PART I Foundations of Social Work in Health Care COPYRIGHTED MATERIAL JJWBT514_ch01.inddWBT514_ch01.indd 1 99/21/11/21/11 77:41:41 PMPM JJWBT514_ch01.inddWBT514_ch01.indd 2 99/21/11/21/11 77:41:41 PMPM 1 Conceptual Underpinnings of Social Work in Health Care SARAH GEHLERT The writing of the fi rst edition of this text co- Chapter Objectives incided with the centennial of the hiring of • Discuss the historical underpinnings of the the fi rst medical social worker in the United founding of the fi rst hospital social work States, Garnet Pelton, who began working at department in the United States. Massachusetts General Hospital in 1905. The • Describe the forces and personalities writing of the second edition fi ve years later responsible for the establishment of the comes at another key point for health social fi rst hospital social work department in the work, namely the passage of the Patient Protec- United States. tion and Affordable Care Act in March 2010, • Determine how the guiding principles of which will radically increase health insurance social work in health care have changed coverage for U.S. citizens over the next de- from the time of the founding of the fi rst cade. It seems an appropriate time to consider hospital social work department to the the history of social work in health care and present time. to assess the degree to which the vision of its • Determine how the techniques and founders has been met in its fi rst 100 years. Ida approaches of social work in health care Cannon (1952), the second social worker hired have changed from the time of the founding at Massachusetts General Hospital, whose ten- of the fi rst hospital social work department ure lasted for 40 years, wrote: “[B]asically, so- to the present time. cial work, wherever and whenever practiced at its best, is a constantly changing activity, Frequent references to other chapters in this gradually building up guiding principles from book capture the current conceptual frame- accumulated knowledge yet changing in tech- work of social work in health care. niques. Attitudes change, too, in response to shifting social philosophies” (p. 9). How, if at all, have the guiding principles of social work HISTORICAL FOUNDATION in health care changed over the century? OF SOCIAL WORK IN This chapter focuses on the development of HEALTH CARE the profession from its roots in the 19th cen- tury to the present. This longitudinal examina- Social work in health care owes it origins to tion of the profession’s principles and activities changes in (a) the demographics of the U.S. should allow for a more complete and accurate population during the 19th and early 20th cen- view of the progression of principles through turies; (b) attitudes about how the sick should time than could have been achieved by sam- be treated, including where treatment should pling at points in time determined by historical occur; and (c) attitudes toward the role of so- events, such as the enactment of major health- cial and psychological factors in health. These care policies. three closely related phenomena set the stage 3 JJWBT514_ch01.inddWBT514_ch01.indd 3 99/21/11/21/11 77:41:41 PMPM 4 Foundations of Social Work in Health Care for the emergence of the fi eld of social work New York City died prior to their fi rst birth- in health care. day, compared to 1 in 6 in London (Rosenberg, A number of events that began in the mid- 1967). Adding to the challenge, the vast ma- 1800s led to massive numbers of people im- jority of immigrants had very limited or no migrating to the United States. In all, 35 to English language skills and lived in poverty. 40 million Europeans immigrated between Immigrants brought with them a wide range of 1820 and 1924. The Gold Rush, which began health-care beliefs and practices that differed in California in 1849, and the Homestead Act from those predominant in the United States of 1862 added to the attractiveness of immi- at the time. gration (Rosenberg, 1967). In the late 1600s and early 1700s, people About 5.5 million Germans immigrated to who were sick were cared for at home. A the United States between 1816 and 1914 for few hastily erected structures were built to economic and political reasons. Over 800,000 house persons with contagious diseases dur- arrived in the 7-year period between 1866 and ing epidemics (O’Conner, 1976, p. 62). These 1873, during the rule of Otto von Bismarck. structures operated in larger cities and were The Potato Famine in Ireland in the 1840s re- fi rst seen before the Revolutionary War. As sulted in the immigration of 2 million people the U.S. population grew, communities de- during that decade and almost a million more veloped almshouses to care for people who in the next decade. Between 1820 and 1990, were physically or mentally ill, aged and ill, over 5 million Italians immigrated to the orphaned, or vagrant. Unlike the structures United States, mostly for economic reasons, erected during epidemics, almshouses were with peak years between 1901 and 1920. A built to operate continuously. The fi rst alms- major infl ux of Polish immigrants occurred be- house, which was founded in 1713 in Phila- tween 1870 and 1913. Those arriving prior to delphia by William Penn, was open only to 1890 came largely for economic reasons; those Quakers. A second almshouse was opened to after came largely for economic and political the public in Philadelphia in 1728 with mon- reasons. Polish immigration peaked again in ies obtained from the Provincial Assembly by 1921, a year in which over half a million Pol- the Philadelphia Overseers of the Poor. Other ish immigrants arrived in the United States. large cities followed, with New York open- Two million Jews left Russia and Eastern Eu- ing the Poor House of the City of New York ropean countries between 1880 and 1913 and (later named Bellevue Hospital) in 1736 and traveled to the United States. New Orleans opening Saint John’s Hospital in The United States struggled to adapt to the 1737 (Commission on Hospital Care, 1947). challenge of immigration. The Ellis Island Im- Although called a hospital, Saint John’s was migration Station opened in 1892 to process classifi ed as an almshouse because it primar- the large number of immigrants entering the ily served people living in poverty who had country. By 1907, over 1 million people per nowhere else to go. year were passing through Ellis Island. The By the mid-1700s, people who became ill massive waves of immigration presented new in almshouses were separated from other in- health-care challenges, especially in the north- habitants. At fi rst they were housed on sepa- eastern cities, where most of the new arrivals rate fl oors, in separate departments, or in other settled. Rosenberg (1967) wrote that 723,587 buildings of the almshouse. When these units persons resided in New York City in 1865, increased in size, they branched off to form 90% on the southern half of Manhattan Island public hospitals independent of almshouses. alone. Over two thirds of the city’s popula- Hospitals eventually became popular among tion at the time lived in tenements. Accidents persons of means, who for the fi rst time pre- were common, sanitation was primitive, and ferred to be treated for illness by specialists food supplies were in poor condition by the outside the home and were willing to pay for time they reached the city. One in 5 infants in the service. JJWBT514_ch01.inddWBT514_ch01.indd 4 99/21/11/21/11 77:41:41 PMPM Conceptual Underpinnings of Social Work in Health Care 5 A number of voluntary hospitals were es- such as hygiene and how to select and cook tablished between 1751 and 1840 with various food and addressed issues of education and em- combinations of public and private funds and ployment. In 1890, Mrs. Robert Hoe provided patients’ fees (O’Conner, 1976). The fi rst vol- funds to the New York Infi rmary for Women and untary hospital was founded in Philadelphia in Children to employ a full-time home visitor to 1751 with subscriptions gathered by Benjamin work under the direction of Dr. Annie Daniels. Franklin and Dr. Thomas Bond and funds from Daniels kept records of family size, income, and the Provincial General Assembly of Philadel- living expenses in the manner of social workers phia. The New York Hospital began admitting of the time, such as Jane Addams, who founded patients in 1791 and the Massachusetts Gen- Hull House in Chicago in 1889. eral Hospital in 1821. In 1817, the Quakers The fi rst medical resident to work with opened the fi rst mental hospital, which began Dr. Blackwell in New York, Marie Zakrzewska, admitting anyone needing care for mental ill- moved to Boston and in 1859 became the fi rst ness in 1834. professor of obstetrics and gynecology at A third type of medical establishment, the the New England Female Medical College. dispensary, began to appear in the late 1700s. Dr. Zakrzewska established a dispensary and Dispensaries were independent of hospitals 10-bed ward in Boston in 1862, the New Eng- and fi nanced by bequests and voluntary sub- land Hospital for Women and Children. It was scriptions. Their original purpose was to dis- the fi rst hospital in Boston and the second in pense medications to ambulatory patients. In the United States (after the New York Dispen- time, however, dispensaries hired physicians sary for Women and Children) to be run by to visit patients in their homes.