of the overseers or commissioners. The local poor law authorities are authorized to operate almshouses (now termed municipal homes) either for their respective units or for several districts. In March of 1943 "each county had one or more almshouses, depending on the need. "5 There is no provincial direction or supervision of the poor law system, and the poor law authorities are evidently free to grant little or no relief if they lack funds for the purpose or if they desire to follow this policy. There remain in the law ancient provisions, including authority for the apprenticing of destitute children and for the commitment to jail of men refusing to accept employment who are likely to become public charges. This old poor law system was unable to meet the heavy demands made upon it during the 1930's, so that the municipal authorities of New Brunswick were compelled to set up separate programmes of 2According to a memorandum from the provincial Director of Municipal Affairs. He states further that "we do not have any record of the actual number in operation. There are no districts in the province which are not served by such homes." The Maritimes 895 unemployment relief, with financial assistance from the provincial and the Dominion governments. Both direct relief and work relief were provided by the leading municipalities. But in 1937 all provincial grants to the municipalities for direct relief were discontinued and provincial and municipal work schemes were substituted, assisted by Dominion grants, until 1939, when all the depression relief measures ceased. Provincial administration of the relief programme was under the Department of Public Works, which made little or no attempt to set up standards or to direct and supervise the activities of the local authorities. In addition to the poor relief system, there is a provincial scheme of old age and blind pensions, administered by the Old Age Pensions Board, which was operated under the Department of Education, Federal, and Municipal Relations prior to its transfer to the Department of Health in 1943. Old age pensions were inaugurated in 1936 and blind pensions two years later. The board has its own staff of inspectors who make investigations throughout the province. A mothers' allowances act was passed in 1930 but was never proclaimed until August, 1943. A new and much revised act was adopted in May, 1944. There are no public provisions for curative medical care to the needy except for hospitalization at the expense of the poor law authorities and such scattered arrangements for the home or clinic treatment of their clients as they may make. All the evidence at hand indicates that this system of public assistance has fallen far short of meeting the needs of destitute persons. According to a report by the Canadian Welfare Council on the situation in Saint John in July, 1941, "aid to persons in their own homes is not available under local poor law practice if there is accommodation in the municipal almshouse."3 Home relief allowances, when available, were at the rate of a dollar a week for one person and $1.60 for two, ranging up to a maximum of $3.50 ^Memorandum re a Community Fund and Campaign for St. John and District, mimeographed, p. 10. II 396 Public Health & Welfare Reorganization for families of eight or more.4 In Moncton, in 1938, according to another report by the Canadian Welfare Council, "the only relief policy that can be stated as such appears to be—'Get by with giving the least possible relief and give it with the implication that it will not be repeated.' . . . Apparently the amount for food varies from a $2.00 order for one week for a family of two, up to a maximum of $4.00 a week for the largest families." Only to a very limited extent were supplementary grants made to cover milk, rent, fuel and light, clothing, and other items, although reasonable provision was made for relief clients to obtain medical care from private physicians.5 At this time the city was offering able-bodied men work relief at the rate of 35 cents per hour, but women and all others incapable of working on the civic projects were compelled to turn for assistance to the Commissioners of the Poor. Although detailed reports are not available for other places, there is no reason to believe that relief policies have been more generous elsewhere than in the two leading cities of Saint John and Moncton. Since the coming of old age and blind pensions the aged and the blind have been relatively favoured groups. On March 31, 1943, there were 11,818 old age pensioners, who made up 56.28 per cent, of the population 70 years of age and over, the highest percentage ♦for any province. There were also more blind pensioners in relation to population than in any other province. The average old age pension payment was only $15.27 monthly, less than in any province except Prince Edward Island.6 The net result of inadequate public assistance just before the war is graphically described in a report of the Saint John Family Welfare Association based upon a survey of 200 destitute families. The report states that "a great many of the families were living in quarters actually unfit for human habitation, there was overcrowding, suffering from cold, lack of clothing, bedding, cooking ±Ibid. ^Welfare Services in the City of Moncton, N.B., mimeographed (1939), pp. 19, 20. ^Labour Gazette XVIII (May, 1943), pp. 727-728. The Maritimes 397 I utensils, and food. There was plain evidence of slow starvation among many adults and little children in this group, and the ravages of disease were apparent as attested by their medical and hospital records. . . . From records of families on relief and those in a similar condition not on relief, there is evidence that there must be 1,000 families in Saint John in greatly depressed circumstances, unable to gain the meanest living in employment, without assistance. "7 The Health Services In marked contrast to the antiquated poor law system is a highly centralized organization of public health, under the provincial Department of Health which was established in 1918. The province is divided into ten health districts, each under the direction of a medical health officer who is appointed and paid by the provincial government. These officers are responsible for communicable disease control, tuberculosis control, school medical work, and other public health functions. In addition they oversee the work of sixteen subdistrict boards of health, one for each county and the city of Fredericton, which are concerned primarily with sanitary inspection and regulation and collection of vital statistics. These boards appoint their own secretaries, sanitary inspectors, and vital statistics registrars, nearly all of them part-time officials, while the Saint John subdistrict has its own child welfare and school nurses. The municipalities are responsible for the modest expenses directly chargeable to subdistrict activities. Thus the functions performed by municipal public health agencies in Ontario and the West have been largely taken over by the provincial government, through its district health officers, with the province bearing some two-thirds of total expenditures.8 The Department of Health has a bureau of laboratories and a 7"Saint John Agency Surveys Relief Families," Canadian Welfare Summary, April-May, 1939, pp. 47-49. 8Annual Report of the Chief Medical Officer, 1941, p. 17. 898 Public Health & Welfare Reorganization venereal disease division, the latter under a part-time director. In 1941 there were thirteen part-time venereal disease clinics in operation, at provincial expense. There is no division of tuberculosis control. However the province operates, through a commission of five members, the Jordan Memorial Sanatorium for tuberculous patients, to the support of which the municipalities contribute very largely through per-diem payments for their residents. The province also contributes, at the rate of one dollar per patient day, towards municipal tuberculosis hospitals at Saint John and Bathurst. There is a provincial mental hospital at Saint John, which is supported largely through the municipalities paying part of the maintenance costs of their residents. These two institutions, although they are under the jurisdiction of the Minister of Health, are autonomous in management, being quite outside the Department of Health. Other governmental health activities include small grants to municipal and private hospitals and subsidies for a few public health nurses, employed by private organizations, who perform services for the health districts. While the public health system of the province is well organized, its resources are clearly far too little to provide adequate service. For the year ending October 31, 1941, public health expenditures (not including tuberculosis, mental, or general hospital expenditures) were only 34.3 cents per capita of population, of which the province provided 22 cents and the municipalities 12.3 cents.9 By contrast, various authorities in the United States and Canada claim that combined provincial-local expenditures of from $2.00 to $2.50 per capita at pre-war prices are necessary. Public health nursing service is very underdeveloped. The provincial tuberculosis hospital is overcrowded and unable to meet demands made upon it, there is a shortage of case-finding and diagnostic facilities for tuberculosis, and there is no specialized tuberculosis service in the provincial health department. Inadequate local provisions for nud. The Maritimes 399 relief interfere with proper utilization of the beds at the Jordan Memorial Sanitorium. The superintendent stated in his annual report for 1941 that "many infirmary beds are occupied by patients who are well enough to be on exercise but who have no home and are unable to support themselves . . . and cannot be allowed to go home." The system of charging the municipalities for the maintenance of their residents in the institution leads the poorer ones to avoid sending patients there; and this contributes to the fact that "the poorest municipalities, therefore, have by far the highest rates for tuberculosis."10 In many other respects the health services of the province are deficient. This was recognized by the provincial government in its submission to the Rowell- Sirois Commission in April, 1938, when it stated that improvements in tuberculosis control, public health nursing, venereal disease control, mental hygiene, and other services were badly needed but that the province and the municipalities could not raise money for the purpose. Child Welfare and Delinquency Services The Canadian Council on Child Welfare reported in 1929, after an extensive survey of child welfare problems, "that throughout the entire province of New Brunswick the need of more adequate protection of children exposed to serious physical and moral neglect is widespread and urgent."11 It was pointed out that many children were maintained in almshouses, that there was no public provision for the care and training of feeble-minded children, that protective service for children in their homes was lacking, that protective legislation was deficient in many respects, and that there was no provincial leadership in child care and protection. Although a new Children's Protection Act was passed in 1930, it has not been put into effect, and but little was done during the 1930's to correct 10A. E. Grauer, Public Health, Rowell-Sirois Commission Studies (Ottawa: 1939), p. 21. ^Op. cit., p. 15. 400 Public Health & Welfare Reorganization the evils disclosed by the survey. However, in 1942 an assistant director of the Old Age Pensions Board was appointed, on a part- time basis, to serve as provincial Child Welfare Officer in the Department of Health, and was charged with responsibility for the administration of the pre-1930 child welfare act, which is still operative. This official succeeded, during 1942, in organizing children's aid societies in seven counties, to be added to four already in existence. The eleven societies operating in 1943 have functions and responsibilities similar to those of the other provinces. The municipalities are required, as in Ontario and the West, to meet the expenses of children committed to their care by the courts. It is expected that these new policies will result progressively in decreasing the number of children cared for in municipal homes and other unsatisfactory institutions. The provincial government operates an institution for juvenile delinquents, the Boys' Industrial Home at Saint John, under a governing board. Part of the costs of maintaining boys at the institution is charged to their municipalities of origin and part is assumed by the province. Delinquent girls are sent to the Maritime Home for Girls at Truro, N.S., or (if they are Catholic) to the Home of the Good Shepherd in Saint John, a private religious institution. In both cases their maintenance costs are met jointly by the province and their municipalities of residence. Only two juvenile courts are operating in the province, at Moncton and Saint John (the latter established in 1943), and there is no organized probation service for either juveniles or adults. The superintendent of the Boys' Industrial Home points out, in his annual report for 1940- 1941, that he has no staff to follow up and supervise boys paroled from the school outside of the Saint John area, which he and his assistants look after themselves. There is no provincial jail in New Brunswick, prisoners being detained in common jails operated by the counties without governmental supervision. However, delinquent girls over sixteen years of age and women offenders may be committed to the Inter- The Maritimes 401 provincial Home at Coverdale, N.B. The Dominion Royal Commission to Investigate the Penal System was outspoken in its condemnation of the local jails of the Maritime Provinces in its report of 1938. The Commission said: "The jail system in the Maritime Provinces is entirely inadequate and . . . the manner in which prisoners are treated in these jails can only result in degrading them morally and physically. Generally speaking, the jails are overcrowded, unsanitary, poorly lighted and ventilated, and provide very limited opportunity for outside exercise. There are no facilities for classification or segregation, and no workshops to provide useful employment. There is no government supervision over the jails in New Brunswick, and only a limited supervision in the other two Maritime Provinces. Young offenders must spend their sentences under these conditions, indiscriminately mixed with older and hardened criminals, many of whom have long prison records."12 Outstanding Problems From this brief review of the New Brunswick system of public health and welfare it will be clear that it is much weaker than those of most provinces. The organization for public health work on the local level is simple and commendable, but the resources at the disposal of the health officers are far less than they need in order to do effective work. Gaps and inadequacies in welfare service are striking, including very limited public assistance measures, underdeveloped child welfare service, and poor provision for delinquents. Moreover, the administrative machinery of the province and its municipal units and their financial arrangements have defects that are even more serious than those to be found elsewhere in Canada. 1. An Archaic Poor Law System From the administrative standpoint, the poor law system of the province has two basic weaknesses—the use of the smallest local 12P. 17. 402 Public Health & Welfare Reorganization units (parishes, towns, and cities) as administrative and taxpaying units and the total lack of provincial supervision. These are two defects of the Elizabethan poor law in England which were remedied a century ago, as a result of the recommendations of the Royal Commission on the Poor Laws of 1834. The New Brunswick legislation, modelled on the Elizabethan law, has never had the cleansing wind of reform blow through it. The obvious steps to be taken are the adoption of larger administrative units and provincial supervision. Fortunately there is a county system already in existence, which might be used as the basis for a modern programme of general public assistance, administered by county welfare departments and financed (to the extent that local funds are employed) by county taxpayers, under the supervision and with the financial assistance of the province. 2. Municipal Functions and Finances The old poor law principle of local responsibility is also incorporated in most other branches of the health and welfare services besides the poor law system, and this leads to operating and financial obligations upon the local authorities that are much to be questioned. The most glaring example of their being required to perform inappropriate functions is their operation of local jails. The Royal Commission on the Penal System suggested that these should be replaced by a central prison farm for the three Maritime Provinces. Short of this, the establishment of a provincial prison would be a very great step forward. While probation and parole services are virtually non-existent at the present time, they are technically the responsibility of the local authorities. In so small a province as New Brunswick there is much to be said for central operation of such services. The same argument holds for medical care for needy persons, now a function that is within the jurisdiction of the poor law authorities. From what has been said previously it appears that the municipal The Maritimes 403 authorities of New Brunswick have full or partial financial responsibility for a much wider range of services than those of Ontario and the West. They are involved financially in poor relief, medical care to the needy, general public health, the support of hospitals, the maintenance of patients or inmates in jails, juvenile reform and training schools, mental hospitals, tuberculosis institutions, schools for the deaf and blind, and the maintenance of children under the care of children's aid societies. Each of these obligations involves a special set of legislation and regulations, including settlement rules,13 and a good deal of administrative work concerned with establishment of obligation, accounting, collection of funds, and settlement of disputes. The various municipal payments towards the costs of services, like mental hospitals, that are no longer operated by the local authorities have been largely abolished in other provinces, and there is no good reason why so many should be retained in New Brunswick. If municipal contributions to institutions in respect of particular persons were abolished, the administrative system would certainly be much simplified, and there would be distinct savings in administrative expense. This is a suggestion that does not involve, of necessity, the contribution of a larger part of total health and welfare costs by the provincial government. The province, if it is unprepared or unable to assume a greater share of the total bill than at present, might make an overall levy upon the municipalities to replace their present direct obligations. The important first step is to simplify a needlessly complicated system of financial relationships and to cut out the administrative wastes and unnecessary expenditures that are inevitably associated with such a system. It is also clear that in New Brunswick, as in other provinces, 13However, it should be noted that there is much greater uniformity of settlement rules in New Brunswick than in most provinces, because the Settlement of the Poor Act governs residence for purposes of most of the social welfare schemes of the province. See Canadian Welfare Council Residence and Settlement Legislation in Canada (Ottawa: 1939), for an excellent statement of the provisions of this act and a tribute to its merits, 404 Public Health & Welfare Reorganization the distribution of financial responsibilities between the province and the municipal authorities does not recognize the varying resources of the municipal units. Taxable valuations per capita of population vary greatly from county to county and from town to town. The counties and towns in the northern part of the province are very poor, by contrast with those in the lower Saint John Valley. The provincial government, in its submission to the Rowell-Sirois Commission in 1938, pointed out the difficulties that the poorer municipalities had in supporting schools and in meeting social service charges. Such problems can only be overcome, as we have seen from our examination of the situation in other provinces, by some scheme of variable grants from the province to the local authorities, adjusted in accordance with their needs, or by some other device to limit their financial obligations. Whether the municipalities are taxed too heavily or not is a question outside the scope of this study. In 1936 only 16 per cent, of their total expenditures went for "social services" (not including education or protection to persons and property).14 The redistribution of this burden among the municipal units in accordance with their resources would at least ease the situation materially for the poorer places and would clear the way for dealing with the total problem of the burden of municipal taxes. 3. Personnel The provincial Department of Health has endeavoured to appoint qualified public health physicians as its district health officers, and of course physicians are in charge of the medical institutions. But apart from this there is little evidence of attempts to recruit and develop trained personnel. The last annual report of the Chief Medical Officer acknowledges the need for more public health nurses. The great majority of sanitary inspectors serving the health subdistricts work only on a part-time basis. The over- * 14H. Carl Goldenberg, Municipal Finance in Canada, Rowell-Sirois Commission Studies (Ottawa: 1939), p. 108, The Maritimes 405 seers and commissioners of the poor do their own administrative work to a very large extent, sometimes receiving small honoraria for their services. Even in Moncton, the second city of the province, there was no full-time welfare officer in 1939, one of the commissioners acting in this capacity on a part-time basis and receiving a small payment for it.15 The Canadian Welfare Council recommended that the commissioners should serve as an unpaid board and that they should appoint a qualified executive. In 1942 there was not a professionally trained social worker employed by any public agency in the province. A correspondent from the University of New Brunswick writes that "in the depth of the depression a Commission of Inquiry found that the relief services were being administered by political appointees on a patronage basis and that relief was actually distributed to men in employment of the right political complexion, while being refused to others in real need." In 1929 the Canadian Council on Child Welfare reported that there was "a marked dearth of trained social workers in the child welfare field" and urged "the great necessity of the appointment of at least a minimum of trained and experienced child welfare workers in certain of the key positions."16 The evidence at hand is that the statement still holds good and that it might be broadened to apply to the whole welfare field. 4. Provincial Organization and Leadership As we have seen, there is a provincial health department in which the public health services are grouped. This is a good nucleus to which other health services may be added as and when the provincial health programme is expanded. But there is no similar nucleus of welfare services, for these are scattered among several departments and independent agencies. There is not likely to be similarity of policy in related areas of administration or good co-ordination of activities when such programmes are widely 15Canadian Welfare Council, op. cit., p. 19, ™0p. cit, p. 32. 406 Public Health & Welfare Reorganization dispersed. In New Brunswick, as in other provinces, there is obvious need for much better integration of the welfare services than at present. A nucleus of related programmes might be created by grouping together old age pensions, the new mothers' allowances scheme, child welfare, and the juvenile delinquency services, to form a separate department of public welfare. With this achieved, and with the director of welfare appointed, there would be, for the first time, provincial machinery through which some sort of over-all leadership in the welfare field might be exercised. It would then be appropriate for the provincial government to undertake supervision of the welfare work of the local authorities with the object of developing a co-ordinated total programme for the whole province. Questions may also be raised about the operation of three institutions, the Jordan Memorial Sanatorium, the Boys' Industrial Home, and the provincial mental hospital, as well as the old age pensions scheme, under independent boards of administration. Arguments against this sort of policy have been presented in preceding chapters. If New Brunswick were to strengthen its departmental organization these services could be brought under the direct control of senior officials of the departments of health or Welfare, with the boards being retained only to perform advisory functions. A vigorous department of public welfare would, of course, encourage the development of local public welfare departments throughout the province. As it has been suggested previously, the existing counties would seem to be the logical governmental units within which these agencies might be organized. NOVA SCOTIA Like New Brunswick, Nova Scotia has a health and welfare system in which local responsibility for administration and finance is very prominent. The basic units of local government are sixty- nine in number, consisting of two cities, forty-three towns, and The Maritimes 407 twenty-four rural *'municipalities." The province is divided into eighteen counties, but these have no independent administrative functions, being judicial districts and administrative areas for certain purposes of provincial government. However, twelve of the counties are also municipal districts, and each of the other six counties is divided into two municipalities. Apart from the two cities of Halifax (population 69,326 in 1941) and Sydney (27,314) and the town of Glace Bay (25,050), the towns are quite small, ranging from about 700 to 10,000 in population. It will be convenient, in the following pages, to use the term "municipalities" to include cities and towns as well as the rural municipal units. The various provincial services which have emerged were highly concentrated in the provincial Department of Public Health at the end of 1943. Recognition within the department of urgent problems of policy led to a request for a survey by the Canadian Welfare Council, and this was undertaken late in the year by the Executive Director, Dr. George F. Davidson. One of the survey recommendations jwas that the importance of welfare in provincial administration should be recognized by establishing a combined department of health and welfare, with one minister but two deputies, one for health and one for welfare. In the spring of 1944 the legislature went somewhat beyond this recommendation, by authorizing separate departments of health and welfare, with both portfolios to be held by the same minister. As this is written reorganization is in process and various important changes may be anticipated, so that the description of conditions prevailing at the end of 1943, which follows, may not hold good for very long. Public Assistance An ancient poor law system is the core of Nova Scotia's welfare programme; and this is the chief, although by no means the only, institution in which the doctrine of local responsibility is expressed. The forty-five towns and cities constitute poor relief districts, while 408 Public Health- & Welfare Reorganization M most of the rural municipalities contain a number of poor districts. Formerly these had the same boundaries as the wards, or electoral districts, and there were 324 of them throughout the province. However, the Poor Relief Act empowers the municipal council to alter the boundaries of poor districts or to constitute the whole municipality into a single district, and this power has been exercised in a number of instances during the last ten years. The net result is that consolidations had occurred in six counties by the end of 1942, reducing the total number of poor relief jurisdictions in the rural districts to an unknown number, not less than 263.17 Adding the town and city districts, there was a total for the province of at least 304? as compared with 369 before the consolidation movement began. The municipal councils are required to appoint annually overseers for each poor district who "shall furnish relief and support to all indigent persons having a settlement in such poor district, when they are in need thereof." Funds for meeting the costs of relief are derived from "poor rates" levied upon the taxpayers of the district. Arrangements for the institutional care of indigents are made by the municipalities, although the poor districts must pay for the maintenance of their residents in municipal institutions. Each municipality is authorized to erect and operate a poorhouse, and there are eighteen of these, commonly called "county homes," throughout Nova Scotia. Those municipalities which have no home of their own send indigents to other institutions and pay the maintenance charges. The municipal councils are also authorized, under the "Local Asylums for the Harmless Insane Act," to establish hospitals for the mentally ill, mentally deficient, and 17By letter from the provincial Department of Public Health, Dec. 7, 1942. It is pointed out in this letter that "there is no uniformity in the method or result of these unions," so that in some cases they represent only partial departure from the old system. In a later letter of Nov. 22, 1943, it is said that "the accurate figure lies somewhere between 324 and 263." The fact that provincial officials lack detailed information upon this development brings out very sharply the autonomy of the local poor relief authorities. The Maritime* 409 epileptics who are considered harmless and are ineligible for care and treatment at the provincial mental hospital. The Dominion Bureau of Statistics reports fourteen "county and municipal institutions" of this type in operation at the end of 1939.18 However, only two of these are classified as "hospitals," the rest being listed as "asylums" or "homes," and these others are really poor- houses where the harmless insane are kept along with other inmates. The Poor Relief Act contains a well-developed code of settlement rules, which not only govern the responsibility of the poor districts with respect to poor relief or maintenance in a county home but also determine the persons chargeable to the municipalities for care provided by general hospitals, local asylums, reformatories, the provincial mental hospital, sanatorium, training school for mental deficients, and the children's aid societies. Thus this legislation is, in effect, a settlement act of general application to the social services of the province. The basic rule to gain settlement in a poor district is severe, being five years' residence after the age of twenty-one without public relief; but payment of one year's property tax and some other alternative provisions moderate considerably the effect of the leading rule. Those in need of relief who are absent from their district of settlement may be given temporary assistance by the district to which they apply, with the costs being charged back to their home community; and there are provisions for the orderly removal of indigent persons to their places of settlement. The logic of the system is completed by sections in the Public Charities Act authorizing the provincial government to make agreements with municipalities for the maintenance in local institutions of transient paupers (those without any local settlement in the province). There are also provisions in most of the hospital and institutional acts authorizing the provincial government to assume responsibility for the costs of 18Eighth Annual Report of Mental Institutions, 1939, p. 18. 410 Public Health & Welfare Reorganization care to persons without local settlement who are admitted to the provincial mental hospital and other institutions.19 The King's Printer of the Department of the Provincial Secretary is the provincial official who administers the programme for transient poor although annual appropriations for this service are made through the Department of Public Health. The leading policies regarding the transient poor have been to seek the deporta- .tion of alien applicants for relief or to assist them in returning to their own countries, to assist the residents of other provinces to return home, and then to arrange institutional maintenance for the remaining group, notably in the Halifax City Home. The poor law system proved unequal to the demands for relief that were made in the 1930's; and as in other provinces a separate system of aid to employable persons and their dependents was established, supported jointly by the Dominion, provincial, and local authorities. The municipalities (quite independently of the poor districts) assumed the major administrative responsibilities, operating work projects and granting direct relief, but some parts of the scheme, including some work projects and special youth training, land settlement, forestry, and rehabilitation measures, were administered by the provincial government. Direction of the whole programme was undertaken by the Supervisor of Relief in the Department of Labour. The extent of relief activities was considerable from 1931 to 1936, total expenditures amounting to about $3,000,000 per year, but after that the programme was curtailed progressively, and annual expenditures fell to a level much lower than in any province except Prince Edward Island. By the beginning of the war, in September of 1939, little was being done, although direct relief grants to the municipalities were not finally discontinued until March of 1941. The relief system operated only in those municipalities where needs were most acute. In the fiscal year ending November 30, 1939, direct relief was granted only 19See Canadian Welfare Council, Residence and Settlement Legislation in Canada (Ottawa: 1939). The Maritimes 411 in twenty of the sixty-nine municipalities, in the following year in eight, and in 1940-1941 only in three.20 The youth training scheme, converted into a war emergency training plan, is all that remains of the unemployment relief system of the depression period. The provincial government administers two categorical aid schemes, old age and blind pensions, and mothers' allowances, through the Department of Public Health. Nova Scotia has more old people in relation to population than any other province except Prince Edward Island and is second only to New Brunswick in ratio of old age pensioners to total population, so that its old age pension system is particularly important relative to its other social services. The administrative authority consists of the Director of Old Age Pensions, who is chairman of a board consisting of himself and two part-time members, which passes on all applications. Since the chairman is also Director of Child Welfare he is, in effect, in general charge of a public welfare division of the Department of Public Health. The old age pensions branch has its own field staff which makes investigations throughout the province. Blind pensions are also administered through this branch. The mothers' allowance system has been in effect since 1930, with the province meeting all costs. Allowances vary from a minimum of $15 monthly to a maximum of $80, in accordance with needs, and are payable to needy widows and certain other mothers with two or more dependent children or, in some cases, with only one child. The system is administered through a second branch, concerned with child welfare services, of the welfare division of the Department of Public Health. A small field staff, consisting of five visitors at the end of 1942, makes investigations, and an advisory commission passes upon applications before they are presented to the Director of Child Welfare for final action. Apart from a co-operative arrangement in one county (Shelburne), where one departmental representative handles old age and blind pensions 20Nova Scotia, Annual Report of the Department of Labour, 1941, p. 22. 412 Public Health & Welfare Reorganization IS and mothers' allowances, the administrative work of the two categorical aid schemes is quite separate. The limited reports that are available suggest that the public assistance system has not been adequate, in scope or in quality, to meet social needs in the province. The provincial government compiles no data on the relief activities of the poor districts, so that there are no summary figures on the number of persons under their care and on scales of assistance. However, it appears that home relief is given very sparingly by most districts, and of course it varies in amount and in type from place to place, in accordance with the judgment of the local overseers as to what is proper. By common testimony the amounts of assistance are usually very low. The general reliance upon institutional care rather than home relief is indicated by the fact that in 1942 the city of Halifax granted no home relief, offering only care in the City Home or nothing at all— a nineteenth-century poor law practice which has been long since condemned by authoritative opinion. In the county homes there is indiscriminate mixture of various types of needy persons—the aged and the widows ineligible for pensions, the physically handicapped, the chronic invalids, the shiftless adults of low mentality, and even the "harmless insane." This cannot but lead to evil results for the inmates and the community at large, as the British Royal Commission on the Poor Laws pointed out so clearly in 1909 when it castigated the "promiscuity" of the British workhouses of that day. As in other provinces the unemployment relief of the depression years was generally insufficient to maintain recipients at minimum standards of health and efficiency. Relief was not granted at all in some municipalities. In 1938 the maximum direct relief grant approved by the provincial authorities was $9 per week for a family of ten or more, with a small shelter allowance additional, but they reported to the Dominion Unemployment Relief Branch that the municipal scales actually in effect were generally lower than the provincial maxima. The scales of assistance in Nova Scotia were The Maritimes 413 usually much less than those prevailing in Ontario and the West, which, as we have seen in preceding chapters, were generally too low for the healthy maintenance of recipients. The province did not develop any special medical care plan for the unemployment relief group, this being left to the casual and varied efforts of the local authorities. The categorical aid schemes of mothers' allowances and old age and blind pensions are much more satisfactory. In 1942 the average monthly payment of mothers' allowances to families averaging about four persons (mother and three dependent children) was $34.67.21 This seems very little, but it is much better than poor relief. The Director of Mothers' Allowances states that: Many of the homes where the beneficiaries are found when allowances are first granted are in destitute condition. . . . Where such families depend upon local poor relief it is almost invariably far too small to maintain the family on an adequate standard of living. Such homes become so depleted of the necessary furnishings and the children so destitute of clothing that it takes considerable money and effort over a long period of time to establish anything approaching normal living conditions.22 At the end of March, 1943, there were 14,080 old age pensioners in the province, about 47 per cent, of the total population seventy years of age and over. The average monthly pension was $15.65, less than in the other provinces with the exception of New Brunswick and Prince Edward Island. Blind pension payments, averaging $19.22 to 620 recipients, were a little less than in other provinces except Prince Edward Island.23 Lower living costs than in other parts of Canada no doubt partly justify these lesser rates of assistance. They were sharply increased in 1943 by virtue of the 21 Annual Report of the Director of Mothers' Allowances, 1942, p. 14. In 1943 an amendment to the Mothers' Allowances Act authorized an increase in the maximum grant payable from $60 to $80, and average grants increased considerably during the year. 22Annual Report of the Director of Mothers' Allowances, 1941, p. 8. 23Preceding figures from Labour Gazette, XLVIII (May, 1943), pp. 727-728. 414 Public Health & Welfare Reorganization federal allowance of $5 additional and a special provincial bonus of $5, so that the maximum grant now possible is $30. This represents an increase mueh beyond the advance in the cost of living during the war—and tacit admission that the rates were too low previously. But whatever the adequacy of the categorical aid grants has been in the past, they have all been so much better than poor relief in amount and in other characteristics as to be relatively high in public esteem. Child Welfare and Delinquency Control The child welfare services are fairly well developed. The Children's Protection Act, enacted in 1906 and progressively improved by amendments since then, contains sections dealing with juvenile courts, children's aid societies, neglected children, reformatories, child labour, and mentally defective children, and this gives some idea of the wide range of administrative duties for which the provincial Director of Child Welfare is responsible. In brief, this official is in charge of all provincial services for neglected, delinquent, and mentally deficient children, as well as for some other children. In addition he also administers mothers' allowances, and since he is Director of Old Age Pensions, all the categorical aids are within his jurisdiction. The children's aid societies, eleven in number at the end of 1942, are similar to those in other provinces. Complete provincial coverage with this type of service is assured by the fact that the Director of Child Welfare and his staff perform children's aid functions in those communities which do not have societies of their own. At the end of 1942 about 300 children were under the direct care of the provincial office. As in other provinces, the municipalities of residence of the children committed by the courts to the care of children's aid societies are required to contribute towards maintenance charges; but only to the extent of 60 per cent, of a maximum charge of $5.00 weekly, the provincial government The Maritimes 415 assuming the remaining 40 per cent. Nova Scotia is the only province which shares these maintenance charges with its municipalities. By virtue of an amendment to the Children's Protection Act in 1942, the provincial government is also empowered to make grants to the general funds of any children's aid society to match contributions from municipalities or from private subscription, provided that the grants do not exceed $1,000 each. This scheme is particularly interesting, since it is the only example in Canada of provincial contribution towards the operating expenses of the children's aid societies, apart from the Ontario subsidies to the salaries of the directors. The provincial grants are payable only on condition that the societies comply with certain requirements prescribed by the government, including standards of service and qualifications of personnel. The conditions thus far specified are simple, stressing qualified personnel. It is required that every agent of a children's aid society to be appointed in the future must be a graduate of a recognized school of social work or, in case such a person is not available or acceptable, must have other qualifications, including completion of a course of training under provincial auspices. In a statement of policy issued on January 18, 1942, the Minister of Public Health declares that "the Department desires the societies to achieve high standards of child and family welfare work. Financial assistance under the Children's Protection Act . . . was granted for this purpose. The Department wishes to see a well-trained and thoroughly competent field staff employed by the societies. Social work is too important to be in" the hands of untrained and inexperienced persons." The Department has developed an in-service training programme to build up staff for the societies, as well as for its own purposes, on account of the wartime shortage of trained social workers. There are six juvenile courts in the province, serving the city of Halifax and five of the counties and covering about half the population. Each court habits own probation officers, full-time in 416 Public Health 8c Welfare Reorganization two (Halifax and Cape Breton) and part-time in the others, agents of the children's aid societies holding these latter appointments. The courts operate under the provisions of the federal Juvenile Delinquents' Act. Delinquent boys and girls may be committed to four reformatories, the Halifax Industrial School for Protestant boys, the Maritime Home for Girls (Truro) for Protestant girls, St. Patrick's Home (Halifax) for Roman Catholic boys, and the Monastery of the Good Shepherd (Halifax) for Roman Catholic girls. These institutions also receive neglected children who may be placed in them by the Director of Child Welfare or by the children's aid societies with the approval of the Minister of Public Health. The Monastery of the Good Shepherd cares in addition for adult female delinquents (over sixteen years of age) who may be committed by the courts. The institutions are all operated by private boards or religious orders, but they are mainly financed by public funds and are inspected by the Director of Child Welfare. Both the municipalities and the provincial government contribute to the maintenance of committed children, and in the fiscal year ending November 30, 1940, 81 per cent, of operating expenses came from these public sources.24 In 1927 a Royal Commission found that numerous mentally deficient children were being kept in county homes and jails, being "mixed indiscriminately with the insane, the aged, the infirm, the degenerates, and low grade imbeciles"25—as well as with normal children—and recommended that a provincial training school for such children be organized. This led to the prompt establishment of the Nova Scotia Training School, which now accommodates about 150 boys and girls. The school accepts only the high-grade mental defectives who have some capacity for vocational learning, and low-grade defectives must be kept in county homes or private 24Nova Scotia, Annual Report of the Director of Child Welfare, 1940, p. 99. 25Report of the Royal Commission Concerning Mentally Deficient Persons in Nova Scotia, p. 35. The Maritimes 417 institutions. It is financed by payments of $200 per annum from the municipalities in respect of each child for whom they are legally responsible, with the deficits being made up by the provincial government. A board of management, with the Director of Child Welfare as secretary, administers the school. There is also a psychiatric service under the provincial child welfare branch. The psychiatrist and the psychologist engaged in this work examine and report upon children in the Nova Scotia Training School and other institutions, those under the care of the children's aid societies, and those attending public schools. In 1943, however, the position of psychologist was vacant. This service, entirely financed by the province, is obviously an important .resource for those engaged in child welfare work. Apart from this programme, the province has no public mental hygiene clinics. Except in the case of women, there is no provincial provision for the care of adult delinquents. Women prisoners are kept in two privately operated reformatories, the Home of the Good Shepherd in Halifax or the Interprovincial Home for Young Women at Coverdale, New Brunswick, to which the province makes grants at the rate of $120 per annum for each prisoner. The legally responsible municipalities also contribute towards maintenance costs. Other prisoners (including women awaiting trial or transfer to a reformatory or a Dominion penitentiary) are detained in local jails, consisting of the Halifax City Prison and twenty county jails. These institutions are financed and operated by the local authorities, subject only to inspection by the provincial Department of Public Health. Conditions in them were very poor in 1938, according to the Dominion Royal Commission on the Penal System, as the quotation on page 401 makes clear; and there has been no important change in the system since that time. In the recent annual reports of the provincial Inspector of Penal Institutions there is frank recognition that all is not well with the prison system and that measures of reform are urgently needed. Ill 418 Public Health & Welfare Reorganization The Health Services The public health system of the province consists of a somewhat complex group of local health boards upon which there has been superimposed a provincial programme rendering direct service to the people. The local boards are the institutions of the past, and they appear to be withering away, or at least not to be growing in function or in importance; while the provincial services have expanded notably in recent years and have assumed certain functions performed by the local health departments in Ontario and the West. In 1935 a survey of the provincial Department of Public Health was made by Dr. W. A. Mcintosh of the Rockefeller Foundation and he recommended the progressive development of a public health system administered and financed by the provincial government. Changes since that time have been based largely upon his proposals. At the level of local government there are local boards of health and county boards of health. Incorporated towns and cities have local boards (the councils, or committees of the councils) and in the rural districts there may be boards for each polling district (the same area as the poor relief district). However, arrangements may be made for the union of two or more polling districts under the one local board, and a good many such unions exist. There may also be county boards of health, to be established on the application of the local governments within the county to the provincial government. These county boards, when established, are empowered to exercise general supervision over the local boards and to make certain regulations regarding health standards. It is required that qualified physicians be appointed as medical officers of health by the local boards for cities and towns, for rural municipalities, or for some combination of towns and rural municipalities. Nearly all of these officials serve on a part-time basis, for very small salaries, which must be at least $100 per year. At the time of the Mcintosh report there were sixty-seven of them in the province, only one of The Maritimes 419 whom held a full-time appointment.26 The boards are also required to appoint sanitary inspectors, who are usually part-time officials. They may employ public health nurses, but there are practically none of these except in Halifax and one or two other towns. While the local and county boards are empowered to offer a substantial range of public health services, it appears that most of them undertake little beyond elementary sanitary inspection and the enforcement of regulations regarding communicable disease control. Their power to make and to enforce health regulations has evidently been used sparingly and not very constructively. The annual reports of the district health officers of the provincial Department of Public Health are full of references to the inadequacy of local sanitary control. For example, the Health Officer of the Fundy Division (a provincial official) says that in his district, in 1941: In general, by-laws governing the production, handling, and sale of milk are hopelessly inadequate and out-of-date. . . . Truro is the only town which has a milk inspector. . . . The other towns in this Division have no regular qualified milk inspectors. This lack of properly qualified milk inspectors must be remedied if we are to eventually obtain a clean and safe milk supply.27 The same health officer reports further that: The general water situation throughout this division still leaves much to be desired. Only three towns out of ten had what might be considered a safe water supply by lenient standards. ... It might be added that the year preceding 100% of the Towns showed B. Coli in their water supplies in such quantities as to condemn them.28 26W. A. Mcintosh, An Administrative Study of the Nova Scotia Department of Public Health With Recommendations (Halifax: King's Printer, 1935), pp. 36, 37. 27Nova Scotia, Report of the Department of Public Health, 1941, p. 72. 28Ibid., pp. 91-92. 420 Public Health & Welfare Reorganization By contrast with this antiquated local system of small units and part-time, unspecialized personnel, the provincial public health services are vigorous and progressive. These are grouped into one of the three major divisions of the Department of Public Health. Leading functions are vital statistics, tuberculosis control, venereal disease control, laboratory service, public health nursing, and sanitary engineering. The Chief Health Officer has functional assistants, or division chiefs, only for vital statistics, laboratories, public health nursing, and sanitary engineering, there being no divisions of tuberculosis control and venereal disease control. The department provides direct service to the people mainly through a system of five public health districts covering the province, each under the direction of a divisional health officer. These districts (which are called "health units" in the reports of the department) have been built up since 1937, when the first one was established in Cape Breton, in line with t<he recommendations of the Mcintosh report. Previously there had been three divisional health officers who were largely concerned with tuberculosis control. The operation of tuberculosis and venereal disease clinics still constitutes a large part of the work of the health divisions; but they have extended their activities substantially to include maternal and child health clinics, immunization against communicable diseases, sanitary inspection, school health work, public health nursing, public health education, and the stimulation of better standards of service by the local health authorities. Public health nurses, under the general supervision of a provincial director, are assigned to duty in the various divisions and do a generalized job under the divisional health officer. In addition they offer a school nursing service in the smaller towns and rural communities where neither the local boards of health nor the school authorities have made provision for such work. The reports of the divisional health officers show that they have done much to bring home to the local authorities the importance of The Maritimes 421 more stringent health regulations and of better enforcement. The stimulation of local activity and the development of cooperative working relationships with the local boards is clearly a very important part of the work of the divisional health officers. Their reports indicate that they have uncovered a great many health problems and that they consider their physical facilities and staff (particularly nurses) to be far from adequate to deal properly *with these problems. The substantial expansion of the provincial public health programme is shown by the fact that expenditures have more than doubled in the last ten years. For the fiscal year ending November 30, 1933, provincial expenditures on public health were $102,553, or 20 cents per capita of population;29 while for the fiscal year ending in 1943 about $286,000, or 50 cents per capita, were authorized in the provincial Estimates. The Mcintosh report estimates local government expenditures in the year 1933 as $180,383, or about 31 cents per capita. Later composite figures on local expenditures are not available, but there is no reason to believe that they are much higher than they were ten years ago.30 Therefore it looks as if the province is now bearing much more than half the costs of public health work in Nova Scotia, a distinctly higher proportion than in Ontario and the western provinces. But the total provincial-local expenditure of perhaps 80 cents per capita in 1943 was far less than the $2.00 or $2.50 per capita commonly regarded as necessary for good public health service—even when all allowances are made for the low salaries and other low costs of public administration that have been common in Nova Scotia. 29W. A. Mcintosh, op. cit., p. 45. 30That is to say, figures on public health proper, not including the costs of institutional care. The provincial Department of Municipal Affairs, in its annual reports on municipal statistics, does not segregate public health expenditures from those for hospitals, etc. A special study by the Canadian Welfare Council, Glace Bay Looks Ahead, gives public health expenditures by the town of Glace Bay (population 25,050 in 1941) as $6,415 in 1939, or about 23 cents per capita. fw 422 Public Health & Welfare Reorganization Health Institutions A third division of the provincial Department of Public Health (besides the public health and public welfare divisions) has been entitled "Public Charities" and has been concerned with the administration of three institutions, grants to general hospitals, and a cancer programme. First on the list of institutions is the Nova Scotia Hospital (for mental patients), which is operated by a Board of Commissioners subject to the general oversight of the Minister of Public Health. The institution deals primarily with patients who are regarded as "hopeful cases," others being returned to the local asylums or county homes. The municipalities contribute towards the maintenance charges for patients for whom they are legally responsible and the province meets deficits. The Nova Scotia Sanatorium (for tuberculous patients) is operated and financed in the same way, except that it has no administrative board. About a third of operating costs is derived from municipal and other payments in respect of patients. In addition to this provincial institution with some 300 beds there are a number of tuberculosis annexes to municipal or private hospitals, which receive provincial aid to the extent of one dollar per patient day. Nova Scotia is the only province in Canada which has a general hospital, the Victoria General Hospital in Halifax. Under a Board of Commissioners, it operates like municipal or private institutions in other provinces, serving both paying and non- paying patients. The municipalities are required to contribute maintenance charges for the indigent patients for whom they are legally responsible, and deficits are met by the provincial government. To other hospitals operated by the municipalities or private associations, which comply with provisions of provincial legislation regarding standards and inspection, the province makes grants at the rate of 30 cents per patient day, up to an amount of $1,500 in any one year to any hospital, and thereafter at the rate of 20 cents The Maritimes 423 per day. The legally responsible municipalities meet maintenance charges for indigent patients to the extent of $2.00 per patient day; and, as in other provinces, the hospitals are required to admit all indigent persons requiring care. A cancer clinic is operated at the Victoria General Hospital, as one phase of a modest cancer control programme. Some Good Points The Nova Scotia system of health and welfare has a number of very good characteristics. A relatively complete and logical system of settlement rules provides the basis for much more orderly policies regarding non-residents than in most provinces. However, the provisions for gaining settlement in any community are rather severe. The schemes of mothers' allowances, old age pensions, and blind pensions compare favourably with those of other provinces in quality of administration, although the grants that are paid have been rather low. In the field of child welfare the provincial government has set a very good model for other provinces to follow through its partial assumption of the costs of maintaining children under the care of children's aid societies, its grants towards the operating expenses of the societies, and its prescription of personnel and other standards for them to follow. The broad jurisdiction of the Director of Child Welfare over problems affecting children has made possible the development of an unusually well-rounded programme of child welfare. In public health, too, there has been real progress. The provincial government has evidently made a sincere effort to implement the forward-looking recommendations of the Mcintosh report of 1935, and it is clear that the new divisional health officers and their associates are doing much, not only to improve the long-standing tuberculosis, venereal disease control, and public health nursing programmes of the provincial department, but also to render new types of service to people throughout the province and to stimulate the improvement of the backward local health boards. Organization at the provincial level has been better 424 Public Health & Welfare Reorganization than in most provinces because of the very complete integration of the health and welfare services under the Department of Public Health and this has made relatively easy the decision of 1944, to establish separate, but closely related, departments of health and of welfare. Leading Problems But, as usual, there is a less favourable side to the picture. There are some serious weaknesses in the Nova Scotia system, which may be described under the headings inadequate or unsatisfactory service; a backward poor law system; unsatisfactory distribution of functions and finances between the province and the municipalities; personnel; and provincial organization and leadership. /. Inadequate or Unsatisfactory Service Considerable evidence in support of this point has been given in the preceding pages. Low standards of general relief, low categorical aid grants, little home or clinic medical care for indigent persons, poor sanitary control, too little public health nursing, and deficiencies in other types of public health work have been common. There is no psychopathic,hospital, nor are there mental hygiene clinics for adults. Probation and parole services for adults are lacking, and there are no special facilities for the lower-grade mental deficients. There is a serious shortage of tuberculosis beds. The provincial government has frankly recognized the inadequacy of existing services. In its Submission to the Royal Commission on Dominion-Provincial Relations in February, 1938, the government listed a number of outstanding needs for improvement and stated that the annual budget of the Department of Public Health should be increased by at least $500,000, an amount which the province could not afford at that time.31 3!P. 138. The Maritimes 425 Besides these examples of inadequate or non-existent service, there are some outstanding cases of unsatisfactory work, particularly on the part of the local health and welfare authorities. These are notably the keeping of the "harmless insane" in poorly equipped local asylums or country homes, the detention of adult delinquents in local jails, the provision of none but institutional relief in some communities, the indiscriminate mixture of various classes of indigent persons in the county homes, and casual sanitary control by many local health authorities. These instances of low-standard service are not to be explained primarily by lack of money. When direct and indirect costs to government are taken into account, without reference to any "costs" passed on to individuals or private associations, such policies are usually more expensive than the alternative and more modern policies of home relief, foster-home care, specialized programmes of treatment, training, and rehabilitation for the institutional group, and efficient sanitary inspection and regulation. Indeed, it is possible that some of the present policies are actually more costly, in direct money outlay than more progressive alternatives. Institutional care for dependent and defective persons, besides being the most expensive way of dealing with them, is for many an undesirable method of treatment. Yet Nova Scotia puts more stress upon this method than any other province. In 1941 the province ranked first in Canada in ratio of adults in charitable institutions (not including jails, mental institutions, or hospitals) to total population. These institutional inmates numbered 1,826, or 315.8 per 100,000 of population, as compared with 22.6 for the lowest province, Alberta, 202.9 for the highly institutionalized province of Quebec, and 151.8 for Canada as a whole.32 The province has more beds for mental patients in relation to population than any other province (40.8 per 10,000 in 1939 as compared with 32Based upon data obtained from the Dominion Bureau of Statistics on the number of adults and children in benevolent and charitable institutions as of June 2, 1941. 426 Public Health & Welfare Reorganization a national ratio of 34.5)33 and is relatively well supplied with general hospital beds, although not with tuberculosis beds. The figures that have been cited reflect the importance of the local asylums and the county homes in the health and welfare system of the province. If less stress were placed on the use of these institutions substantial amounts of money might be saved that could be spent to far greater advantage on constructive programmes of prevention and rehabilitation. « >!;; 2. A Backward Poor Law The poor law system is open to the same criticisms as that of New Brunswick. Most of the 300-odd poor districts are far too small to be suitable administrative or taxpaying units for poor relief. The average population of the rural districts in 1941 was only 1,171 persons.34 Great variations in policies and standards are inevitable when there is no provincial supervision, and old ideas and bad practices are simply inherent in a system which depends so much on local effort. As we have seen, the movement for voluntary union of the poor law districts has had only limited success. An obvious improvement would be to do away entirely with the rural poor districts, transferring their functions and obligations to the municipalities; and the establishment of county or district public assistance units serving both the towns and the rural communities within a municipality would be a still further measure of progress. Provincial grants-in-aid and supervision are other obvious needs to reform the old poor law system and to transform it into a modern public assistance programme. 33Dominion Bureau of Statistics, Eighth Annual Report of Mental Institutions, 1939, p. 11. 34Based upon total population of 308,146 in the rural municipalities, as reported in Nova Scotia Department of Municipal Affairs, Annual Report on Municipal Statistics, 1941, p. 7, and upon an assumed number of 263 districts, a figure that may be too low. See footnote 17. The Maritimes 427 8. Provincial-Local Distribution of Functions and Finances There are at least two local functions which should certainly be taken over by the provincial government—the operation of penal institutions and the care of the harmless insane. The provincial government has recognized for some time the desirability of a central prison, but lack of money has evidently stood in the way of its establishment. The failure of the government to provide adequate facilities for the care of the mentally ill marks Nova Scotia as backward in this field. It is the only province in Canada which leaves the care of large numbers of these persons to the local authorities, which are in no position to provide adequately for them. On the other hand, questions may be raised about the extent to which public health functions have been taken over by the provincial government. The case for this is certainly very strong— indeed, overwhelming—so long as the present system ,of local health boards prevails. For it is quite clear that these authorities are too numerous and that most of them are too small to become satisfactory health units. But if this system were thoroughly reformed, with the present town and rural local boards being abolished, it would seem possible that new health agencies might be established on a municipal basis, to serve both towns and rural districts within the boundaries of each municipality. This would give the province twenty-four local health units. Since some of these would have too little population for good administration (less than 20,000 or 25,000) arrangements might be made for the combination of two or more small contiguous districts into one health unit. And it might be appropriate to continue the city of Halifax as a separate district. Assuming some such reorganization and the development of a system of provincial grants-in-aid to the local authorities, it might be advisable for the provincial health department to transfer to them certain of its present direct services, such as public health nursing, some sanitary inspection, clinic service for mothers and babies, and immunization against communicable diseases. 4S8 Public Health & Welfare Reorganization This suggestion runs quite counter to the recommendations made in the Mcintosh report of 1935, from which the recent progressive developments in the provincial department have largely stemmed. No doubt Dr. Mcintosh and the provincial health officials who have followed his lead have felt that, for reasons of practical politics, there was but little chance of reforming the local public health system, and that therefore the only hope of progress lay in the expansion of provincial services. If their premise is right their policy is right. But it should be pointed out that the logical conclusion of this policy is the total surrender of public health functions to the provincial government by the local authorities. There are obvious arguments against the continued existence of two separate systems of public health performing functions which, although different in many respects, are bound to overlap to some extent. The stronger system is the one that will, and that should, prevail in a field where monopoly, not competition, is to be desired. Should this take place a function which is commonly considered to be one of the most suitable for local government would be transferred entirely to the provincial level. Another serious weakness in the present system of provincial- municipal relations is that a number of different charges are levied against the local authorities in respect of the services rendered by provincial or private organizations to local residents. The municipalities or poor districts pay part of the maintenance costs for children under the care of children's aid societies, in the Provincial Training School, and in reformatories; for the women detained in reformatories; and for the indigent patients or inmates of the Nova Scotia Hospital, the Victoria General Hospital, the Nova Scotia Sanatorium, and the general hospitals. In the case of each person investigation must be made to determine the legally responsible local authority, negotiations regarding collections must follow, and disputes are inevitable. Thus the administrative work required under this system is very considerable, both for the agencies making claims and for the local authorities. The latter are naturally The Maritimes m reluctant to pay institutional charges in respect of their residents any more than is absolutely necessary, and there is some evidence that this prevents some people from obtaining service of the right kind when they need it. In 1940 only 25.4 per cent, of new pulmonary tuberculosis cases were admitted to tuberculosis institutions within one month after diagnosis, a percentage much lower than in other provinces except New Brunswick and Prince Edward Island.35 This low rate of early admission, a serious obstacle to effective tuberculosis control, was one of the major factors which led Dr. J. G. Wherrett, Secretary of the Canadian Tuberculosis Association, to state recently to the House of Commons Special Committee on Social Security that "there is urgent need in Quebec, Nova Scotia, and New Brunswick for relieving individual municipalities of the burden of tuberculosis costs."36 Since the municipal authorities have some degree of control over the transfer of inmates from their cheaply operated county institutions to the more adequately equipped and more expensive provincial institutions and since they can also avoid taking action that might lead to the admission of persons to institutions, financial considerations may stand in the way of suitable institutional care for certain people. On the other hand, it may prove to be cheaper for the local authorities, in some instances, to pay maintenance charges in a provincial or private institution for a person than to make provision for him in the home community outside an institution, so that they are tempted to resist his discharge. Thus the present system of charges is all too likely to impede good service. As we have seen, the provincial government offers no financial support towards the local health and welfare functions, notably poor relief, the care of the harmless insane, the operation of jails and of probation services, and public health. It is quite clear 35Dominion Bureau of Statistics, Annual Report of Tuberculosis Institutions for the Years 1939 and 1940, p. 7. 36Minutes of Proceedings and Evidence, April 9, 1943, p. 192. 430 Public Health & Welfare Reorganization that many of the local authorities will be financially unable to meet substantial demands for general relief in the postwar period, so that provincial assumption of some part of the costs of this service is particularly desirable as a permanent policy. There are the usual arguments, which have been given in preceding chapters, for provincial contributions towards the costs of the local functions, accompanied by supervision of administration. The local share of the costs of health and welfare was higher in Nova Scotia than in any other Canadian province at the beginning of the war period. In 1940, according to the latest summary figures available, total provincial and local expenditures on public welfare (the public health and welfare services as defined in Chapter 1 but not including delinquency control) were approximately $4,064,000, of which the local authorities contributed $1,800,000, or 44.3 per cent., and the provincial government $2,264,000.37 For all of the provinces the municipal share was 34.7 per cent. ^Public welfare made up 19.2 per cent, of the total expenditures of Nova Scotia municipalities (including debt retirement), falling well below education, which cost 33.4 per cent. Whether the total health and welfare bill has been too large to be met readily from municipal resources is a complicated question that will not be examined in detail here. Suffice it to say that the view is widely held in the province that the burden upon local taxes is too great, or at least that it was before the war. The provincial government, in its Submission to the Royal Commission on Dominion-Provincial Relations in February, 1938, stated that "the burden of municipal finance falls almost entirely on real and personal property, and it is a burden already too heavy, and certainly a burden which cannot be further increased."38 But whether the total burden upon the municipalities is too great or not, it is abundantly clear that it is too much for some of them. For in Nova Scotia, as in all the other provinces that have been 37See Table V, p. 193. 3»P. 124. The Maritimes 431 discussed, both needs for social services and taxpaying capacity differ from community to community. The variation in taxpaying ability is shown by the fact that in 1941 net taxable assessment ranged from a low point of $48.24 per capita of population in the municipality of Inverness to a high point of $922.33 in the city of Halifax.39 There are likewise sharp differences in tax levies per capita and in per-capita expenditures on health and welfare services. Various Nova Scotia studies in the field of education have shown great inequalities in educational service from school district to school district and from municipality to municipality, largely due to variations in financial resources.40 The problem in the health and welfare field is exactly parallel. The obvious solution is some system of equalization grants to the local authorities which will spread the burden of costs more equitably and will enable the poorer places to build up their services to' reasonable standards. As in other provinces, it is probably much more important to work out such a grant system than it is to reduce the municipal share of the total health and welfare bill, although there appears to be more reason for doing this too than in most provinces. 4. The Personnel Problem The provincial government has a relatively good record in personnel policy. The Department of Public Health has followed for some time a consistent practice of recruiting well trained public health physicians and nurses. Similar efforts to obtain qualified staff have been made by the child welfare branch of the department. The personnel requirements recently prescribed for the children's aid societies represent a very progressive move. But salaries are low, there was a shortage of qualified personnel even before the war, 39Department of Municipal Affairs, Annual Report on Municipal Statistics, 1941, p. 9. 40This problem is well examined in a recent study by Prof. B. A. Fletcher of Dalhousie University, The Next Step in Canadian Education (Toronto: 1939), Chapter II of this book gives much detail on the Nova Scotia situation, 432 Public Health & Welfare Reorganization war conditions have greatly accentuated the shortage, and it has been difficult for the provincial authorities to build up personnel standards to their satisfaction. On the other hand, trained personnel are conspicuously lacking in the local health and welfare agencies and there is but little evidence of progressive personnel policy on the part of the local authorities. The medical officers of health, serving on a part-time basis, have not had public health training, only a few public health nurses are employed, and technical qualifications are not usually demanded of those who administer relief, operate local institutions, deal with delinquents, or undertake sanitary control. So much of the work of local administration is done by part-time personnel at very low remuneration that it would be difficult to require the employment of technically qualified workers even if there were a will to do so. 5. Provincial Organization and Leadership Despite the fact that the health and welfare services of the provincial government have been well concentrated for a number of years in the Department of Public Health, their integration was far from satisfactory. The public health programme was a unit, and there was a welfare nucleus of the categorical aids and child welfare under the Director of Child Welfare. But there was not complete integration of public assistance, because administrative work regarding the transient poor was handled by the King's Printer and the remnants of unemployment relief were in the Department of Labour. A still more serious defect was that various institutions and miscellaneous services shown to be in the Public Charities division of the department on organization charts operated pretty much by themselves, a number of them under boards, without very effective central direction. The department had no deputy minister but there were two senior officials of somewhat the same status, the Provincial Health Officer and the Director of Child Welfare, who, in effect, took the lead respectively on health and welfare matters. The Maritimes 433 The department, although it was a unified department of health and welfare .on paper, was not so in practice. The recent decision of the legislature to establish separate departments clears the way for a logical distribution of the health and welfare services under each agency, and for better central direction of each branch of work than in the past. The three hospitals (the Nova Scotia Hospital, the Nova Scotia Sanatorium, and the Victoria General Hospital) along with grants to hospitals and certain other health activities should be placed in the new health department; while the welfare department can be organized around the nucleus of the categorical aids and child welfare, to include also a general assistance division (absorbing the care of the transient poor and the remnants of unemployment relief), the delinquency services, possibly the Nova Scotia Training School, and certain new services that are needed such as vocational rehabilitation. Provincial reorganization should contribute towards the extension of provincial authority over the local health and welfare services. More than in most provinces these are operated without central guidance or supervision. The contrast between the progressive characteristics of various branches of the provincial Department of Public Health and the backwardness of the local health and welfare services has been most striking; and the fact that the provincial and the local systems of health and welfare are almost altogether independent and unco-ordinated has been the central weakness of the Nova Scotia programme. Effective reorganization will certainly call for provincial leadership, through grants-in-aid, the setting of standards, and supervision, to build up the services left with the local authorities and to co-ordinate them with the work of the provincial government. The system of grants-in-aid to children's aid societies inaugurated in 1942 is a first step in this direction, offering a pattern of general application. Another problem of organization is presented by the fact that several of the institutions, the Victoria General Hospital, the Nova Scotia Hospital, and the Nova Scotia Training School, are adminis- 434 Public Health 6c Welfare Reorganization tered by boards, while the provincial sanatorium is not. Considerations of consistency suggest that the same pattern of administration would be appropriate for all of these. Arguments against the use of administrative boards have been presented in earlier chapters. It would seem advisable to limit the boards to advisory functions and to bring the institutions more under the direct control of the senior officials of the health and welfare departments, thus making easier the co-ordination of institutional and non-institutional service. IS PRINCE EDWARD ISLAND41 Canada's smallest province, both in area and in population, naturally presents less difficult problems of health and welfare organization than others. Since the population is a little less than 100,000, is thickly settled in a compact area of 2,184 square miles, and is more than three-fourths in rural districts, there is much less need for a complex system of local government than in other provinces. There are only eight municipalities, consisting of the city of Charlottetown (population 14,460 in 1941) and seven towns, of which only the two of Summerside and Souris have more than 1,000 inhabitants. In addition there are school districts, covering the Island, which numbered 482 in 194142 and which were tax- paying and administrative units for the operation of public schools. Outside of the municipally organized towns, public services of all kinds, except education, are administered by the province; and this means that the provincial authorities perform the ordinary functions of local government, including health and welfare, for most of the population. The centralization of health and welfare activities is much greater than in any other province. In 1940 the combined health and welfare expenditures of the province and the munici- 41The section that follows, on Prince Edward Island, is based on factual data up to the end of 1942. So far as the writer has been able to discover, there have been no changes of significance since then. 4 Prince Edward Island, Annual Report of the Department of Education* 1941, p. ix The Maritimes 435 palities (excluding federal contributions towards old age and blind pensions and relief) were $441,000, of which the municipal share was only $25,000, or 5.7 per cent., much the smallest proportion among the provinces.43 The public health system is almost entirely provincial. Local health boards are authorized under the Public Health Act, but those that exist are virtually inoperative. The city of Charlottetown makes a small annual grant to the expenses of the provincial Department of Public Health. This department, established in 1931, operates tuberculosis and venereal disease clinics and a laboratory, collects and compiles vital statistics, provides a public health nursing service through a staff of five nurses, undertakes school health work and sanitary inspection and* regulation, and performs incidental public health functions. In effect, the province is a single health unit. Expenditures are low, the provincial per- capita expenditures having amounted only to 33 cents in 1941,44 an amount far too little, even when due allowances are made for the low costs and the relatively simple social conditions of Prince Edward Island, to provide adequate public health service. Tuberculosis patients are treated in the Provincial Sanatorium, which operates under a board, the Provincial Sanatorium Commission, and has its deficits met by a provincial grant. In 1941 the legislature appropriated $7,000 to provide financial aid for needy families of tuberculosis patients and for needy patients before admission to or after discharge from the sanatorium. In its annual report for 1941 the commission states that the province "has approximately only half the number of beds required for the treatment of pulmonary tuberculosis."45 The commission goes on to praise the new system of extramural grants to tuberculosis patients and their families, but points out that the annual grant is not large 43See Table V, p. 193. 44Based on reported gross expenditures of $31,807, Annual Report of the Department of Public Health, 1941, p. 21. 45Appendix \o the Annual Report of the Department of Public Health, 1941, p. 5. 436 Public Health & Welfare Reorganization enough "because when it is divided up, it does not provide a sufficient amount for each needy family, for each patient who is taking treatment at home and is unable to work, or for the patient who has been discharged but is yet unable to return to work."46 There is a provincial mental institution, Falconwood Hospital, which provides care and treatment for about 275 patients and is administered by a board of trustees now composed of the members of the provincial cabinet. The government makes lump-sum grants to four general hospitals to assist them in caring for indigent patients. There is no obligation upon the municipalities to contribute to the support of hospitals, but Charlottetown and others have made some grants voluntarily. Apart from old age pensions and blind pensions, there is little organized provision for public assistance. The two pension schemes, supported in large part by Dominion grants in the usual way, are administered by the Old Age Pension Commission. Average monthly pensions are the lowest in Canada, having been $11.32 for old age pensioners and $13.58 for blind pensioners on March 31, 1942.47 During the depression years there was an unemployment relief programme, consisting of direct relief, work relief, and special assistance to fishermen. Grants were made to the municipalities for both work schemes and direct relief under the direction of the provincial cabinet, a subcommittee of the cabinet took charge of the distribution of relief to persons living outside of the municipalities, and aid to fishermen was given by the Fishermen's Loan Board. There is no poor law in effect, but it is accepted that the municipalities have a certain moral obligation to look after the needy within their boundaries and in some cases they have continued to grant small amounts of aid since discontinuance of the joint Dominion-provincial system of unemployment relief grants in 1941. The provincial government, through the Relief Com- **Ibid. 47Dominion Department of Finance, Report on the Admini&fration of Old Aye and Blind Pensions, 1942, p. 15. ' The Maritimes 437 mittee of the cabinet, also continued to give some assistance to needy persons outside the municipalities. Relief allowances have been very small. It was reported to the Unemployment Relief Branch of the Dominion Department of Labour at the beginning of 1939 that in the city of Charlotte town maximum relief scales per family were $10 per month in summer and $30 per month in winter, with $5 per month in addition for shelter; and that they were far less in the rural.districts. Child welfare services are organized in much the same way as in Ontario and the West, with two children's aid societies operating in Charlottetown and in Summerside respectively and a provincial superintendent of neglected children serving the communities not within the jurisdiction of these societies. This official reports directly to the provincial cabinet. There are no institutions for juvenile delinquents, who are sent when necessary to reformatories in Nova Scotia or New Brunswick at the expense of the province. Three county jails, administered by the Department of the Attorney-General, are used for the punishment of adult delinquents, as well as for the temporary detention of persons awaiting trial before the courts. An Appraisal / The simplicity of the Prince Edward System is commendable. [The fact that virtually all of the public health and welfare work is (done by the provincial government means that the difficult prob- I lems of provincial-municipal relations which are so prominent in i other provinces are almost totally absent. The public health services have been well integrated in the provincial Department of Health, and it appears that there has been considerable progress in this field in spite of the small expenditures that have been made. But on the other hand there are serious weaknesses. Although social problems are no doubt much less acute on the Island than in other provinces on account of the absence of complex urban communities, it is pretty clear that the existing public services are not 438 Public Health & Welfare Reorganization sufficient to cope with the problems that exist. Even so favoured a community as Prince Edward Island needs mothers' allowances, an orderly programme of general assistance, probation and parole services, mental hygiene clinics, medical care for the needy, and other programmes that are either lacking at present or scarcely developed at all. Expenditures on public health, the programme that is best developed, are far too low. Nothing much has been done to attract well trained personnel, except in the case of public health doctors and nurses. And administrative organization could . be improved materially. The outstanding administrative weakness is the lack of integration of the existing welfare services under a responsible provincial officer. Without this there is little hope of effective co-ordination of activities and of good technical leadership. As we have seen, a committee of the cabinet directs the relief work that is done, a commission handles old age and blind pensions, child welfare comes under a superintendent reporting to the cabinet, and the Attorney- General is responsible for the operation of the jails and for dealing with problems of delinquency in general. These several activities are important enough in provincial administration to be grouped together in a department of public welfare, under the direction of a technically qualified official reporting to a provincial minister. There is no need for relief responsibilities being delegated to the few small municipalities, as is done at present on a somewhat informal basis. On the other hand, it seems that the peculiar circumstances of Prince Edward Island call for complete centralization of both welfare and health services at the provincial level. Both in size and in population the Island is very suitable to be a health unit or a welfare unit. A provincial welfare department, of the sort that has been suggested, would provide an excellent nucleus to which might be added other welfare services as and when it becomes possible to develop them. To the existing public health department there might be added the provincial mental hospital and the provincial sanatorium, and The Maritimes 439 it might also be given responsibility for the administration of grants to hospitals. Direct supervision of these institutions by the deputy minister of health, under his minister, rather than by the boards which now operate them, would have advantages which have been pointed out in earlier chapters. The boards might remain as advisory bodies. The question arises, of course, as to whether there might not be a combined department of health and welfare in such a small province. Such a department would no doubt operate satisfactorily if it consisted of two distinct divisions, one for health and one for welfare, headed by competent permanent officials. But in this case it would be the equivalent of two separate departments. It seems, therefore, that there is not much point in joining the two divisions together on paper. Prince Edward Island has the area and the population of a middle-sized county in the United States, where it is generally considered that the health and welfare functions should be handled separately under different departments of local government. Conclusion This review of the three Maritime Provinces has shown that the health and welfare services of all three are underdeveloped and that some important services are almost entirely absent. In Nova Scotia and New Brunswick an outstanding weakness is the continuance of an old-fashioned poor law system quite without provincial supervision or control. Local jails and other institutions in all three provinces are unsuitable agencies to provide institutional care. The public health services have made considerable progress in spite of insufficient appropriations, but the welfare programmes are very weak except in Nova Scotia. There is much need of administrative reorganization in the three provinces, particularly to integrate the welfare services at the provincial level and to build up welfare departments or divisions under whose direction the activities of both provincial and local governments might be co- 440 Public Health & Welfare Reorganization ordinated effectively. In Nova Scotia such reorganization is under way. Lack of money has been a real barrier to the extension and improvement of the health and welfare services of the Maritime Provinces. The three provincial governments, in their representations to the Rowell-Sirois Commission in 1938, argued very convincingly that their financial resources were insufficient to support the expansion of their social services which they recognized to be necessary, and their arguments were accepted by the Commission. It seems clear that in the post-war period Dominion grants-in-aid or some other measures must be taken to help them out. Conceding this point, there still remains much to be done that is within the power of the provincial governments. Redistribution of provincial and municipal functions and finances, administrative reorganization, and improvement of personnel are steps which they might take themselves without waiting for help from Ottawa. These administrative reforms need not lead to increased total expenditures. On the other hand, they may actually bring about some savings on administration, and they will certainly contribute a great deal towards improvement in the quality of service. Moreover, they are essential to provide administrative machinery for the expanded Dominion-provincial system of social services that must be built after the war. The Road Forward JLhe preceding chapters have shown that throughout Canada there are serious weaknesses in the provincial and local social services. It is not to be expected that the existing system will measure up to the heavy responsibilities to be placed upon it under a national system of social security which divides responsibility for administration between the three levels of government—Dominion, provincial, and local. The defects of the present system Ml into two categories which have been described as those of "content" and "administration." The -major deficiencies are summarized below.1 Flaws in the Present System 1. Important types of service are totally lacking in some provinces or in many parts of most provinces. For example, medical care for the needy, adult parole and probation, psychiatric clinic service, and general assistance are not available in many communities. 2. The extent and quality of service provided by existing public agencies is often inadequate. This point is illustrated by expendi- 1See Chapter 4 of the writer's Social Security and Reconstruction in Canada for a fuller summary. 443 444 Public Health & Welfare Reorganization tures on public health that are generally far too low, shortages of tuberculosis and mental hospital beds, low public assistance grants, and poor standards of child welfare work in some provinces. 3. There is great variation in the extent and the quality of social services from province to province and from community to community. In 1940 provincial and local expenditures on health and welfare, apart from relief, varied from $3.56 per capita in Prince Edward Island to $12.44 in British Columbia.2 There are also great differences in expenditures from community to community within each province. 4. Transients or non-residents are ineligible for various social services. Many Canadians who do not comply with existing provincial and local residence rules are not entitled to the benefits of public assistance or other programmes. Most provinces have confused, inconsistent, and illogical sets of residence rules which prevent many needy people from obtaining services they require, while the rules are dubious instruments for their main purpose, the protection of the local taxpayer against unreasonable charges. 5. There has been insufficient emphasis on policies of prevention and rehabilitation. In general, constructive programmes to prevent dependency, sickness, and delinquency or to rehabilitate social casualties are much underdeveloped. These defects vary in importance from province to province. In some they are very great indeed, while in others they are not so serious. However, the fact that our analysis of the situation in British Columbia, the leading province in health and welfare, has shown substantial gaps and inadequacies, suggests the great distance which all the Canadian provinces have to go in building up the content of their programmes to a satisfactory level. The weaknesses in programme content which have been noted derive in large part from serious defects in the organization and the finances of the health and welfare system and in their administrative management. The leading flaws of an administrative nature are the following: 1. Operating functions in most provinces are not well distributed between the provincial and the local governments. 2See Table II, p. 142. The Road Forward 445 2. The distribution of financial obligations between the provinces and their local authorities is often very unsatisfactory, pressing heavily upon the poorer communities, and in most provinces there is a tangled fabric of financial relations between the provincial and local governments which is unnecessarily complicated. 3. The great majority of the existing municipalities are unsuitable units of administration because they are too small in population. 4. In large part, integration of the health and welfare services is unsatisfactory, administrative machinery is weak, and standards of administration are poor on both the provincial and local levels. 5. There is commonly poor co-ordination between the social service activities of the provinces and the local authorities. 6. Administrative personnel is often unskilled and there has not been much in the way of progressive personnel policy. Stated so briefly the situation is perhaps made to look worse than it really is. The generalizations that are made above do not apply equally to all provinces, to all communities, and to all branches of service. Recently vigorous efforts have been made in a number of provinces to overcome problems of organization and administration and this has resulted in marked improvements. But while there is much that is good in the health and welfare systems of the various provinces, particularly in certain fields such as public health and child welfare, there is a great backlog of administrative weakness to be overcome. Principles of Reorganization Clearly a national system of social security will make demands upon the provincial and local services far too great for them to meet without undergoing major adjustments. The deficiencies of content which have been outlined above must be remedied, and everywhere there should be a great deal of administrative reorganization. The analysis of the preceding chapters, particularly those on British Columbia, points toward the administrative reforms that are required. While reorganization plans for the different 446 Public Health <fc Welfare Reorganization provinces should not be the same in detail (for they must take into account the peculiar characteristics of each situation) they should be based upon certain principles, as follows: 1. Operating functions to be assigned to the local authorities should be limited to those which the majority of them are potentially able to manage well. This means that specialized programmes involving service to limited groups of people, such as the mentally ill, the mentally deficient, juvenile delinquents, and the tuberculous should generally be undertaken by the provincial authorities, for in few local communities will the number of such people be large enough to justify establishment of the complex facilities required for their care. On the other hand, generalized public health, public assistance, and constructive welfare service can be left to the local authorities if the conditions set forth in the next two points, regarding suitable administrative units and finances, are met. These are the programmes which touch large numbers of people and which are likely to offer at all times sufficient volume of work to warrant the operation of local health and welfare departments* 2. Administrative responsibilities should be delegated only to local units that are suitable in population and in other characteristics for the efficient performance of such obligations. Unless operating units are formed that are larger in size than the great majority of the Canadian municipalities, the case for delegating administrative obligations to the local authorities falls down completely. Health units of at least 20,000 to 25,000 in population are necessary. Although welfare service may be carried on with reasonable efficiency in districts of smaller population, it is desirable that the welfare unit and the health unit should have the same boundaries. Therefore there is much to be said for health and welfare districts which have a population of at least 25,000. Such districts would also be appropriate for the purpose of educational administration. These health and welfare units may be organized within the framework of the existing municipal system by utilizing many of the present counties in Ontario, Quebec, and the Maritime Provinces; and by grouping together the smaller municipalities of the West. 3. Provincial-local financial relations regarding health and welfare should be so arranged that the financial burden is divided equitably, that every local authority is protected against unreasonable costs, and that the system is compatible with good administrative standards. The Road Forward 447 Compliance with this principle is another condition for the delegation of the generafeed health and welfare services to the local authorities. For unless equitable financial arrangements are made to protect the poorer municipalities against unreasonable costs they cannot be expected to perform administrative functions well. In most provinces there is a tangled fabric of provincial-local financial arrangements with the province making certain grants to the local authorities and the latter assuming a variety of charges, including the obligation to contribute to the operation of provincial and private institutions. Typically, the existing systems have grown up, item by item, without reference to any total plan, and they commonly stand in the way of good service to individuals. Many of the present charges .may be removed from the municipalities in the interests of simplification and equity. Still more important, the provincial grant systems should be revised so that they are consolidated into a few grants based upon the principle of giving aid to the local authorities in accordance with their varying needs. The general application of the method of equalization grants, accorc&ng to various formulse which may be developed, should overcome the second major barrier (the first being small units) in the way of the efficient performance of social service functions by the local authorities. 4. Reorganization of administrative machinery at both the provincial and local levels is necessary. At the provincial levels the health and welfare services should be integrated as closely as possible, preferably into two separate departments of health and of welfare. As a general rule the programmes concerned with public health, with curative medicine (medical care to the needy, hospitalization, crippled children's services, etc.) and with mental hygiene may be grouped in the health department; while the appropriate jurisdiction of the welfare department includes public assistance, child welfare, the delinquency services, and vocational rehabilitation. Separate agencies for health insurance and for workmen's compensation are generally to be desired. Both health and welfare departments in all the provinces should give much attention to the improvement of internal organization, which should be such as to stimulate effective co-ordination between the different branches of the departments and between the major agencies themselves. The welfare departments will generally have need of unified field services, which may also serve the health departments. Advisory 448 Public Health & Welfare Reorganization boards and commissions are very much to be commended; but in general boards should not be used for purposes of direct administration. However, an outstanding exception to this rule is to be made in the case of the prospective provincial health insurance systems, for which the commission form of administration appears to be appropriate. At the local level, similar measures of integration and organization are required. A simple pattern of organization is suggested, to consist of a health department and a welfare department in each administrative district with advisory committees which will serve, among other things, to encourage citizen participation in the programme. At the provincial level, co-ordination between the health and welfare departments may be achieved by the establishment of interdepartmental advisory councils which should contribute also towards the formation of major policies for the social services. 5. Provincial departments should be empowered to set standards of service to be observed by local and private health and welfare agencies and should undertake a positive programme of supervision, designed to assist the supervised agencies in solving their problems even more than to check upon their deficiencies. So long as the provinces make grants to the local health and welfare agencies and delegate certain administrative responsibilities to them it is clear that they must supervise the grant-aided units, at least in the negative sense of making sure that the latter do not misspend the grants. But they should go much farther than this. They should assume vigorous leadership in developing the public social services within provincial and local jurisdiction as well as the related private services. Grants should be made to the local authorities only on condition that they maintain reasonable standards of service. They7 should be helped to comply with the prescribed conditions by field officers of the provincial departments who offer technical advice and assistance at every point. This positive programme of supervision should yield great results in the way of a friendly partnership between the provincial and the local authorities towards the common end of a good system of social services. Standards should also be set for various private services and supervision should assist them to measure up to these requirements. Thus the provincial governments will exercise leadership within their respective domains. The Road Forward 449 6. There should be worked out under provincial direction a positive personnel policy designed to develop thoroughly trained and competent administrative personnel for both provincial and local agencies. There is little hope that the present acute personnel problems can be overcome unless vigorous efforts are taken by the provincial governments to develop better staff. The provinces must think not only of their own employees but also of the employees of the local authorities—for there are few local agencies which are large enough or strong enough to develop good personnel without outside aid. The employment of qualified staff in accordance with standards to be prescribed by the provincial authorities is one of the appropriate conditions to be attached to grants-in-aid. The preceding proposals for reorganization have important implications regarding broader aspects of government in the provinces and the local communities. Much of what has been said about provincial-municipal relations in the fields of health and welfare applies also to other areas, including education, recreation, police and fire protection, and housing. Complete or nearly complete municipal autonomy, without much financial assistance or supervision from above, has not given the country a satisfactory system of local government. There is general need for the amalgamation of small units, the revision of provincial-municipal financial relations, and the development of good personnel. Provincial financial assistance, standards of performance, supervision, and leadership are as necessary in the municipal field in Canada as they have proven to be in Great Britain and other countries. If this larger programme of municipal reform were undertaken vigorously many of the problems of organization and administration in health and welfare would be solved automatically. If it is not, improvements in provincial-local relations regarding the social services should contribute notably to solution of the larger problem—for precedents will be thus created which will be applicable also to other branches of administration. Moreover, the reorganization of administrative machinery on both the provincial and local levels is desirable not only for the 450 Public Health & Welfare Reorganization health and welfare services but also for other activities of government. The administrative structure of most provincial governments could be thoroughly revised with great profit and the same is certainly true of most municipalities. In Canada but little serious attention has been given by politicians, by civil servants, by the universities, by research agencies, and by the general public to problems of public administration; and the country is not distinguished for its administrative system. If the larger problems of provincial and local administration were tackled seriously, many of the existing defects of the health and welfare machinery would be overcome. But in this case, too, it is appropriate to undertake housecleaning in the social service field without waiting for complete administrative reform—and so far as this is done, an important contribution will be made towards solution of the larger problem. The Importance of Local Units The precise manner in which the national agencies of social security will relate their activities to the provincial and local units is a question which has not been discussed to any extent in the preceding chapters. The problem is one which will require a good deal of ingenuity for its solution, but it should not be unduly difficult to solve if the provincial and local services are well developed and soundly organized. Three examples may be cited of the importance—indeed, the indispensability—of strong provincial- local agenciea to the federal programme; and these relate to measures to which the Dominion is thoroughly committed, health insurance, family allowances, and unemployment insurance. It is perfectly clear that a national system of health insurance calls for a good public health system. For it goes without saying thai everything possible should be done to prevent illness rather than to cure it. What is needed, as we have seen from the preceding chapters, is a system of vigorous health units covering the whole country. Without this essential machinery there will be a vast The Road Forward 451 deal of preventable illness and physical defect and the burdens upon the health insurance system will be correspondingly high. This has been recognized in the health insurance measure proposed by the Heagerty Committee and the general principle has been thoroughly accepted by the Social Security Committee of the House of Commons. Efficient local welfare units have potentially a very important role to play in connection with the operation of a national system of family allowances. Determination of eligibility for the allowances may be undertaken by a chain of federal social insurance offices. But in a small proportion of cases there will probably be trouble on account of the failure of the parents to utilize the grants in behalf of the children. "The experience of the Dependent's Allowance Board during the war years would seem to indicate that this percentage will not exceed more than one to three per cent, in all eases. "3 Even this relatively small proportion will represent a substantial number in total and will call for effective supervisory measures involving a large amount of administrative work. Efficient local welfare agencies will be equipped to undertake the responsibility for this work. Indeed, such a task will fit in very well with their normal activities—for probably a large number of families where supervision is required will already be among their clients. In the absence of good public welfare departments throughout the country the federal agency administering family allowances will have to create special machinery for the supervision of grants to certain families; or alternatively will have to make a series of special arrangements by calling upon the services of children's aid societies, of provincial welfare field services, of private social agencies, and of other organizations—as has been done by the Dependent's Allowances Board and the Board of Dependent's Trustees during the war years for the administration of grants to military families. 3Canadian Welfare Council, 24th Annual Report, 1944, p. 18. 452 Public Health & Welfare Reorganization Authorities on the subject are generally in agreement that unemployment insurance must be supplemented by a strong system of public assistance for both employables and unemployables. Without local units to administer the assistance programme, the Dominion, or the province, will have to create special machinery for the purpose. This policy would lead to many difficulties, which were pointed out in Social Security and Reconstruction in Canada* Whatever the precise formJ of the general assistance programme, it can be administered by local welfare departments. Indeed, the importance of the local health and welfare units cannot be overstressed. Only three examples of their value have been given here. But it is probable that in a dozen and one ways they can undertake services of value to the Dominion social security agencies. The building up of this basic machinery of health and welfare throughout the country should be a first objective of national social security policy. Once the machinery is there the possibilities of its effective utilization are many. It is bound to be needed whatever the details of the federal security programme may be. Provincial Action Even without full knowledge of national policy on social security the provinces can undertake a great deal of housecleaning and improvement of their social services which will contribute towards a national plan. During the last couple of years, and particularly during 1944, there has been a most encouraging disposition on the part of the provinces to face up to the problems of health and welfare. In Ontario, Quebec, ancf Nova Scotia, there have been extensive surveys of the social services; in Manitoba, such a survey is under way; and in Alberta and Saskatchewan there have been useful inquiries by special committees. In the spring of 1944 there was a wave of progressive legislation which has been reported in the preceding pages. The formation of public welfare depart- 4Pp. 100-104. The Road Forward 453 ments in Alberta, Saskatchewan, Quebec, and Nova Scotia marks a great step forward. Reorganization in British Columbia during the last two years and the improvement of the content of the provincial and local programmes has been very significant. Across the country there is far more interest in obtaining trained personnel for the health and welfare services than ever before. There is a stirring in the provinces which indicates that they are willing to face up to the realities of social security in the post-war period even before the lead is clearly given by the Dominion. This is very much to the good. Many of the suggestions for administrative reform which have been made in the preceding pages are within their powers, legislatively and financially, and would be appropriate whether there was to be a federal programme of social security or not. The examples which have been set by Ontario, Nova Scotia, Manitoba, and Quebec in undertaking comprehensive surveys are particularly to be commended. Detailed examination of the problems of each province, covering even more ground than that in the British Columbia chapters of this book, should yield results which will be invaluable in the formation of policy. National Leadership But by themselves the provinces and the local authorities cannot go beyond a certain point. In Social Security and Reconstruction in Canada, it was argued that national leadership was essential to the development of a satisfactory system of social security in Canada. This, it was stated, "is the very kernel of the proposals put forth in this book."5 The provinces need help from the national government and they need it urgently if they are to play their part fully in building the new security system. In the first place they must be given clear premises of national policy. In Chapter 1 two major premises for provincial planning were proposed—first, that the provincial and local governments will sp. 170. 454 Public Health & Welfare Reorganization be expected to operate substantially the same range of health and welfare services as at present; and, secondly, that the Dominion will have to provide financial aid in such amount and in such manner as to enable- them to discharge these obligations satisfactorily. It may be predicted with considerable assurance that the federal government must commit itself to these premises when it undertakes to formulate its plans fully. But until the Dominion makes such commitments overtly, the provinces are obviously handicapped. They have legitimate reasons for hesitating to go too far in their own planning in advance of clear assurances from Ottawa, particularly on finances. Thus far the federal government has made definite or virtually definite commitments on health insurance, on family allowances, and on the establishment of a department of health and welfare. But it has not yet laid before the provinces a comprehensive outline of a national system of social security and this is what must be done to clear the way for really effective work on the provincial and local level. A second point very closely related to the first is that there must be some answer to the vexed question of Dominion-provincial financial relations. The Rowell-Sirois Commission formula for settlement still remains for serious consideration. In the writer's view this formula is a reasonable one provided that some "incentive grants" towards the provincial social services are coupled with it.6 The whole question is on the agenda of the Dominion-provincial conference which is planned for some time in 1944. If some agreement between the Dominion and the provinces can be obtained on this fundamental issue the way will be very much cleared for effective planning both in Ottawa and in the provinces. Thirdly, the provincial governments must be assured of technical services of various sorts from the federal authorities. This is another of the main proposals for federal action which was made in Social Security and Reconstruction in Canada. The writer's 6See Social Security and Reconstruction in Canada, p. 171. The Road Forward 455 observation has been that there is much willingness on the part of provincial and local officials to accept technical advice and assistance from Dominion officers as well as from outsiders. The eagerness of the provincial health officers to participate in national planning regarding health insurance, to exchange ideas one with another, and to accept the leadership of the Heagerty Committee in planning for better public health services throughout the country is an indication of the attitudes that prevail among the better provincial civil servants. The analysis of the preceding chapters will have shown that there are many difficult technical problems to be solved at the provincial arid local levels. It cannot be expected that there should be enough knowledge and capacity in every province and in every local community to cope with these problems. The provinces must look to the Dominion, as the local communities look to the province, for assistance in dealing with these issues. It is to be hoped that in the new federal department of health and welfare there will be far more provision than in the past for rendering such technical service. A fourth point at which national leadership is needed is in the field of personnel. Various suggestions were made in Social Security and Reconstruction in Canada for Dominion policy on personnel,7 including specific grants towards the salaries of technically equipped provincial and local officials, formulation of personnel standards, support of training programmes, and contributions towards professional schools in the universities. In addition there is great need for a concerted attack upon the personnel problem by professional associations and national agencies concerned with the social services. Schools of public health, of social work, of medicine, and of public administration in the universities must be greatly strengthened and extended to turn out the trained staff to Joe needed in the postwar period. The provincial and local authorities need the help of both the national government and of national 7See pp. 179-181. 456 Public Health & Welfare Reorganization private agencies if they are to find enough of the right kind of people to man their services. A fifth area in which there must be national leadership is that of research. Here again the federal government has an important role to play, but here, too, there is a valuable contribution to be made by the universities and by private agencies like the Canadian Welfare Council, the Canadian National Committee for Mental Hygiene, and the Canadian Public Health Association. Both official and non-official research are badly needed to provide the knowledge requisite to effective planning for the social services. These suggestions for national leadership, which summarize very briefly points that were made in greater detail in Social Security and Reconstruction in Canada, express a doctrine of Dominion contribution towards the development of social security which is basic to the proposals for policy made in this book and in the preceding one. Social security is all of a piece. One part depends upon another and no part can be removed without grievous effect upon the whole. It cannot be divided simply and sharply into Dominion, provincial, and local elements. Only as each element is in place, closely related to the others, will the system work properly. This means that there can be no sharp and clear delimitation of jurisdiction over the subject matter of social security, as the Rowell-Sirois Commission proposed. On the other hand, the Dominion government must be concerned with the whole programme and so must the provinces and the local authorities, even although each undertakes major responsibility for certain operating functions. The key to success will be agreement that there must be a partnership between the three levels of government in operating the system. Only as this partnership is worked out on equitable terms, only as it operates with understanding and tolerance among the partners, and only as they feel that each is pulling his fair share is the system likely to be really successful. It is the writer's faith that such a partnership regarding social security can really be achieved in Canada. An attempt has been APPENDIX Note on Sources A brief selected bibliography of secondary sources on the social services is appended to Social Security and Reconstruction in Canada, and to this the reader of this book is referred for further study <d problems discussed here. A few important items, issued since the publication of Social Security and Reconstruction, should be added to the list, as follows: House of Commons Special Committee on Social Security, Sess. 1943, Report on Social Security for Canada, by L. C. Marsh, prepared for the Advisory Committee on Reconstruction. House of Commons Special Committee on Social Security, Sess. 1943, Report of the Advisory Committee on Health Insurance. Charlotte Whitton, The Dawn of Ampler Life (Toronto: Mac- millan, 1943). U.S. National Resources Planning Board, Security, Work, and Relief Policies (Washington: 1942). The sources from which the factual data in this book are derived have been indicated wherever possible in footnotes. To a considerable extent annual and special reports of the provincial health and welfare agencies have provided basic data. But from these reports alone the student would gain only a very imperfect understanding of the provincial and local social services. Usually the narrative reports are brief and perfunctory, giving only a slight impression of the activities and the problems of the agencies, and they are supplemented by a good deal of statistical data, good, bad and indifferent. Some provincial agencies and most local agencies do not issue reports at all. Most provincial reports should be vastly improved if the citizen is to be given, year by year, adequate 458 Appendix 459 information about his public social services. The Provincial Board of Health of British Columbia has set a good example for other agencies by describing its organization and functions clearly in its 1942 report and by giving a very full account of its activities in its annual reports for a number of years. A few special reports of the last few years are particularly valuable. These include: American Public Health Association, Public Health in Manitoba (1941). W. A. McIntosh, An Administrative Study of the Nova Scotia Department of Public Health with Recommendations (Halifax: (King's Printer, 1935). D. Bruce Wilson and W. A. McIntosh, A Survey of the Public Health Services of the City of Halifax, Nova Scotia, 1942 (Halifax: King's Printer, 1942). Quebec, First Report of the Quebec Health Insurance Commission (1944). Other survey reports on Nova Scotia (by the Canadian Welfare Council), on Ontario (by Miss Charlotte Whitton), and on Manitoba (by the American Public Welfare Association), have been prepared but not yet published. Such reports as those listed and those in process will offer the most useful supplementary reading to students of the questions discussed in this book. In short, the literature of the Canadian health and welfare services is very sketchy; and one must go to original sources and must make field visits in order to get good information about them. INDEX Administrative functions and responsibilities, Distribution of, 4, 8-10, 19, 20, 23-28, 67, 80, 138, 188-193, 204, 208-213, 240-241, 289-290, 301ff, 318-322, 336ff, 344, 349ff, 365ff, 393ff, 403, 427-431, 445, 446 Administrative reform, 3-4, 29-32, 66ff, 121- 143, 235-279, 344ff, 372 Administrative standards and supervision, 15, 22, 230ff, 294ff, 358ff, 451 Adoption laws, 6, 49, 101, 378 Advisory councils, 259-260 Alberta, 142, 193, 219, 247, 249, 284-301, 310, 311, 333-334, 338, 425 Amyot, Dr. G. F, 79, 90, 94 Appraisals of provincial systems, 35ff, 140-143, 145-148, 287ff, 307ff, 317, 323ff, 333-334, 345ff, 375ff, 401-405, 423f, 432, 437ff, 439, 440 B Bell, Miss Marjorie, 347, 348 Beveridge Report, 1, 12, 134 Birth control, 151 Blind pensions, 116, 132, 137-138, 170-171, ^ 185, 287, 339, 346, 349, 356, 371, 395-396, 413, 423, 436 Blind welfare, 54, 55, 102, 117, 179, 180, 264, 396 Bow, Dr. M. R., 288 Boyes, Mr. F. C, 98 British Columbia, 35-279, 286, 298, 310, 320, 350 Buck Report, 318, 320, 325-326, 328, 330," 332, 333, 334 I Cabinet Committee on Unemployment Relief, 61, 104-108 Canadian Red Cross, 55 Cameron, Dr. Maxwell A., 353 Cancer control, 150, 151, 303, 308, 319, 337, 423 Cancer Control Act (1944), 303 Cancer Treatment and Prevention Act, 285 Case loads, 25, 175-178, 314, 359 Categorical aids, 25, 171-172, 262ff, 349, 411, 413-414 Child guidance clinics, 5, 49, 97, 99 Child welfare, 4, 6, 8, 22, 41, 49-50, 55, 100- 102, 181, 264, 285-286, 305, 315, 319, 331- 332, 338, 340, 346, 356, 362, 372, 378, 399ff, 414-415, 423, 437 Children's allowances, 2 footnote, 3, 14, 20, 173, 451 Children's Protection Acts, 49, 101, 372, 378, 389, 399, 414, 415 Civil service reform, 271, 274 Collections, 73, 74, 255 Combined health and welfare department, 242ff, 329ff, 346, 387, 407, 433-434, 439 Commission. See Royal Commission. Communicable disease control, 76, 397, 419, 420. See also under specific diseases Compulsory school attendance, 53 Constitutional problems, 27-28 Corrections. See Delinquency services and also Industrial schools. Crease, Dr. A. L., 97 Crippled children, Treatment of, 17, 102, 150, 156, 337 Crouch, Mr. W., 121 D Davidson, Dr. George F., 117, 120 footnote, 137, 407 Davison, Dr. R. O., 313 Deaf welfare, 54, 179, 264 Decentralization, Arguments for, 205-207 Delinquency services, 4, 6, 22, 50-51, 98-100, 163-169, 185, 208-209, 264, 287, 289, 322, 324, 340-342, 346, 357, 369, 378-379, 400, 416-417, 437. See also Industrial schools Dental service, 78, 150, 151 Departmental organization, 68ff, 137, 242ff, 254ff, 260ff, 299-301, 312ff, 320, 328ff, 354ff, 387ff, 405-406, 432-434, 438ff Depression, The impact of the, 56ff, 283, 301, 317, 356, 365, 374, 377, 405, 410-412, 436 Disability allowances, 171, 185 . Divorce Act, 101 Dolman, Dr. C. E., 87, 90 Dominion financial aid, 3, 8-9, 15, 17, 19, 21, 23-28, 42, 44-48, 53, 59-61, 98, 106, 107, 110, 115, 370, 433, 440. See also Financial responsibilities, Distribution of Dominion Juvenile Delinquents Act (1908), 51 Dominion - provincial relations, 454. See Rowell-Sirois Commission Dominion Unemployment Insurance Commission, 92 Education, 6, 43, 53-54, 58, 75, 211-212, 256, 291-293, 327, 341, 351, 353 Employment and Social Insurance Act (1935), 27 Employment Service of Canada, 108, 113 Equal Guardianship of Infants Act, 101 Equalization grants, 217, 219, 221ff, 226, 291, 351-352, 431 Expenditures, health, 66, 88, 152, 302, 355, 368, 398, 421, 424, 435, 438; welfare, 46, 58, 177-179, 320; health and welfare, 56, 62, 69, 141-142, 186-187, 192-200, 366, 371, 386, 410, 430, 434-435 461 462 Index Factories Act (1908), 52 Fagan, Dr. J. J., 41 "Fair hearing and appeal," 174, 231 Family allowances. See Children's allowances Farm security programme, 21, 106 Feeble-minded, Care of, 5, 8, 161-162 Field service, 71-75, 118, 132-137, 164, 252, 265, 308, 355 Financial aid. See Dominion financial aid Financial responsibilities, Distribution of, 2, 4, 8, 9-10, 15, 16, 18, 20, 23-28, 60, 138, 188-193, 214-216, 289-290, 301ff, 344, 349ff, 366ff, 370f, 386, 393, 403, 406, 427- 431, 445, 446, 454 Fishermen, Aid to, 436 Flaws in provincial systems, 443-445. See also Appraisals and Inadequate services Food allowances, 114, 347, 396, 412 Forestry schemes, 107, 110, 410 Inadequate service, 288-289, 308-310, 324- 325, 346-349, 398, 443 Income insurance. See Social insurance Indians, 9, 37, 81, 98 Indigent relief. See Poor relief. Industrial schools, 6, 51-52, 66, 69, 72, 98-100, 164, 165-167, 305, 315, 349, 369-370, 378- 379, 400, 416 Infants Act (1901), 49, 50, 101 Infirmaries, 45, 54, 72, 92, 96, 159-160, 185, 238, 251, 305, 319 Insane Asylums Act (1873), 48 Inspection of foods, 41, 150, 419 Institutional care, ReUarice on, 342, 378, 380- 381, 412, 425-426 Insulin, 337 Integration, 15, 76, 77, 159, 235-238, 312ff, 329, 355, 357, 382, 406 Investigation, Public Health, t7 General assistance, 172, 262-263. See also Poor relief Goldenberg, Mr. H. Carl, 318 Grancher system, 369 Grants-m-aid, 129, 215-218, 370, 374, 433. See also Provincial grants, Equalization grants and Dominion financial aid Griffith, Mr. E. W., 105, 137 Juvenile courts, 51, 99, 164-165, 208-209, 322, 341, 346, 372, 400, 415 Juvenile delinquency. See Delinquency services K Kidd committee, 58, 63, 179 King, Major H. B., 204 H Harper Commission on Municipal Taxation (1933), 195, 223 Hart, Hon. John, 64-65, 67 Harvey, Miss Isobel, 73-74 Hatfield, Dr. W. H., 80, 82, 90 Heagerty Report, 1, 15-17, 25, 28, 451, 455, 458 Health grants, 216-217, 284. See Dominion financial aid Health insurance, 2, 7, 53, 152-160, 185, 209, 227, 267, 307, 344, 354, 372, 451. See also Public medical care Health Insurance Act, 153 Health Insurance Commission, 267 Health units, 43, 75-78, 146, 210-214, 311, 337, 343-345, 347, 368, 373, 375, 420, 427, 452. See also Local Administrative Units Holland, Miss Laura, 50, 71, 137 Hospital Act (1937), 94 Hospital grants, 45-46, 93-94, 102, 154-159, 185, 338, 366, 422 Hospitalization, 5, 45, 92, 103, 285, 307-308, 331, 343 Hospitals, 72, 92-96, 306, 422, 426, 433. See also Mental hospitals Hours of Work Act (1921), 52 Housing, 6, 183 Laboratory services, 42, 86-87, 149, 284, 318, 345, 369, 397, 420, 435 Labour protection, 6, 52-53 Land settlement schemes, 8, 107, 304, 321, 410 Leadership, Dominion, 22, 453-457; provincial, 129, 202, 204ff, 295ff, 320, 323, 334, 346, 365, 375, 384, 420, 432ff, 452-453 Local administrative units, 201, 210-214, 290- 294, 311-312, 327-328, 345, 352-353, 387, 427, 445, 450ff Local Asylums for the Harmless Insane Act, 408 Local Government Act of Great Britain (1929), 217 Local government organization, 57, 341, 373, 393, 406, 434 Local health and welfare organization, 263-264,. 267-268, 374 M Manitoba, 52, 142, 193, 219, 223, 249, 300, 317-334 Maritime Provinces, 392-440 Marsh Report, 1, 12-15, 24-28, 174, 458 Marshall, Mr. J. T., 87, 90 Maternity Hospitalization Act (1944), 285 McGhie, Dr. B. T„ 345 footnote Mcintosh Report, 418, 419, 420, 421, 423, 428, 459 Index 463 Medical Services Act, 354 Mental hospitals, 5, 7, 48-49, 66, 68, 72, 97-98, 302, 305, 309, 318, 338, 367, 398, 408, 416, 422, 425, 427, 436 Mental Hospitals Act (1940), 98 Mental hygiene, 4, 5, 17, 22, 48, 66, 97-98, 160-163, 185, 248-251, 284, 338, 345-346, 367-368, 382, 399, 417, 427, 438. See also Psychiatric clinics Merits of provincial systems. See Appraisals Minimum Wage Acts, 40, 52 Minville, Prof. Esdras, 364-365, 380, 384, 388 Mothers' Allowances, 5, 8, 14, 58, 103, 116, y 117-118, 171, 2*7, 305, 309; 319, 3d9r346, S 349, 356, 380, 4*1-413, 423, 438 Mothers' Allowances Acts, 118, 138, 171, 395 Mothers' Allowances Commission, 356 Mothers' Pensions Acts, 46, 118 Municipal Health Services Act (1944), 344 Municipal charges, 190-191, 227-228 Municipal Hospital Act, 285 Municipalities, 39, 97, 99, 188-234, 291, 293, 327, 341, 352, 373, 387, 393, 407, 434 Municipal responsibilities, 188, 287, 306-307, 322-323, 341-344, 373ff, 386-387, 393, 402- 404, 406 N National Employment Commission (1938), 10, 24, 26 National employment programme, 12 National plans for social security, 12 New Brunswick, 142, 193, 381, 393-406, 429, 437, 439-440 Non-residents. See Transients Nova Scotia, 53, 141, 142, 193, 247, 249, 338, 381, 400, 401, 406-434, 437, 439-440 Nutrition, 79, 150, 347ff, 369 O Old Age and Blind Pensions Commission, 356 Old age pensions, 2, 5, 8, 117, 132, 137-138, 169-170, 185, 241, 287, 305, 321, 339, 346, 349, 356, 371, 395-396, 411-413, 423, 436 "Old Age Pensions Act (1927), 8, 14, 47, 116 Ontario, 11, 53, 142, 193, 219, 223, 249, 335-363, 373, 379, 382, 397, 415 Ontario Public Welfare Commission (1930), 31 Organization charts, British Columbia: Department of Provincial Secretary, 70, 122,237; Provincial Board of Health, 89; Department of Welfare, 261; Department of Health, 255 Orientals, 37, 52, 98 Penal institutions, 6, 164, 166-169, 185, 360i 369, 401, 417, 427 Personnel problems, 30, 66, 72, 135-137, 147, 175-177, 185, 269-276, 297-299, 315-317, 332-334, 360-363, 389-391, 404, 431-432, 438, 449, 455 Poliomyelitis, 285 Politics and social welfare, 153, 158, 356, 361, 383, 405, 428 Political repercussions of the depression, 62-65 Poor laws, 44, 394, 407, 426 Poor relief, 5, 8, 44-47, 54, 67, 107, 116, 117- 118, 138, 209, 322, 342, 393-396, 401-402, 408ff, 425, 436-437 Poor Relief Act, 409 Prairie Provinces, 283-334 Premises for provincial planning, Iff, 23ff, 145 Present system of health and welfare services, 7-11, 443ff Preventive medicine, 5, 15, 149, 313, 368, 450 Prince Edward Island, 142, 193, 194, 381, 396, 401, 410, 429, 434-440 Private health and welfare services, 45, 49-50, 52, 54-55, 59, 73, 181-183, 340, 364ff, 369, 374-376, 380, 384, 391, 429 Proposals for reorganization, 445ff "Pro-Rec," 168, 266 Provincial grants, 58, 95, 112, 189-190, 284- 286, 318-320, 326-327, 336, 338, 348, 350, 366, 370, 382, 395, 415, 426, 436. See also Financial responsibilities, Distribution of Provincial Infirmaries Act (1937), 96 Provincial-municipal relations, 10, 56, 105 127-128, 188-234, 279, 310, 325-327, 349ff, 391, 427ff, 437, 446ff Provincial problems, 235ff, 288ff, 308-317, 324ff, 346ff, 376ff, 401ff, 424ff, 437ff, 443ff Provincial standards and supervision, 230-232 Psychiatric clinics, 5, 49, 97, 161-163, 183, 185, 285, 338, 380, 417. See also Mental hygiene Public assistance, 3, 6, 14, 18, 21-22, 44-48, 104-143, 169-179, 183, 262ff, 338, 348, 370, 393-397, 407-414, 436-437 Public Charities Act (1921), 365ff, 375, 378, 386, 391, 409 Public health, 3, 4, 5, 8, 15-17, 22, 41, 75-79, • 145-148, 185, 248ff, 357, 375, 397-398, 418-421, 435 Public Health Act (1944), 344 Public health nursing, 45, 95, 285, 318, 332, 398-399, 419, 420, 435 Public medical care, 3, 4, 5, 6, 14, 15-17, 18, 22, 53, 66, 90-92, 106, 111-112, 139, 145, 151- 160, 339, 346, 379, 395 Parole of delinquents, 6, 98-100, 163-165, 340, 346, 379, 402 Parole of mental patients, 6, 98, 162-163, 424 Patterson, Premier W. J., 314, 315 footnote- Patullo, Hon. T. D., 63-64, 90, 104 Pearson, Hon. George S„ 64-65, 67, 132 Peebles, Dr. Allon, 91-92 Quebec, 142, 193, 219, 247, 338, 364-391, 425 Quebec Commission of Inquiry into Hospitals (1941), 372, 385 Quebec Social Insurance Commission (1933), 31, 372, 383, 388, 390 Quebec subsidy system, 365ff, 380ff 464 Index Recreation, 6, 168-169, 183, 185, 266. See also "Pro-Rec" Reform, Suggestions for, 185-186 Relief administration, 112-117, 286, 303-304, 319, 321, 322, 338, 342, 358-359 Research, 456 Residence and Responsibility Act (1936), 118- 121, 350 Rockefeller Foundation, 43, 275, 311, 418 Rogers, Dr. G. F., 353 footnote. Rowell-Sirois Commission (1936), 10, 23, 24, 25, 26, 28, 57, 58, 215, 219, 309, 348, 359, 364, 380, 392, 399, 404, 430, 440, 454, 456 Royal Canadian Mounted Police, 58, 298-299, 322 Royal Commission Concerning Mentally Deficient Persons in Nova Scotia (1927), 416 Royal Commission on Health Insurance (1932), 64 Royal Commission on Mental Hygiene, 161 Royal Commission Municipal Taxation. See Harper Commission Royal Commission on Penal System (1938), 22, 26, 166, 169, 360, 362, 401, 402, 417 Royal Commission on Public Welfare (1930), 338, 349 Royal Commission on Poor Laws (1834), 402, 412 Royal Commission on Public Welfare (1930), 338, 360, 362 Sanatoria for Consumptives Act (1938), 336, 342 Sanitation, 5, 41, 78, 284, 318, 345, 369, 419, 435 Saskatchewan, 142, 193, 219, 247, 249, 301-317, 320, 333-334, 338 Saskatchewan Cancer Commission (1930), 303 Social insurance, 2, 3, 6, 7, 13, 19, 20, 53, 172. See also Workmen's compensation Social insurance collections, 3 Social Security Act of 1935 (U.S.A.), 11, 174, 231 Social Security and Reconstruction in Canada, 20-23, 24-28, 144-145, 184, 205, 452-457 Soldiers' Aid Commission, 340, 356 Standards of social services, 144-145, 230ff, 448 Surveys, 31, 47, 83, 94, 300, 318, 344, 357-358, 399, 407, 418, 452 Training for social work, 55, 102, 135, 163, 270, 274-275, 415. See also Personnel problems Transients, 59, 60, 103, 108-111, 119-120, 127, 181, 377, 378, 410, 444 Tuberculosis control, 5, 17, 41, 42, 54, 67, 69, 72, 79-82, 139-140, 147, 148-149, 150, 151, 179, 185, 284, 303, 308, 319, 336-337, 342, 345, 346, 354-355, 368-369, 375, 380, 398- 399, 420, 422, 429, 435 U Unemployment insurance, 8, 452 Unemployment relief, 5, 8, 44, 58, 59-62, 96, 104-117, 286, 294, 338, 356, 371, 376, 436- 437 United States National Resources Planning Board, 218, 458 Venereal disease control, 5, 17, 42, 72, 82-86, 147, 149-150, 151, 284, 318, 337, 346, 368- 369, 375, 398-399, 420, 435 Vital statistics, 5, 72, 86-87, 284, 318, 337, 369, 420, 435 Vivian, Hon. Dr. R. P., 336 Vocational rehabilitation, 6, 179-180, 183, 185, 264, 304, 325 Vocational Training Co-ordination Act (1942), 179 W Ward, Mr. Percy, 94 War veterans, Programmes for, 9, 116, 179, 279 Weir, Hon. George M., 64-65, 67, 92, 132 Welfare federations, 55, 76 Welfare grants, 217-221 Welfare Institutions Licensing Act (1937), 102, 241-242, 264 Wherrett, Dr. J. G., 429 Whitton Report, 1-2, 17-19, 24-28, 458 Willard, Dr. Alice, 347, 348 Williams, Dr. D. H., 83-86, 90 Wood, Magistrate H. S., 164, 165 Work and maintenance programmes, 6, 8, 13, 21, 60, 105-108, 110-111, 174-175, 410 Workmen's compensation, 7, 46, 53, 145, 153, 183-185 Tisdall, Dr. F. F., 347, 348 Tolmie, Hon. S. F., 62-63, 93, 117 Training for public health, 17, 43, 56, 270, 274- 275, 345. See also Personnel problems Young, Dr. Henry Esson, 42-43, 49, 75, 79 Youth training schemes, 411
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Social security--Canada
Public health--Canada
Public welfare--Canada
Public health and welfare reorganization : the postwar problem in the Canadian provinces
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