Document X7YYKjrdQZaLb8j72kQ75Z2xg

RSPQRT CF THETFCRD r\ ON `l For a nunber of yoars the Letropolitan Life Insurance Company v' has thought it desirable to demonstrate sonewher^in French Camda, that the condition- of mothers i childbirth, and of babies during their first year of life, could be grerily ir.-.-rovrd. In order to arrange for r. d uc.cr.ctrr.tion of such a progrenne it presented a plan to the rcli. ice.. -t-c!-.critics of ch^cbec and obtained their hearty approval. Hie ' -c.io_ . f Quebec, !'g'.-r. Roy thought that an industrial community lil. cford -iii-s would be typical of French Canada, and that if succer -r~ r.~. 'L'-rr there, it could be obtained in any community of this provii.ee. .Tier consultation with the .authorities of Thetford Hines, who were entirely rgrecable to cooperation with the Company, the work was begun ir. coot c ccior with that Community early in nineteen hundred and twerrty-or.u (itil). The first step was e survey of the city which showed very clearly that no mistake had been unco in the choice of Thetford MineB, The infant mortality rates in this city of close to 9,000 population were 232 per 1,000 births in the year 1919-1and 261 per 1,000 births in the year 1920-1921. (Figures are from icy to liy). The Community responded in the most hopeful manner. The clingy rrc enthusiastic from the very beginning; the City Council-and the Hoyc- cooperated and voted 700 toward the establish ment of the Center and agreed, further, to pay the rent for a period of three years. At the beginning of the second year, the Council voted a further sum of 200 toward the doctor^B salary. The sum of 600 was also*voted toward ' y the naintemnee of the Center during the third year as well as 200 toward the doctor's salary. /. .JaO**T-.' 3P: . 'y* 1244 rsv 2- - The doctors in the beginning, were skeptical but as the work c-qT^rinuod r -ite advent ages becai-c more and more evident to then and th-'ir cooperation was, also given. Mien the- work sterteci ndfmorc than 10} of all expectant mother; retained their physician, for the expected confinement and only the few cases which suffered fror 3erious complications, were under medical care. fin effort was made at once by the nurses to get all prenatal patients under nediccl care before the third prenatal nursing visit. This effort was so successful, that it might safely be said, that from one-half to two-thirds of all expectant mothers now register with their physicians between the third and fifth month of pregnancy. The actual work was started lay 6, 1921. The Center was located in the rear basement of a building on the main street;; which was formerly used for a store-room. It was completely renovated by the Metropolitan with the aid of the City. The Reception and Clinic Rooms were both v*.ry well equipped for demonstration. It took about two months to get the Center ready for use. JSs soon as it was ready the Parish driest* announced the opening. They did this with so much enthusiasm that the place was filled to capacity for the first Mothers' Club. At these Mothers' Clubs, the mothers were given a series of sixteen talks, each of which did not last more than thirty minutes. These talks covered everything from the reason for the necessity for prenatal care, to the care and feeding of the pre-school child. Each of the three nurses took turns in giving these talks. 124 ,,b At the beginn_ng it wac almost impossible to get the mothers to take active part in these meetings. After a feu months, however, it became-quite the habit for the woman to give the talks themselves, not directly, but each one taking part, answering ..uestions, and ex plaining why and vhorefore. After the work had been going on a whilejlt tree possible to get som3 of the mothers to bring their babies and have them demonstrate to their companions the proper way to bathe and dress a baby. Others to demonstrate how to prepare for delivery, etc.; and others to teach how to make poultices and apply coulter-irritants of various kinds. Light refreshments were an added inducement to the mothers to attend the weekly conferences. It became knov?n in Thetford Lines that the nurses always procured better apples than any one else could, and on the principle that, "An apple-a day keeps the doctor away", the nurses served almost nothing else. The program consisted primarily, howeyer, of pronatal and postnatal nursing end baby welfare work. The prenatal and postnatal nursing were done according to the method of the Maternity Center Association, New York City, and the baby welfare procedure was copied from t he best of its kind in Hew York City. A full nursing visit which comprised; the taking of iBmperature, pul^e, respiration^blood pressure, doing Urinalysis, counting of fetel heart rate , questioning patient generally as to her condition, diet, etc. and giving of advice as indicated by the picture obtained from her answers, also assistance in solving any social problems which might have an effect either directly or indirectly on the patients condition.was made on all expectant mothers either at home or at the 1246 Center (preferably at the letter place) until the seventh month of pregnancy, every reel: or oftener thereafter,. After confinementT^Tio cticr.ts wore every cloy for the first three days, every second or third day until the 10th day, and then every woek or ofte: or' until tlio t-ty we one month old. .At the end of that time the mother '..as ciacliaryed ajxi the baby registered separ ately for Baby `..oil - r- . hot here wore invited to bring their babies every week to thr l.:r. >r ~o be rriyhod and looked after, and all babies registered c r. : Ighec as for as possible once e north. Sick babies ven. viaited doily if necessary. Feeding cases and cases of diarrheal disease were frequently visited more often, either to keep up i... methera interest or to keep her from killing the baby by following so..< kind relative or neighbor's advice. Visiting Uur-c Icrvicc for Fo.icyhclders was added after the first six months of the work. In June 1922, the Company provided the nurses with a Ford Car. This enabled then to cover a much larger area than they could otherwise have done. .Around Thetford Hines and all small French banadian towns, there ar6 vhat is called "Hangs" which translated near.s ranges. Around Thetford there are eight of these. The nurses frequently spent their sunmar evenings covering these ranges in their Ford. They would park the car on the roadside and each nur3e go off in a different direction. It was quite a common occurrence to have expectant mothers as well'as mothers with babies cons to the Center from places that fcere anywhere from five to fifty mileB distant, for advics and help, also to receive letters, a number of which are still on file, from persons rany milos away asking advice on all sorts of subjects.. limy replies were received to t hese letters telling of the wonderful re_ailts obtained due to the following of the nurses' adyice. The work was not easily developed fcr the very good reason that the community had never had any similar activity, that nurses, expect practical nurses, had not been available heretofore and every step had to be taken with due regard to ihe natural prejudices of the community to show that what was attempted was right and useful. Never theless, the Clinic was successful from the very start because of the common sense of the people end the excellent support of the Clergy. Jit the first meeting of the lathers' Club the attendance wan 46. Sincethat time the average attendance has been 15 a week in spite of snowstorms and religious holidays. The.work grew quickly and beginning .with .two nurse3 it .was found before the close of 1521 that three nurses were needed. Soon, virtually, 1; all the babios born in the community came under the care' of tthe station. For example in May 1922, ont he-first anniversary of the experiment ther,, were already 326 babies under care in a community where the total number of births in that year and the preceding year was approximately 450. In Hay 1923, there were 515 babies under care although the number of babies born in the preceding year was only 392. This means, very obviously, that few babies escaped the care of the baby station. The total number of visits made in the last year of the experiment, Hay 1, 1928 fts 14,731, of which 12,707 were home visits and 2,038 were Clinic visits. The Clinic visits do not include the attendance at Mothers* Clubs although this wras an important activity. These figures are given in order to show not 1248 -6- only -the large extent of the activity in this snail community but also the large amount of work cone b y the nurses. Under the pressure- of -thS""naed of this Community, the nurses everaged thirteen visits a day including the service at the clinic as well as at home. The result of the work as measured by the drop in infant mortality rate is very gratifying.. In the first year, hay 1, 1921 to hey 1, 1522 the infant mortality rate declined to 149 per 1,000 births and in the second year to May 1, 1523 it declined to 117 per 1,000 births. In the two months of Kay 1922 and 1923 the average monthly rate was 85 per 1,000 births. At is evident, therefore, that a very marked diminution in the mortality was brought about and the decline is continuous. It is now, in fact, less than one half what it was at the beginning of the Demonstration two years ago. More significant than the figure is the fact that such an 'activity could be established in a community like Thetford lAines and win for itself the support of all the people. This it has accomplished, not because of any figures of infant mortality, uhich, after all, people do not understand, but rather because of such simple facts as that mothers who have heretofore uniformly lost their babies are now bringing live babies into the world and keeping them in good health for the first time. Any number of instances of this kind could be given. Such facts are very dramatic and convincing to people who know little about new fashioned health activities but who are willing to benefit from what is good. "tt is beeause'of this that good has been accomplished and the Community of Thetford Mines has been able to take over the experiment at the end of a little less than two years as a community project and will support it henceforth with the assistance of the Metropolitan life -7- Inoutarce Company who will continue to pay the salaries of three nurses until January. 1, 1924 and of two nurses from January 1, 1924 to July 1, 1924. The important lesson^of Thetford lines are that tho mortality can be reduced in other communities where the effort ia made and that any effort must take into consideration the local conditions and the traditions and habits of the people. Respectfully Submitted, HuR SC" t'('l * c W i_ rcu* .1 1256 3 REPORT OF 7HETF3RD MINES For & nuober of years the Metropolitan Life Insurance Company has thought it desirable to demonstrate somewhere in Flinch Canada, that the con dition of mothers in childbirth, and of babies during their first year of life, could be greatly improved. In order to a. range for r. demonstration of such fc programme it presented a plan to the- religious authorities of Quebec end obtained their hes-rty approval, Hie Auxilia.-y Bishop of Quebec, Ugsr. Roy thought that an industrial community like Thetford Hines would be typical of French Canada, and that if success were obtained there, it could be obtained in any community of this province. After consultation with the authorities of Thetford Mines, who were entirely agreeable to cooperation with the Company, the work was begun in cooperation with thut Community eurly in nineteen hundred and twenty-one (1921), The first step was a surrey of the city which showed very dearly that no mistake n&d been made in the choice of Thetford Hines, The infant mortality i rates in this city of close to 9,000 population were 232 per 1,000 births in the year 1919-1920 and 261 per 1,000 births in the year 1920-1921. (Figures are from May to May). The Community responded in the most hopeful manner. The olery were enthusiastic from the very beginning; the City Council and the Mayor cooperated and voted $700 toward the establishment of the Center and agreed, further, to pay the rent for a period of three years. At the beginning of the second year, the Council voted a further sum of $200 toward the doctor's salary. The sum of $600 was also voted toward the maintenance of the Center during the third year as well as $200 toward the doctor' salary. 1251 The doctors in the beginning were skeptical but us the work continued its advantages became nore and more evident to thes and their cooperation was also given. When the work started not core thtin 10jt of all expectant mothers retained tneir physician for the expected confinement, and only the few oases which suffered from serious complications were under medical care, An effort was made at once by the nurses to get all prenatal patients under medical cure beforo the thirc prenatal nursing visit. This effort was so successful that ;iit sight safety be said th-t from one-half to two-thirds of all expectant mothers no* register with their physicians between the third and fifth month of pregnancy. The actual work was started Bay 6, 1921. The Center was located in the rear basement of a building on tht- main street, which was formerly used for a storeroom. It was completely renovated by the Metropolitan with the aid of the City. The Reception and Clinic Rooms were both very well equipped for demonstra tion. Zttook about two months to get the Center ready for use. As soon as it was ready the Parish Priests announced the opening. They did this with so much enthusiasm that the place was filled to capacity for the first Mothers' Club. At these Mothers' Clubs, the mothers were given a series of sixteen talks, each of which did not last more thirty minutes. These talks covered every thing from the reason for the necessity for prenatal care, to the care and feeding of the pre-school child. Each of the three nurses took turns in giving these talks. At the beginning It was ulmost impossible to get the mothers to take active part in these meetings. After a fen months, however, it beoaae quite the habit for the worn to give the talks themselves, not directly, but each one taking part, answering questions, and explaining why and wherefore. -3- After the work had been going on a wile it wub possible to get some of the motr.ers to bring their babies and h&ve then demonstrate to their com panions the proper way to bathe and dresB a baby. Others demonstrated how to prepare for delivery, etc.; and others taught ho* to make poultices and apply counter-irritants of various kinop. Light refreshments were -n aeded inducement to the mothers to attend the weekly conferences. It became knows in Thetford fines that the nurses always procured better applfcs than any one else conic., and on the principle that, "An apple u day keeps the docto: away", trie nurses served almost nothing else. The program consisted primarily, however, of prenatal and postnatal cursing and baby welfare work. The prenatal and postnatal nursing were done according to the method of the Maternity Center Association, New Tork City, and the baby welfare procedure was copied from the best of its kind in New Tone City. A full nursing visit which comprised! the taking of temperature, pulse, respira tion and blood pressure, doing urinalysis, counting of fetal heart rate, question ing patient generally as to hei condition, diet, etc. and giving of advice as in dicated by the picture obtained from her answers, also assistance in solving any social problems which might Lave an effect either directly or indirectly on the patient's condition. These tests were made on all expectant mothers either at home or at the Center (preferably at the latter place) until the seventh month of and pregnancy,/every week or oftener thereafter. After confinement the patients were visited every day for the first three days, every second or third day until the 10th day, and then every week or oftener, if necessary, until the baby was one month old. At the aid of that time the mother was discharged and the baby registered separately for Baby Welfare. Bothers were invited to bring their babies every week to the Center to be weighed and looked after, and all babies registered were weighed as far as possible once a month. -4Sick babies were visited dully if necessary. Feeding cases and cases of diarrheal disease were frequently visited more often, cither to keep up the Mother's interest or to keep her froa killing the baby by following some kind :> relative or neighbor's advice. Visiting Burse Service for Policyholders wue added after the first six months of the work. In Xune 1922, the Company provided the nurses with a Ford Car. This enabled them to cover a much larger area than they could otherwise have done. Around Thetford Bines and all smell French Canadian towns there are what is called Range" which translated means ranges. Around Thetford there are eight of these. The nurses frequently spent their summer evenings covering these ranges in their Fords. They would park the car on the roadside and each nurse go off in a different direction. It was quite a common occurrence to have expectant mothers as well as mothers with babies coois to the Center froa places that were anywhere froa five to fifty miles distant, for advice and help, also to receive letters, a number of which are still on file, froa persons many miles away asking advice on all sorts of subjects. Many replies were received to these letters telling of the wonderful results obtained due to the following of the nurses' advice. The work was not easily developed for the very good reason that the community had never hod any similar activity, that nurses, exoept practical nurses, had. not been available heretofore,and every step had to be taken with due regard to the natural prejudices of the community to show that what was attempted was right and useful. Nevertheless, the Clinic was successful froa the very start because of the common sense of the people and the excellent support of the Clergy. At the first meeting of the Mothers* Club the attendance was 46. Since that time the average attendance hae bean 15 a weak in spite of snowstorms and religious holidays. ; w* 1254 -5The nark grew quiddqr and beginning with two nurses it was found before the close of 1921 that three nurses were needed. Soon, virtually all the babies born in the community come under the cue of the station. For example, in Hay 1922, on the first anniversary of the experiner.t there were already 326 babies under care in a ooaurunity wfuere the total number of births in that year and the preceding year was approximately 450. In May 1923, there we-c 515 babies under' care although the number of babies bora in the preceding year was oniy 392. This means, very obviously, that few babies escaped the care of the baby station. The total number of visits made in the last year of the experiment. May 1, 1922 was 14,731, of which 12,707 were home visits and 2,038 were Clinic visits. The Clinic visits do cot include the attendance at Mothers1 Clubs although this was an important activity. These figures are given in order to show not only the large extent of the activity in this small community but also the large amount of work done by the nurses. Under the pressure of the need of this Community, the nurses averaged thirteen visits a day including the service at the clinic as well as at home. The result of the work as measured by the drop in infant mortality rate is very gratifying. In the first year. May 1, 1921 to May 1, 1922 the infant mortality rate declined to 149 per 1,000 birthi,and in the second year to May 1, 1923 it de clined to 117 per 1,000 births. In the two months of May 1922 and 1923 the average monthly rate was 85 per 1,000 births. It is evident, therefore, that a very marked diminution in the mortality was brought about and the decline is continuous. It is now, in fact, less than one half what it was at the beginning of the Demonstration two years ago. More significant than the figure is the fact that such an activity could be established in a community like Thetford {lines and win for itself the support of all the people. This it has accomplished, not because of any figures of infant mortality, which, after all, people do not understand, but rather because of such simple facts as that mothers who have heretofore uniformly loet their babies are now bringing live - 1255 babies into the world ana keeping then in good health for the first time. Any number af instances of this kind could befeiven. Such facts ere very dramatic and convincing. to people who know little about new fashioned health activities but who are willing to benefit from what is good. It is because of this that good has been accomplished and the Community of Thetfard Mines has been able to take over the experiment at the end of a little less than two years as a community project and will support it henceforth with the assistance of the Metropolitan Life Insurance Company who will continue to pay the salaries of three nurses until January 1, 1924 and of two nurses from January 1, 1924 to July 1( 1924. The important lessons of Thetford Mines are that the mortality can be reduced in other communities where the effort is made and that any effort must take into consideration the local conditions and the traditions and habits of the people. Respectfully submitted. Approximately January 1925 (SIGNED) Alice Ahern Nurse-in-Charge -V4 1256 REPORT OF 7HFTF3PD MIKES For u number of years the Metropolitan Life Insurance Company has thought it desirable to demonstrate somewhere in French Canada, that the con dition of mothers in childbirth, and of babies during their first year of life, could be greatly improved. In order to arrange for a demonstration of such a programme it presented a plan to the religious authori ties of Quebec and obtained their hearty approval. The Auxiliary Bishop of Quebec, Mg3r. Roy thought that an industrial community like Thetford Bines would be typical of French Canada, and that if success were obtained there, it could be obtained it any community of this province. After consultation with the authorities of Thetford Mines, who were entirely agreeable to cooperation with the Company, the work was begun in cooperation with that Community early in nineteen hundred and twenty-one (1921). The first step was a survey of the city which showed very clearly that no mistake had been made in the choice of Thetford Mines. The infant mortality rates in this city of dose to 9,000 population were 232 per 1,000 births in the year 1919-1920 and 261 per 1,000 births in the year 1920-1921. (Figures are from. May to May). Tne Community responded In the most hopeful manner. The clery were enthusiastic from the very beginning; the City Counoil and the Mayor cooperated and voted $700 toward the establishment of the Center and agreed, further, to pay tho rent for u period of three years. At the beginning of the second year, the Council voted a further sum of $200 toward the doctor's salary. The sum of $60C was also voted toward the maintenance of the Center during the third year ns well as $200 toward the doctor's salary. 121,7 The doctors in the beginning were skeptical but us the work continued its advantages became sore and sore evident to then end their cooperation warn also given. Phen the work started not aore than 10 of all expectant mothers retained their physician for the expected confinement, and only the fee oases which suffered froa serious complications were under medical care. in effort was made at once by the nurses to get all prenatal patients under medical care before the third prenatal nursing visit. This effort wus so successful that -nit sight safely be said that from one-half to two-thirds of ail expectant mothers no* register with their physicians between the third und fifth month of pregnancy. The actual work was started Kay 6, 1921. The Center was located in the rear b&seaect of e building on the main street, which was formerly used for a storeroom. It was completely renovated by the metropolitan with the aid of the City. The Reception end Clinio Rooms were both very well equipped for demonstra tion. It look about two months to get the Center ready for use. As soon as it was ready the Parish Priests announced the opening. They did this with so much enthusiasm that the place was filled to capacity for the first Hothers* Club. At these Bothers* Clubs, the mothers wers given a series of sixteen talks, each of which did not last more titan thirty minutes. These talks covered every thing from the reason for the necessity for prenatal care, to the care end feeding of the pre-school child. Each of the three curses took turns in giving these talks. At the beginning it was almost impossible to get the mothers to take active part in these meetings. After a few months, however, it beoase quite the habit for the women to give the talks themselves, not directly, but each one taking part, answering questions, end explaining why and wherefore. 1258 After the work had been going on a viiile it nus possible to get some of the mothers to bring their babies ana bare then demonstrate to their com panions the proper way to bathe and dress & baby. Others demonstrated hoe to prepare far deliverytetc.j and others taught ho* to make poultices and apply counter-irritants of various kinds. Light refreshments were an aaded inducement to the mothers to attend the weekly conferences. It become known in Thetford ?aines that the nurses always procured better apples than any one else c-oulc, and on the principle that, "in apple & day keeps the doctor away", the nurses served almost nothing else. The program consisted i.riourily, however, of prenatal and postnatal nursing and baby welfare work. The prenatal ;nd postnatal nursing were dona according to the method of the Maternity Center Association, New York City, and the baby welfare procedure wns copied from the best of its kind in New Yors City, A full nursing visit which comprised: the taking of temperature, pulse, respira tion and blood pressure, doing urinalysis, counting of fetal heart rate, question ing patient generally as to her condition, diet, etc. and giving of advice as in dicated by the picture obtained from he?- answers, also assistance in solving any social problems which might nuve on effect either directly or indirectly on the patient1 s condition. These tests were made on all expectant mothers either at home or at the Center (preferably at the latter place) until the seventh month of and pregnancy,/every week or oftener thereafter. After confinement the patients were visited every day for the first three days, every second or third day until the 10th duy, and then evory week or oftener, if necessary, until the baby was one month old. At the end of that time the mother was discharged and the baby registered separately for Baby Welfare. Mothers were invited to bring their babies every week to the Center to be weighed and looked after, and all babies registered were weighed as far as possible once a snath. 1259 Sick babies were visited daily JLf necessary. Feeding cases and cases of diarrheal disease were frequently visited more often, either to keep up the Bother1 s interest or to keep her from killing the baby by following some kind relative or neighbor's advice. Visiting Burse Service for Policyholders was added after the first six months of the work. In 2une 1922, the Company provided the nurses with a Ford Car. ThiB enabled them to cover a ouch larger area than they could otherwise have done. Around Thetford Bines and all small French Canadian towns there are what is oalled "Bangs" which translated scene ranges. Around Thetford there are eight of these. The nurses frequently spent their summer evenings covering these ranges in their Fords. They would pork the car on the roadside and eaoh nurse go off in a different direction. _ It was quite a common occurrence to have expectant mothers as well as mothers with b&bies come to the Conter from places that were anywhere from five to fifty miles distant, for advice and help, also to receive letters, a number of which are still on file, from persons many miles away asking advice on all sorts of subjects. Many replies were received to these letters telling of the wonderful results obtained due to the following of the nurses' advice. The work was not easily developed for the veiy good reason that the community had never had any similar activity, that nurses, except practical nurses, had not been available heretofore,and every step had to be taken with due regard to the natural prejudices of the community to show that what was attempted was right and useful, nevertheless, the Clinic was successful from the very start because of the common sense of the people and the excellent support of the Clergy. At the first meeting of the Mothers' Club the attendance was 46. 8inoe that time the average attendance has been 1$ a weak in spite of smovstozas and religious holidays. - 12G0 -5The work grew quickly and beginning with two nurses it was found before the close of 1921 that three curses were needed. Soon, virtually all the babies bom in the community came under the core of the station. For example, in Hay 1922, an the first anniversary of 'tbs' experiment there were already 326 babies under c&re in a community where the total cumber of births in that year and the preceding year was approximately 450. In May 1923, there were 515 babies under care although the number of babies bora in the preceding year was only 392. This means, Very obviously, that few babies escaped the care of the baby station. The total number of visits cade in the last year of the experiment, Hay 1, 1922 was 14,731, of which 12,707 were hose visits and 2,038 were Clinic visits. The Clinic vlBits do not include the attendance at Mothers* Clubs although this was an important activity. These figures ore given in order to show not only tbs large extent of the activity in this small community but also the large amount of work done by the curses. Under the pressure of the need of this Community, the nurses averaged thirteen visits a day including the service at the clinic as well as at home. The result of the work as measured by the drop in infant mortality rate is vary gratifying.' In the first year, Hay 1, 1921 to Hay 1, 1922 the infant mortality rate declined to 149 per 1,000 hirtht,and in the second year to Hay 1, 1923 it de clined to 117 per 1,000 births. In the two months of Hoy 1922 and 1923 the average i monthly rate woe 85 per 1,000 births. It is evident, therefore, that a very marked diminution in the mortality was brought about and the decline is continuous. It is now, in fact, less than one half what it was at the beginning of the Demonstration two years ago. Uore significant than the figure is the fact that such an activity could be established in a community like Thatford Hines and win for itself the support of all the people. This it has accomplished, not because of any figures of infant mortality, which, after all, people do not understand, but rather because of such simple facts as that mothers who have heretofore uniformly lost their babies ere now bringing live - 1201 ' r~ -6babies into the world and Steeping then is good health for the first tine. Any cumber of instances of this kind could be given. Such facts are very dramatic and convincing to people who know little about new fashioned health activities but who are willing to benefit from what is good. It is because of this that good has been accomplished and the Community of Thetford Mines has been able to take over the experiment jr.t the end of a little less than two years as a community project and wiil support it henceforth with the assistance of the Metropolitan Life Insurance Company she will continue to pay the salaries of three nurses until January 1( 1924 and of tw^ nurses from January 1, 1924 to July 1, 1924. The Important lessons of Thetford Mines are that the mortality can be reduced in other communities where the effort is made and that any effort must taka into_ consideration the local conditions and the traditions and habits of the people. Respectfully submitted. Approximately January 1925 (SIGNED) Alice Ahern Hurse-in-Charge 1262