PUBLIC HEALTH THEN AND NOW

A History of in

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- 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 , 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:

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frst, the community-oriented settlement house movement, made famous by activists such as , who used place-based interventions to address , 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 as a key value and goal. However, the defni- tion, function, and practice of social justice were, and remain, contested. The nascent profes- sion 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 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 . 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

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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 Communist groups. Although establishment of the federal surveys in eight cities and rural initially successful in resist- Children’s Bureau. The agency’s areas, bureau workers gathered ing accusations of subversion, purpose was to call attention to data. The bureau released a series the Sheppard–Towner Act fell women’s and children’s issues, of reports enumerating the mag- victim to allegations of fostering such as shockingly high mater- nitude of infant and maternal socialized medicine and expired nal and infant mortality rates, morbidity in the United States; in 1929. Nonetheless, it served widespread child labor, orphan- simultaneously, it commenced as an important precursor to ing of children, and lack of a multilevel prevention eforts, future maternal and child health comprehensive birth registration reaching deeply into households programs, such as Title V of the system.11 and communities to raise aware- Social Security Act, and it il- ness, promote sanitation, and lustrated social work’s leadership educate about health. Simulta- capacity in public health.14 neously, the bureau engaged in vigorous legislative advocacy aimed at garnering federal, state, PROFESSIONALIZATION and local funds for improve- OF SOCIAL WORK ment of social conditions.13 As social work grew, it These eforts epitomized branched into subdisciplines the convergence of social work with divergent, often competing and public health, helping to interests and organizations. By defne the early characteristics 1918, hospital social workers had of public health social work: created the American Associa- willingness to investigate social tion of Hospital Social Work- factors as causes of poor health, ers and, like much of the feld, combined use of epidemiologi- became interested in the profes- cally informed casework and sionalization of social work.7 community-level interven- By the 1920s, a notable split tions, and policy advocacy and between medical and psychiatric change eforts to bring about social work occurred as a result structural change. During the of a variety of infuences, includ- years that the Children’s Bureau ing Freudianism and the trend focused on infant mortality, toward professional specializa- the rate was halved. Although tion.15 , ini- many factors contributed to its tially inclusive of all social work Julia Lathrop decline, analyses have afrmed in health, began to focus more

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tightly on individually focused casework. Although Cabot’s original vision had conceptual- ized social work as the bridge between hospital and com- munity, casework increasingly focused exclusively on patients’ social and psychological prob- lems while they were in the hospital.16 This trend continued, and by 1934 the newly renamed American Association of Medical Social Workers de- fned medical social work as casework aimed at addressing the relationship between the patient’s disease and social mal- adjustment.17 By midcentury, although medical social work continued to articulate a per- son-in-environment approach, ship in Franklin D. Roosevelt’s lished the National Institutes Milk Depot in New York the earlier focus on community economic stabilization eforts of Health and the Centers for linkage lessened. This refected and helped to establish the New Disease Control, funding health 20th-century advances in curing Deal and the Social Security research and treatment, including disease and medical technology, Act of 1935. The prominence social work.13 As public health which had strengthened the of social work leaders in federal and social welfare modernized, public’s confdence in hospitals positions enabled the profes- social work in public health and medicine and made recov- sion to shape the myriad social expanded. Social work devel- ery more attainable. Anxious welfare programs—Maternal and oped innovative roles in medical to secure its role, hospital social Child Health, Child Welfare, and clinics, engaged in the frst work garnered acceptance by Crippled Children’s Services— eforts at disaster and crisis social adapting to the medical model, that emerged. work, and created nontraditional embracing its auxiliary role, and Social work in public health social work in areas such as focusing on supporting patient grew as well. By the 1920s, social dentistry.21,22 recovery within the institution’s work was integrated into the US As social func- walls.18 Public Health Service (USPHS), tions evolved in the mid-20th The devastation of the Great providing services that defne century, the profession consid- Depression for a time resulted in public health social work today: ered new roles. Before the 1960s, greater cooperation among dis- direct clinical services; case fnd- most social work in public parate social work groups as they ing and consultation; program health focused on secondary struggled to respond. Whereas planning; and research, train- prevention; however, interest in some labored strenuously for the ing, and prevention in a public primary prevention gradually establishment of a national social health framework. Through the intensifed. Elizabeth Rice, social welfare system, others ques- USPHS, social work expanded worker and Harvard School of tioned the profession’s evolution to include specifc roles in heart Public Health professor, vehe- in capitalist society and became disease, venereal disease, tubercu- mently supported an explicit active in community organizing, losis, and mental illness.20 emphasis on primary preven- labor unions, and radical political Social work expansion con- tion and urged social workers to movements.19 Social workers tinued during and after World “understand, solve and prevent Harry Hopkins and Francis War II, when social workers [health problems].”23(p87) Like Perkins, director of Federal served in the military and were many public health social work- Emergency Relief Administra- integrated into rehabilitation and ers, then and now, she lamented tion and US Secretary of Labor, veterans’ services. By the 1950s, that much of social work still respectively, provided key leader- broad federal actions had estab- seemed “to be working on

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a patient-by-patient basis in of Medicaid and Medicare.26 hospital social work departments clinical services,” neglecting the Social workers engaged in were decentralized or eliminated; “potentialities that exist for the community development, set the roles of hospital-based social more comprehensive practice of up preschool programs, and workers shifted from counseling social work.”23(p88) Milt Wittman promoted economic opportu- to discharge planning and case argued for a new preventive nity and civil rights. Meanwhile, management, and some tradi- social work. Wittman, who rose social work education broadened tional social work tasks moved through the ranks of the Na- to include a stronger focus on to allied professionals.27 Medical tional Institute of , social problems. The movement social work entered a protracted presided over a federal task force to community health—although phase of self-justifcation, con- on social work education and not wholly advantageous to tracting into a state of functional was the frst social work profes- medical social work—ofered survival.28 sional liaison ofcer for the US public health social work new The turbulence led to a Public Health Commissioned opportunities.17 Boston-based search for solutions to enhance Corps, wrote, public health social worker Ruth the profession’s visibility and Cowin observed, “We are in impact, including appeals to The profession stands today at the midst of a social revolution redirect the profession toward the brink of a vast opportu- and adaptations in traditional prevention and public health.29,30 nity to make good its greatest practice . . . have to be made; The USPHS’s Division of usefulness to society. The field should work diligently to de- experimentation and innovation Maternal and Child Health held 27(p860) velop . . . preventive social work. are the order of the day.” a Public Health Social Work . . . Only in this way can a She presided over the success- Forward conference in 1985 to new generation of social work- ful integration of “indigenous facilitate integration of pub- ers learn to apply social work workers”—a precursor to com- lic health concepts into social skills in an attack on the roots 4 of social problems. This move munity health workers—into a work. Some educators em- is long overdue and should family health center. braced the charge, introducing have our serious, considered Despite substantive advances epidemiology and prevention attention.24(p28) [emphasis in social work education, train- into social work education.14 added] ing, and practice, the idealism The frst – and funding that fueled the Master of Public Health (MSW– Despite these appeals, howev- Great Society waned as the Viet- MPH) programs were launched er, public health and prevention nam War ground on; gradually, at this time, building on the were not widely reintegrated fscal cutbacks undercut progress natural synergy between the into social work education or in many aspects of social welfare. felds.4 Community prevention practice. Most of social work Although social work practice in partnerships grew, highlighting remained centered on casework. public health continued, 1970s the value of social work skills in The 1960s civil rights, wom- disinvestment gutted many inno- community outreach, cultural en’s, and other social movements vative health and social programs, responsiveness, and capacity de- renewed social work interest in and community-oriented social velopment, and a small body of activism, and, predictably, ten- work jobs decreased. As the con- prevention research emerged.31 sions resurfaced regarding the servative climate strengthened, Still, as the millennium ap- profession’s roles. Intense debates the larger profession redirected proached, there was an unmis- surrounded the value of case- its attention to advancing social takable air of concern regarding work; disconnected from social work survival through licensure, recognition of social work’s change eforts, some viewed third-party reimbursement, and role in public health. When the it as inefectual or destruc- private practice.26 National Academy of Science, tive.25 Scholars and practitioners Institute of Medicine released a engaged in vigorous discus- major report, The Future of Public sions regarding the profession’s FUNCTIONAL SURVIVAL Health,32 Ruth Knee, a veteran role in systems change versus By the 1980s, escalating public health social worker who service provision. Systems-level health costs unleashed market- had served in the USPHS and social work proliferated through driven cost containment eforts National Institute of Mental opportunities made possible by throughout the health arena. Health, was the only social the War on Poverty, the Great Lacking the needed data to worker to participate on the Society, and the establishment prove their fnancial value, many panel. The report acknowledged

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broad disarray in the public system that emphasized disease focus on trauma and mental Grand Challenges for the feld, health feld, including funding treatment over prevention, used health, igniting interest in social the majority of which require and workforce issues; lack of a maze of bureaucratic struc- work as a preventive force.36 The public health approaches. coordination with primary care, tures to contain spiraling costs, US Department of Health and Some 43 MSW–MPH pro- mental health, and social ser- produced gross health inequities, Human Services’ health goals, grams produce graduates who vices; and mounting challenges and failed to meet the needs known as Healthy People, enabled practice in all core public health such as AIDS.33 Knee believed of a signifcant portion of their the profession to better locate services, from community mobi- that social work, with its proven clients.31 The national tragedy its work within the nation’s lization and health promotion to track record of leadership, had of 9/11 and its ongoing efects health framework, which in program evaluation and surveil- an important role to play in reafrmed new health concerns turn strengthened the science of lance.4 The integration of public strengthening public health. She such as bioterrorism, disasters, social work.12 health content into social work urged the profession to more and community trauma. Social Finally, recent health reform is not limited to MSW–MPH clearly articulate its value and workers were close witnesses to eforts issued a clarion call to programs; a recent review of function in public health.18 the changing social, environ- the profession to once again health content found that 38.5% Yet, many questioned mental, and economic determi- widen its lens for greater impact. of MSW programs (n = 86) now whether the broader feld, now nants of health as mental illness, Although the future of health ofer wide-lens public health heavily focused on therapeu- violence, suicide, trauma, chronic reform remains uncertain, the content.38 tic work with individuals and disease, and substance use in- expanded integrated health so- families, could refocus on public creased. An ever-expanding array cial work model that emerged in health. Rosenberg and Holden of studies highlighted health response emphasizes care coor- FUTURE OF SOCIAL acknowledged the feld’s limited disparities, particularly racial dination, prevention, community WORK IN PUBLIC understanding of its actual or inequalities, and articulated the engagement, and interprofes- HEALTH potential roles: need for upstream social work sional teamwork; these are all Harry Hopkins may have interventions.34 areas of deep practice expertise believed that these two felds We urge social work educa- Public health’s broadened that began a century ago and are were inseparable and in frm tors, practitioners and research- focus on social sciences, social still deeply needed.26,36,37 possession of common ground, ers to engage in a dialogue to determinants, and ecological but a century later it appears find ways to focus the profes- sion away from pathology and frameworks increasingly recon- necessary to remind ourselves of towards prevention, [and] pop- nected to the interests of the so- THE BRIDGE: PUBLIC the past and to assess the con- ulation [health] practice.30(p11) cial work profession. Social work HEALTH SOCIAL WORK tinuing validity of his assertion. responded early and forcefully Public health social work Clearly, social work and public Bracht, tracing the arc of to the HIV epidemic, engaging serves as an important base for health have much in common: support for social work in public broadly in outreach, advocating a new era of health social work shared Progressive Era roots, health and prevention, con- for destigmatization, and crafting in two critical ways. First, it a joint commitment to social cluded, culturally responsive preventive provides a century’s worth of justice, and a history of collabo- interventions. Collaborations experience in how to marry ration. Yet, despite clear evidence The structural, educational, between the felds expanded to clinical, intermediate, and popu- of past and potential synergies philosophical and incen- include community-based ef- lation approaches for greater between the two felds, social tive bases of practice are so forts in substance abuse and HIV impact; second, it serves as the work’s foothold in public health ingrained at the individual treatment level as to inhibit prevention, chronic disease man- interprofessional bridge between has never been fully established. either quick or major changes. agement, child abuse prevention, public health and social work. We suggest some of the . . . The ‘will to change’ [first] and toxic waste activism.4,35 The rebuilding of this bridge historic reasons for social work’s needs to be rekindled.29(p6) Social work researchers began to is now evident across a wide lack of visibility as a public systematically use the power- range of professional activi- health actor, including choices ful tools of public health, such ties: membership in the Public regarding professionalization, the RENEWED INTEREST IN as epidemiology, to inform the Health Social Work Section of dominance of clinical interven- PUBLIC HEALTH profession’s long-standing com- the American Public Health tions, and a failure to articulate As Bracht29 predicted, the mitment to serving vulnerable Association has doubled, a new its public health history. Despite convergence of numerous fac- populations.4 Major research Social Work in Public Health jour- Hopkins’ perspective a century tors gradually rekindled the fndings on the impact of ad- nal was launched in 2007, and ago, social welfare and health profession’s interest in public verse childhood experiences, the prevention has been integrated were cleaved into separate health. By the century’s end, global burden of mental illness, into educational and practice domains. Today, however, there the nation’s half million social and the potential for prevention standards. The American Acad- is a growing understanding of workers had grown frustrated; of mental disorders afrmed emy of Social Work and Social how the unmet social needs of they labored in a fragmented the profession’s long-standing Welfare has established a dozen humanity detract from health

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and produce inequitable health As Hopkins knew a century ago, Browne T, eds. Handbook of Health Social 23. Rice E. Social work in public health. outcomes. Clearly, eforts to ad- social work, with its deep roots Work. 2nd ed. Hoboken, NJ: Wiley; Soc Work. 1959;4(1):82–88. 2012:20–40. vance health equity will be un- and ongoing pragmatic presence 24. Wittman M. Preventive social work: 6. Gibelman M. The search for identity: a goal for practice and education. Soc dermined if these two domains in public health, is a sister profes- defining social work—past, present, fu- Work. 1961;6(1):19–28. are not consciously reconnected. sion of consequence, involved in ture. Soc Work. 1999;44(4):298–310. 25. Gilbert N, Specht H. Dimensions of Social Welfare Policy. Englewood Cliffs, Social work, with its depth of addressing what matters now. It 7. Gehlert S. Conceptual underpinnings NJ: Prentice Hall; 1974. involvement across all of social is time to recognize its historic of social work in health care. In: Gehlert welfare, is vital to these eforts. signifcance, value its current ca- S, Browne T, eds. Handbook of Health 26. Reisch M. The challenges of health Social Work. 2nd ed. Hoboken, NJ: care reform for hospital social work in The challenges facing the two pabilities and contributions, and Wiley; 2012:3–19. the United States. Soc Work Health Care. felds—health inequities, racism, provide leadership to expand 2012;51(10):873–893. 8. Social Work Archives. Cambridge 27. Cowin R. Some new dimensions climate change, violence, mental its place in the broader public Hospital/Mt. Auburn Hospital, Cam- of social work practice in a health set- bridge, MA. 1909. illness, persistent infectious and health enterprise. ting. Am J Public Health Nations Health. chronic diseases, and economic 9. Bracht NF. Social Work in Health Care: 1970;60(5):860–869. inequality—are profound, press- ABOUT THE AUTHORS A Guide to Professional Practice. New 28. Silverman E. From ideological to Betty J. Ruth is with the Dual Degree ing, and intractable. Even this York: Haworth Press; 1978. competency-based: the rebranding and Program in Social Work and Public Health, maintaining of medical social work’s 10. Folks H. Points of contact be- brief historical review reminds School of Social Work, Boston University, identity. Soc Work. 2008;53(1):89–91. us that changing society at the Boston, MA. Jamie Wyatt Marshall is with tween the health officer and the social the Group for Public Health Social Work worker. Am J Public Health (N Y). 29. Bracht N. Prevention: additional level of social determinants is Initiatives, Boston. 1912;2(10):776–781. thoughts. Soc Work Health Care. 2000;30(4):1–6. never easy and is nearly always Correspondence should be sent to Jamie 11. Almgren G, Kemp S, Eisinger A. 30. Rosenberg G, Holden G. Preven- controversial, even today. Our Wyatt Marshall, MPH, LICSW, c/o Group The legacy of and the tion: a few thoughts. Soc Work Health for Public Health Social Work Initiatives, 264 Children’s Bureau in the American predecessors’ resolute eforts to Care. 1999;28(4):1–11. Bay State Road, Boston, MA 02215 (e-mail: mortality transition. Soc Serv Rev. improve health were, by necessi- [email protected]). Reprints can be 2000;74(1):1–27. 31. Marshall JW, Ruth B, Sisco S, et ty, transdisciplinary, cross-sectoral, ordered at http://www.ajph.org by clicking the al. Social work interest in prevention: a “Reprints” link. 12. Combs-Orme T. Infant mortality political, and closely linked to content analysis of the professional litera- This article was accepted June 14, 2017. and social work: legacy of success. Soc ture. Soc Work. 2011;56(3):201–211. the expansion of social welfare. doi: 10.2105/AJPH.2017.304005 Serv Rev. 1988;62(1):83–102. 32. National Academy of Science. The If social work’s past is truly 13. Sable M, Schild D, Hipp JA. Public Future of Public Health. Washington, DC: CONTRIBUTORS prologue, the stage is now set for health and social work. In: Gehlert S, National Academy Press; 1988. B. J. Ruth was the primary writer of this Browne T, eds. Handbook of Health Social an important shift in trajectory. article and conducted extensive research. 33. Keefe RH. Health disparities: a Work. 2nd ed. Hoboken, NJ: Wiley; Within a decade, the number J.W. Marshall supplemented the literature primer for public health social work- 2012:64–99. ers. Soc Work Public Health. 2010;25(3– of social workers employed in review and assisted in both writing and editing. 14. Siefert K. An exemplar of primary 4):237–257. health is expected to swell to prevention in social work: The Shep- 34. Turnock BJ. Public Health: What It Is 75% of the feld. Moreover, ACKNOWLEDGMENTS pard-Towner Act of 1921. Soc Work and How It Works. 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