A History of Social Work in Public Health

PUBLIC HEALTH THEN AND NOW A History of Social Work in Public Health Betty J. Ruth, MSW, MPH, and Jamie Wyatt Marshall, MPH, LICSW Social work is a core health profession with origins deeply connected to the development of con- ing from individuals and families temporary public health in the United States. Today, many of the nation’s 600 000 social workers to neighborhoods, organizations, practice broadly in public health and in other health settings, drawing on a century of experience and government. in combining clinical, intermediate, and population approaches for greater health impact. Yet, the The umbrella of health social historic significance of this long-standing interdisciplinary collaboration—and its current implica- work includes numerous sub- tions—remains underexplored in the present era. This article builds on primary and contemporary disciplines, such as public health, behavioral health, oncology, sources to trace the historic arc of social work in public health, providing examples of successful nephrology, and palliative care collaborations. The scope and practices of public health social work practice are explored, and we social work. Most health social articulate a rationale for an expanded place for social work in the public health enterprise. (Am J workers serve in direct care roles, Public Health. 2017;107:e1–eXXX. doi: 10.2105/AJPH.2017.304005) such as counseling, health educa- tion, and crisis intervention. However, social workers also n 1926, Harry L. Hopkins, American Journal of Public Health practice at intermediary levels Ithen director of the New republished a 1966 article by as navigators and care manag- York Tuberculosis Society, who John Stoeckle, illustrating the ers and at the macro level in would go on to be one of public health value of social health administration, prevention Franklin Delano Roosevelt’s work in a medical clinic.2 As and health promotion, research, closest advisers and an architect noted in a letter of response, advocacy, and policy.5 of the New Deal, wrote, “The social workers have been deeply A note on terminology: no felds of social work and public involved in addressing social one term describes health-relat- health are inseparable, and no determinants of health for ed social work. Where indicated, artifcial boundaries can separate more than a century.3 However, we use the terms of the era to them. Social work is interwoven although some older writings describe social work practice. To in the whole fabric of the pub- attest to social work’s historical promote clarity, the term health lic health movement, and has relationship to public health, social work describes contempo- directly infuenced it at every its contemporary signifcance rary practice within health and point.”1 Ninety years later, the is sometimes overlooked. The public health social work refers to purpose of this article is to the subdiscipline that integrates trace the arc of social work’s public health into social work. involvement in public health over the past century, highlight examples and examine forces PROGRESSIVE ERA that both drove and hindered Although public health social work in public health, predates social work, both felds and illuminate how contempo- evolved into their contemporary rary social work can add value forms during the early 20th to public health. century. Refecting Progressive Social work in the United Era values, they shared an over- States is a large, diverse profes- lapping commitment to health sion of 600 000 practitioners, and social well-being and, by the approximately half of whom second decade of the 20th cen- are employed in health.4 tury, collaborated on issues such Dedicated to improving human as maternal and child health, well-being, social workers use infuenza epidemic response, and ecological, clinical, and biopsy- venereal disease control.4 chosocial approaches to work at Social work drew its inspira- President Franklin Delano Roosevelt multiple levels of society, rang- tion from two primary sources: e1 Public Health Then and Now Peer Reviewed Ruth and Marshall AJPH Supplement 4, 2017, Vol 107, No S4 PUBLIC HEALTH THEN AND NOW frst, the community-oriented settlement house movement, made famous by activists such as Jane Addams, who used place-based interventions to address poverty, overcrowding, immigration, and child labor, and second, the charity organi- zation movement, which used casework to help individuals overcome poverty and avoid dependence on society for aid. Tensions regarding social work’s goals have afected the profession since its inception. From the beginning, social work explicitly elevated social justice as a key value and goal. However, the defni- tion, function, and practice of social justice were, and remain, contested. The nascent profession struggled to identify a unifed approach to encompass seemingly incongruent aims, ultimately settling on two ma- the hospital is saved much tance from doctors and nurses expense and the individual and Children’s Bureau Leadership. Library of jor methods that have coexisted, Congress, Prints & Photographs Division, in their frst eforts at Mas- community are greatly ben- often uneasily, under the banner LC-DIG-hec-05755 sachusetts General Hospital. efited.8 [emphasis added] of social work. Dubbed the However, once the positive “dual heartbeat,” these methods Although hospitals were impact of assisting patients with evolved into casework, or clinical an important venue for early the consequences of illness social work, and community, or health social work, social work became clearer, hospital social macro, social work. Casework in public health—or public work grew rapidly. Because few addressed the social and, later, health social work, as it was of the rampant diseases, such as psychological needs of individu- later known—had its genesis tuberculosis and syphilis, were als and families, and community in the community. Local public curable, social work ofered valu- or macro social workers engaged health departments integrated able and pragmatic psychosocial in cause-based or structural casework into infectious disease assistance.7 The founders of reforms intended to improve programs to facilitate reaching one Boston-area hospital social community well-being.6 the hard to reach and to pro- work department, established in Social work’s early eforts in mote family coping in the face 1910, described their purpose as health used both approaches. of unemployment and extended follows: Social workers carefully demar- hospitalization.9 cated their scope of practice by In a 1912 presentation to limiting its focus to the “social Sickness is rarely an isolated the American Public Health side of illness,” leaving disease fact, but is related to condi- Association, Homer Folks, a and disease control to medicine tions under which people sociologist and social welfare live. Thus the aim of the and public health, respectively. department is to find out the advocate, described the alli- Hospitals, and the doctors who social causes of the trouble, to ance between the two felds. controlled them, were initially cooperate with the hospital in Folks noted that community, unconvinced of the need for remedying the case, to prevent more than the hospital, was the social services. Hospital social its recurrence and by doing so, focal point: “Health ofcers and safeguard the community, as work pioneer Ida Cannon and well as aid the individual. By social workers have met because visionary physician Richard rendering social aid, for which their work brings them to the Cabot faced signifcant resis- the hospital itself has no time, same place, namely, the home Supplement 4, 2017, Vol 107, No S4 AJPH Ruth and Marshall Peer Reviewed Public Health Then and Now e2 PUBLIC HEALTH THEN AND NOW in which there is both commu- The Children’s Bureau that the Children’s Bureau’s ef- nicable disease and poverty.”10 refected social work’s growing forts were key.11 Folks’s enthusiasm for how visibility. Beginning with Julia These early successes, fu- public health and social work Lathrop, fve of its frst direc- eled by Children’s Bureau data could join forces—without turf tors were social workers, as were and advocacy, set the stage for battles—promoted collabora- many staf. Lathrop directed enactment of the 1921 National tion in infectious disease control, the bureau’s frst eforts toward Maternity Act, also known as maternal and child health, and building scientifc understanding the Sheppard–Towner Act. The prevention of poverty.10 of infant and maternal mortality. Sheppard–Towner Act provided The successful transdisci- Lathrop was outspoken in her the frst-ever federal funding for plinary campaign to reduce belief that infant mortality was innovative prevention program- infant mortality serves as the not merely, or even primarily, ming and laid the groundwork clearest example of social work’s a medical issue, but one that for later federal–state col- impact in public health. Dur- was socially constructed and laboration in maternal and child ing an era in which women infuenced by preventable social, health. The successful reforms, could not yet vote, Lillian Wald economic, and family condi- however, were opposed by and Florence Kelley, former tions.12 Using an epidemiologi- numerous entities, including the settlement house activists, social cally sophisticated investigation, American Medical Association, workers, and civic leaders, which included house-to-house antisufragists, business, and anti- successfully advocated for the feld research and prospective

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