FUTURE POLICY IN DEALING WITH DIS- ABLED CIVILIANS; SOME CONCLU- SIONS FROM EXPERIENCE. By DOUGLAS C. McMURTRIE, NEW YORK. DIRECTOR, RED CROSS INSTITUTE FOR CRIPPLED AND DISABLED MEN, PRESIDENT, FEDERATION OF ASSOCIATIONS FOR CRIPPLES. The rehabilitation for self-support of disabled sol- diers and sailors has attracted wide public interest. As we now enter upon the reconstruction period there arises the question as to how far the policies developed in dealing with military cripples can be carried over for the benefit of disabled civilians. Some results have already been accomplished in the reeducation of industrial cripples. What conclu- sions helpful to the formation of future state or national policy have been drawn? The first conclusion from experience is that re- habilitation of the disabled does not consist solely in vocational education. It is as largely a piece of social work as it is educational. The chief prob- lem of any individual disabled man is a character problem. The chief necessity is to inspire his ambi- tion, to overcome the tendency to inertia, combat the psychological conditions which inevitably de- velop with a permanent injury, and to inspire per- Copyritfht William Wood ft Company. 1 severance to continue the effort at rehabilitation when once begun. Successfully to deal with the disabled men re- quires a special understanding of their difficulties and extraordinary patience on the part of direc- ( tors, advisers, teachers, or social workers. The average disabled man, and particularly the civilian cripple, who enters on a course of training, is likely to abandon it in discouragement at the end of the first week. The average teacher who deals with him is likely to become disgusted before that time and be perfectly willing to let him abandon the course in the sure belief that the man is not worth bothering about. Yet those who have dealt with cripples understand that this is not the case, and that with the rule of "try, try again" success can be attained in the great majority of instances. Although I heartily believe in the restoration of a disabled man to a place in the community as a nor- mal being, rather than committing him to a special colony for cripples, I am convinced that the most effective agency of rehabilitation is a special school for the physically handicapped. In such a school every facility is designed for disabled pupils and all members of the staff are originally picked for aptitude in dealing with cripples, and their cumu- lative experience makes them more skilled in doing so. All the members of the staff of the Red Cross Institute testify that difficulties they considered insuperable in the first twenty men dealt with are now minimized by experience. A special school for the disabled can have its own social service staff, an attending physician to keep watch on the condition of the men from the medical or surgical viewpoint, and a staff of teach- ers fully familiar with the special requirements of the work. 2 Foreign experience in rehabilitation seems to point most clearly to the need of special schools. Practically all the schools of reeducation in France have been organized for war cripples. In Great Britain, where the existing facilities of technical institutes have been largely availed of, it has been found in experience necessary to start special classes or sections for the disabled, as the men did not mix successfully with the regular pupils. Even in Can- ada, with the exception of the interesting placement in apprenticeship which has been done, the most successful reeducation has been in schools given over to become special institutions for disabled sol- diers. These considerations lead me to believe that mis- cellaneous introduction of disabled persons into a general system of vocational education would be unwise, but that the establishment of special insti- tutions for the disabled would be most highly de- sirable. The mere offer of vocational rehabilitation ad- vantages does not by any means solve the problem of the idle disabled men, and it cannot safely be assumed that any considerable number of injured men in the United States will take advantage of rehabilitation opportunity, unless there is very radi- cal readjustment of present state legislative provi- sions. Our experience at the Red Cross Institute for Crippled and Disabled Men in New York very clearly illustrates this point. For over a year this school of re-education has been in operation. It offers a reasonable variety of subjects of instruc- tion, six in all : mechanical drafting, moving-picture operating, oxyacetylene welding, printing, the mak- ing of artificial limbs, and jewelry work. All its 3 advantages are free, yet it has at the present time less than forty pupils. There are in New York City, however, according to statistics, thousands upon thousands of cripples who would profit by reeducation. What is the rea- son they do not take advantage of the opportu- nity? The answer is found in the other influences upon the disabled man. The most potent of these is the theory and practice of workmen's compensation. Practically every compensation case that has ever come to the Red Cross Institute has come upon the day compensation expired. For one year, for two years, or for four years, the man had existed in idleness, drawing compensation, and when this support was cut off he cast about and became inter- ested in rehabilitation. When we come to examine the compensation provisions of the various States we find that they encourage idleness, in that the compensation payments are adversely affected by any improvement in earning capacity. At a recent conference there was discussion of who should meet the cost of rehabilitating the disabled men. As far as the industrial cripple is concerned, so soon as the movement and its philosophy shall have gained some headway there should be no cost whatever. Merely by a reappor- tionment of funds already provided, effected through an understanding of the possibilities of rehabilita- tion, there will be a net cash saving rather than increase in expenditure. I can more clearly illus- trate the possibility of this by statement of a typical case than by much theoretical elaboration. A worker in Massachusetts was injured by a fall while working inside a submarine, and his hand became permanently crippled. In due course his 4 compensation rate was determined, and he was re- ferred to the insurance carrier to be paid ten dollars a week for a long period, with a maximum total pay- ment of four thousand dollars. Since the disability was manifestly permanent the insurance company wrote the case off their books as a four thousand dollar loss and transferred that amount to reserve to cover the weekly payments. After the compen- sation had been paid for nearly a year a new official of the insurance company began looking over the list of men to whom the company was paying com- pensation. His attention was directed to the man in question, and the latter was requested to call at the office of the company. The case was, like many thousands of others, susceptible of rehabilitation for self-support, so the insurance company official put a proposition to the man in very frank terms. "I believe that you can be trained to earn a good living. I want you to understand very clearly, how- ever, that this proposal is to the financial advantage of the company, but I also believe it is to your ad- vantage as well. A total income of ten dollars a week is not very attractive to you, and you would probably rather return to work at a good wage than remain idle. If you will consent, the company will send you to a school of reeducation and see if we cannot get you back on your feet in good shape." The injured man consented to the proposal, and the company sent him to the Red Cross Institute in New York. They began to pay him not ten dollars a week as required by law, but forty dollars a week, twenty to him in New York and twenty to his wife at home. The company also paid liberally his traveling expenses in both directions. In the period of eight weeks he was reeducated in oxy- acetylene cutting and welding and returned home. He is now making not only a satisfactory wage, but twice as much as he had ever earned before the accident took place. In the whole transaction every party at interest was benefited. The man was advantaged in that his general living standard was distinctly raised, and the necessity of working for his living could not be considered as a hardship. The company paid less than five hundred dollars for his rehabilitation, and this expense, in conjunction with the five hundred dollars already paid in weekly compensation during the first year of idleness, made a total for the case of one thousand dollars. They were thus enabled to charge three thousand dollars of profit to the account of profit and loss. Had the course of train- ing been earlier begun, there would have been saved five hundred dollars more. The community was infinitely the gainer in that the man, formerly an unproductive consumer, became a useful producer instead. The community further gained in the elim- ination of the disabled man from the category of a prospective dependent, because while compensation might have taken care of him in a very insufficient way during the period the payments ran, there would have come a time when compensation ceased, and then he would have been in a desperate economic status indeed — confirmed in habits of idleness, un- trained for skilled work, and without any source of support. It is perfectly clear that if State compensation authorities will alter their practice so as to encour- age rehabilitation rather than discourage it, if cas- ualty insurance companies will see the path of true economy (and they are coming to this at the present time), there will be no cost in the rehabili- tation of the industrial cripple but rather a great 6 economic and social saving. The case just cited throws interesting light on the question raised as to whether future legislation should embrace in its scope accident cripples not under protection of workmen's compensation laws, congenital cases, and disease cripples. If any legislation is to be passed these classes should most emphatically be included because they constitute the cripples who are most in need of assistance. As has been shown, with developments which can confidently be expected within the next couple of years, the industrial crip- ple will not be in much need of financial assistance. It is the other cripples who contribute most largely to dependency and who involve the greatest com- munity expense. Their restoration is desirable in the extreme, because the elimination of dependency due to physical handicap will lift a colossal burden from the agencies of philanthropic relief. It has been already stated that rehabilitation is intimately related to workmen's compensation. So far as the industrial cripple is concerned the ad- ministration of rehabilitation should be coincident with that of compensation. It has not as yet been possible conservatively to draw definite conclusions regarding the exact provisions of compensation laws which should be altered. It seems clear, however, that one suggestion can come from the experience of all the belligerent nations in providing for the pensions of disabled soldiers. It has been evident from the first efforts at reeducation that pension must be paid for physical injury only and not be prejudiced by increase of earning capacity and sub- sequent restoration to self-support. Unless this provision is made it is almost impossible to per- suade men to undertake re-education. A man does not like to lose one definite advantage, even though 7 there is a greater advantage in store. All the mili- tary pensions, therefore, are fixed, and a man may earn twice as much after his injury as before, and yet his pension will be paid to him just the same. On the other hand, we have learned that the scale of pensions is of comparatively little importance if adequate rehabilitation advantages are offered. In fact, a fairly low pension scale may be a means of character building and encouragement, whereas an extremely high pension scale may tend to demorali- zation and prove an encouragement to idleness. It is possible, for instance, that in the field of workmen's compensation there may be a small statu- tory award for specific injury, and then be extended in addition opportunity of reeducation at the ex- pense of the State fund or insurance carrier. If an earnest attempt at rehabilitation is made by the man, and for one reason or another he fails, there might then be a further discretionary award by the State compensation authority making the total payment as great or preferably greater than called for by the present scale. At any rate, the rehabilitation and compensation of industrial crip- ples are so intimately related as to be almost impos- sible of administrative division. In rehabilitation of civilian cripples what are the financial circumstances involved? It is my belief that the cost of rehabilitation will average between two hundred and three hundred dollars per case, but this is, of course, highly economical, because when a man is rehabilitated his economic problem is solved for good and he is no longer a charge in any sense of the word. The expense of rehabilitation will be apportioned about as follows: « Per cent. Salaries of administrative and teaching staff . . 20 Maintenance of pupils during training 50 Rent, or depreciation and interest on capital investment in building 1° Depreciation and interest on equipment 10 Supplies and material 10 You will note that maintenance is the large item. If you take the average cripple met on the streets and offer him the finest course of reeducation in the world, it is unlikely he will be able to take advan- tage of the opportunity. Though he is earning seven dollars a week, and there is prospect of increasing his income to thirty dollars weekly, it will be im- possible for him to take the course offered, because he will starve meanwhile. This was one of the first lessons learned in starting out to rehabilitate dis- abled civilians. There is necessary for the average case some form of living allowance, and if the same governmental principle is to be applied to the crip- pled civilian as is now applied to the disabled sol- dier, this is properly a charge upon the rehabilita- tion organization. For the industrial cripple, of course, this maintenance may come out of compen- sation reserves if intelligent adjustment of practice and legislation is made, but for the general accident, disease, or congenital cripple, no such source of support is available. Any provision of rehabilita- tion would be, in the mind of the public, a failure unless maintenance were provided for. In the table iust presented there has not been taken into account the medical, social service, and follow-up attention which should likewise be encour- aged. Statistics show the number of disabled persons to be very great. Of course, a very large proportion 9 of these men, particularly those with any character or initiative, readjust themselves industrially and get back in the work of the world in such a way that their employers hardly think of them as cripples. A large number can satisfactorily be put back into employment through provision of special and ex- pert placement facilities. An essential link in the rehabilitation program is the provision of special placement bureaus for the disabled. The Red Cross Institute in New York has operated for the past year such a bureau, and has found that many men need only vocational guidance and intelligent search for a suilable job in order to have their problem solved. There has been already delegated to the United States Employment Service of the Depart- ment of Labor a vast placement enterprise. This service should be encouraged to develop in every large center of population a special bureau for the physically handicapped. Such placement work can- not satisfactorily be done through the ordinary public employment office, but when done carefully and thoroughly is certainly a public economy. 10 «... )