 |
Health Services in
a Stranded Coal Community: Scotts Run, 1920-47
By Sandra Barney Volume 53 (1994), pp. 43-60 |
Scholarship on health care in the coal mining regions of Appalachia has focused almost exclusively on the relationship of the inhabitants to direct care providers. In the absence of substantial historical literature, research has generally concentrated upon the company doctor and the care dispensed to miners and their families. Recent publications, such as Appalachian Passage and Miners and Medicine, offer valuable anecdotal accounts of these relationships and of the conditions faced by both miners and physicians in the coal camps of West Virginia. The demise of this system after World War II and its replacement with the United Mine Workers of America (UMWA) Welfare and Retirement Fund have also been studied in recent works.1
While providing important information on one aspect of health care in Appalachia, these publications fail to examine the relationship of coal miners and coal communities to larger health care systems. To appreciate fully the paradigms which shaped the interchange between Appalachian coal miners and the medical community, it is necessary to extend the study beyond the company doctor system and to consider the interrelationship of the coal camps to the larger community and existing health care networks.2
The relationship between miners in West Virginia coal camps and the larger health care system is well illustrated by events in the coal communities along Scotts Run. During the 1920s and 1930s, a struggle over the implementation of public health services developed in Monongalia County. Although initially limited to public health services, the debate ultimately evolved into a discussion of the relationship between private physicians and rural miners with union health programs.
Public health services, here defined as any preventive effort provided on a not-for-profit basis, took a number of guises during the period. Vaccinations, sanitation efforts, prenatal and infant screenings, and well-child clinics were all recognized as falling within the realm of public health. The attitude of the local medical community toward the extension of public health services into the coal mining hollow of Scotts Run offers telling insight into the origins of the inequitable distribution of medical resources within the county.
The residents of Scotts Run, many of whom were racial and ethnic minorities, were handicapped by poverty and lived in crowded and disjointed communities which often lacked stability or permanence. The unsanitary conditions and relative geographic isolation of these coal camps further burdened the miners who lived there. Although less than five miles from West Virginia University in Morgantown, with its modern health care facilities and numerous doctors, they faced entirely different circumstances than residents of the city or those in more rural areas.
During the 1920s and 1930s, the communities along the Run were accessible from Morgantown by public ferry, trolley, or via a winding secondary road which followed the Monongahela River. The ferry connected Star City, a community just northwest of Morgantown, and Jere, the nearest of the Scotts Run settlements. For miners who were underemployed or unemployed the cost of this ferry was sometimes prohibitive, leading to frequent, but unsuccessful, petitions from Scotts Run residents to the Monongalia County Court asking for the implementation of a free ferry system.3 Inadequate transportation, then, created a sense of isolation and separation from Morgantown.4
The ethnic and racial composition of the coal camps further segregated inhabitants from the rest of the county. Recently arrived immigrants spoke little English and, initially, had minimal comprehension of American customs or institutions. African Americans, often brought to the coalfields as strikebreakers during the struggles over unionization, found themselves in hostile territory. Morgantown, unlike the more integated communities of Scotts Run, was segregated and offered few opportunities for African Americans.5 As in other West Virginia coal camps, miners and their families were isolated by the composition of the work force and the rural nature of the coal industry.
The social and economic conditions on Scotts Run reflected national and local events. Like the rest of the bituminous mines in the country, the Scotts Run region went through an extensive boom period during World War I. In the 1920s, however, due to a decreased demand for coal and worker-management conflicts, that growth disintegrated and the market plummeted. As part of this economic decline, production at the mines along Scotts Run and elsewhere in the bituminous regions was reduced dramatically. Many miners were underemployed, while others had no work at all.6
In the mining communities, social problems, such as inadequate health care and poor sanitation, were exacerbated by the economic decline of the 1920s. Public and private agencies began to study the problems of workers in the bituminous mining industry. Their efforts increased notably after this depression spread to the entire economy during the 1930s.
Scotts Run saw a variety of health care reform initiatives in the 1920s and 1930s. Most significant were efforts by local citizens to establish a public health department for the county. The Methodist Episcopal Church and the Presbyterian Church, U. S. A. also supported the development of health care. Other groups, such as the American Friends Service Committee, assisted for brief periods of time, but the public health department and churches maintained the longest, most profound presence on Scotts Run.
Supporters of a county public health service and missionary workers faced numerous obstacles as they attempted to modernize medical services. Some obstructions, like the Monongalia County Medical Society, were external. Others, such as the churches' hesitation to focus on acquiring health care services, were internal reflections of larger social attitudes toward the medical profession's monopoly.
Unsanitary and unhealthy living conditions in the coal camps attracted the attention of progressive reformers during the 1920s. Although progress had been made nationally in public health during the first decades of the century, West Virginias mining camps lagged behind in sewage disposal, clean water and basic medical services.7 The living conditions of bituminous miners in southern West Virginia were documented in 1923 by Nettie McGill, an employee of the United States Department of Labor's Children's Bureau. McGill's research showed that frequent outbreaks of typhoid fever were caused by the absence of sewage disposal systems in many of the camps. She also found that drinking water supplies were contaminated by raw sewage and drainage from the mines. The camps, marked by communal outhouses, open privies, and refuse piles near the houses, were ideal breeding grounds for rats, mice, and other vermin.8
The conditions McGill observed in southern West Virginia were replicated on Scotts Run. When the Society of Friends established a supplemental nutrition program for the communitys children in 1931, they found poor sanitation and sewage problems in the public schools.9 William E. Brooks, in a 1934 report for the Upper Monongahela Valley Planning Board, described "one camp [where] all the toilets were erected over a running stream which in turn runs through several other camps below and empties into the Monongahela River."10 A social survey undertaken by the Monongalia County Welfare Board in 1932 described the rat-infested communities of Jew Hill and North American Hill along Scotts Run and reported that sixteen families there shared six toilets. None of the shanties had running water, requiring residents to carry water more than one-quarter of a mile from an unsanitary creek.11
Inadequate health standards extended beyond public hygiene and sanitation. The Welfare Boards survey portrayed a community burdened by poor health and chronic illness. "There is scarcely a family that does not need medical attention," a soial worker wrote. She noted the high number of sick children, but claimed that the community's ill health was rooted in venereal disease, asserting that the most common ailments were syphilis and gonorrhea. Because of the perceived epidemic of venereal disease, nurses and social workers were warned to be wary, "for almost everyone has some sort of social disease."12
The Friends Service Committee also uncovered ill health among the children, who suffered from chronic tonsillitis, poor vision, and malnutrition. In addition to providing food, the Quakers sought medical care for the most severely afflicted. They first approached local doctors for help, but frequently had to turn to outsiders because of the absence of physicians in the coal camps.13
Residents who lived along Scotts Run during the era remember that doctors who served the miners and their families during the 1920s and 1930s were primarily company doctors. These doctors were paid by the check-off system, a method by which a standard deduction was made from each miner's pay to cover medical care. The physicians kept office hours weekly and saw only those patients who were in good standing with the company. Maternity cases and hospitalization were not included in the payroll deduction and clients were expected to travel to Morgantown for office visits if they needed a physician when the mine office was closed. Doctors made house calls but such visits fell outside the company agreement.14 Hospitalization was a matter to be arranged between the patient and the physician, although most doctors sent their indigent patients to Monongalia General Hospital because the county court, pressured by the local medical community, had an agreement with the hospital to pay for those who could not afford to settle their bills.15
Some company doctors employed by mines along Scotts Run enjoyed close relationships with mine owners and fought to protect their lucrative arrangements. When a new doctor came to Morgantown in the 1930s he was quickly warned against seeking a position with the mines. Dr. J. C. Pickett, employed by the Pursglove mines, reported to the Monongalia County Medical Society that his mine had been solicited by Dr. Peter Caserta, a physician newly arrived from Italy. Dr. Caserta was also charged with seeking clients from among the employees of the Shriver mine, an operation traditionally served by Dr. E. F. Heiskell. Shriver's management, apparently satisfied with Dr. Heiskell, wrote the medical society to report Dr. Casertas actions, suggesting an alliance between some of the established physicians and the mine operators. The medical society censured Dr. Caserta, coming within one vote of expelling him from the society, and explained to him that doctors' relationships with local mine operators were not to be challenged.16
The Monongalia County Medical Society's treatment of Dr. Caserta and defense of the company doctor system was typical of its conservative approach to the economics of health care. In the 1920s, many local doctors, through the county medical society, advocated limited competition and the self-imposition of a uniform fee schedule, insuring that no doctor received more than what was his perceived share of the market. This opposition to competition in health care revealed the inadequacies of the company doctor system. As Richard Couto argued in his essay, "Appalachian Innovation in Health Care," the persistence of company-supported monopoly undermined the quality of care provided to miners and their families by preventing competition and prohibiting younger, possibly better trained, physicians from offering superior services to the mining community.17
Whether campaigning against competitors, like chiropractors and midwives, or defending the sanctity of ties between mine owners and company doctors, the medical society acted to promote its professional status and to insure its dominance over health care delivery. Based in Morgantown and focused upon the city's residents, the medical community's efforts to develop its professional stature within the town were typical of many medical practitioners during the era. As specialization and its accompanying dependence upon technology grew, many doctrs turned from general practice to more narrowly defined fields.18 This, and the medical professions focus on treatment rather than prevention, discouraged doctors from addressing the needs of Scotts Run. An example of the physicians' hesitancy to confront conditions was the ambivalence of the local medical society toward the establishment of a county public health unit.
West Virginia created its first board of health in 1881. Although the state began adopting modern standards of sanitation and hygiene in the nineteenth century, each county was left to create its own public health unit. Throughout the first decades of the twentieth century, counties around the state began establishing either city, county, consolidated city-county, or regional health units.19
Without aggressive leadership from the local medical society, Monongalia County was slow to build a public health system. In the early 1920s, a nurse was hired to visit the county schools. She was acceptable, according to the minutes of the Monongalia County Medical Society, because "she did not pose as one whose knowledge was superior to the doctors."20 Other than passively supporting the part-time activities of this county nurse, the medical society did little to encourage the creation of a public health division. In 1922 and 1923, the society went on record in support of a public health agency, as it did again in 1925 after a typhoid epidemic struck the county.21 In general, however, this enthusiasm was mixed with concern over the repercussions of such an institution on the doctors' private practices, a hesitation often expressed by physicians across the United States during public health campaigns.22
The medical association had neither been ardently sympathetic nor actively opposed to a county public health unit. By 1929, however, renewed agitation for a public health office met with resistance from the county's doctors. Rather than continue the benign neglect of earlier in the century, the medical society's actions demonstrated a growing fear of socialism and state interventionism so strong that some medical associations in the state appealed to the West Virginia attorney general, beseeching him to investigate "Socialized Medicine."23
While the physicians struggled with their concerns over methods of payment and government interference in their profession, the community became increasingly adamant in its call for a public health unit. In 1927, nearly one thousand rural residents, many of whom were from the Scotts Run area, petitioned the county court to establish a public health office. When those pleas were ignored, more than twelve hundred signed a similar petition the next year.24 In spite of the support of these rural citizens, the court did not take the issue under advisement again until the summer of 1929, when Dr. Lemley, a Michigan physician with family ties in Morgantown, was asked to speak at a public meeting about his experience with the Detroit public health agency. Dr. Lemley succeeded in convincing the local newspaper editor and the county court of the value of such an agency. He received, however, a less enthusiastic response from many local physicians.25
Following Lemley's speech, the medical society's members retired to discuss the merits of a public health office. They debated the usefulness of free inoculations and warned one another of the dangers of "state medicine." Their tentative consensus was willingness to accept the premise of a county health department, if it did not actually practice curative medicine. As long as its duties were limited to inoculations and sanitation issues, the doctors agreed not to oppose the measure when it came before the county court.26
Apparently, the medical community's primary concern was the issue of payment and the danger of government intrusion between a physician and client. The society's legislative committee revealed its apprehension over the establishment of the public health unit by insisting that cases able to afford medical or surgical treatment be referred to private physicians: "We feel it is unfair to the taxpayers of the county to bear the expense of medical and surgical services to those wh are able to pay for the same, nor, do we feel it is just to the medical profession that such people be treated by the Board of Health or other agency of like character."27
Two weeks before the county court voted on the issue, strong pressure was levied against the ambivalent physicians. The New Dominion editorialized that there were few doctors in Monongalia County besides those in Morgantown, arguing that the health of those in "the thickly populated mining sections" should not "be sacrificed because public immunizations against contagions and infections can be given free."28 The newspaper also reminded readers that, while many within the medical community were concerned with their own financial security, this was an advantageous proposition for the county, since 40 percent of the public health units annual budget would be paid by grants from the state and federal governments and the Rockefeller Foundation.29
Despite these practical advantages, Morgantown physicians did not enthusiastically condone the creation of an institution founded on the principles of "social medicine." At the county court session convened to decide the matter, some city doctors sought to postpone the vote. Failing that, they attempted to alter the proposed structure of the unit to include the city within its administration. Had they been successful, the public health unit would have increased services to the city while increasing costs to the county by five hundred dollars per month.30 Their efforts to amalgamate city and county services revealed the medical societys primary focus on Morgantown. In addition to concerns over government intervention in their profession, the doctors' actions suggest other divisions which separated them from the miners who resided along Scotts Run. In 1923, only four active members of the medical association maintained offices in communities on the Scotts Run side of the Monongahela River. Association records show that by 1930, no members of the Monongalia County Medical Society kept their primary offices in Scotts Run.31
A few physicians practiced outside the city, but the majority of local physicians focused their practices within the city limits of Morgantown, creating their own network of professional alliances and social relationships. The story of Dr. W. W. Stonestreet's application for admission to the county medical society illustrates the professional tensions among doctors in the county. In 1923, Dr. Stonestreet applied for membership in the society, which was not a daunting obstacle. Only a few months earlier the secretary of the association noted that no one, except an African American who was warned not even to present his qualifications, had ever been rejected by the organization.32 Just six months later, Dr. Stonestreet became the second man to gain the notoriety of being turned down by the society.33 Interestingly enough, Dr. Stonestreet later provided medical care to indigent patients through the Scotts Run Community Center in the late 1930s.34
Although the records of the county medical society do not explain Dr. Stonestreets rejection, and his professional isolation may have resulted from some misconduct or incompetence of which we are not aware, there are other, more detailed, examples of bias by the city's doctors. A venereal disease clinic established in Morgantown in 1928 limited its services specifically to city residents.35 In April 1929, a diphtheria outbreak occurred in Monongalia County, and the physicians volunteered to perform low-cost or free vaccinations in the city and county schools to prevent the disease from spreading. A comparison of those schools visited with another list of schools published during the same period indicates that not all of the county's students were inoculated. A number of schools along Scotts Run, probably the most susceptible due to crowded and unsanitary conditions, were overlooked.36
Discrimination against Scotts Run residents did not end with the creation of the public health unit in 1929. Local physicians still concentrated their public health assistance in the city. Members of the medical society were approached by a public health nure in 1933 requesting permission to conduct a birth control clinic on the Run. The society went "on record being opposed to giving any time for such a clinic,"37 reflecting ongoing efforts to find "means of cutting down charity work. . . ."38 Several years later the society volunteered to contribute to just such a program in the city, agreeing to provide medical services as well as office space.39 In 1934, these doctors again set up a diphtheria immunization program for Morgan District and Morgantown proper, clearly stating that they would not provide services to areas outside the city.40
This disparity illustrates the Inverse Care Law, a theorem articulated by Julian Tudor Hart, a Welsh physician, in The Lancet in 1971. Comparing medical services in Wales and England, Hart discovered that those communities most in need of health care are frequently those least capable of demanding it.41 While his criticism was not directed specifically toward Appalachian concerns, his comments certainly echo the inequities of service available to Scotts Run.
The inattention of the Morgantown medical establishment to Scotts Run was strikingly contrary to the interest displayed by humanitarian agencies, particularly the Methodist Episcopal Church and the Presbyterian Church, U. S. A. Committed to improving daily life in the coal camps, the churches original agenda focused on spiritual and social concerns. It was years before their work expanded to address the secular, but fundamental, problem of health care in these coal communities.
The Methodist Episcopal Church was the first religious group to apply progressive settlement ideals in Scotts Run, beginning in 1922 under Edna L. Muir, a graduate of the Kansas City National Training School and a deaconess of the Wesleyan Church in Morgantown. Initially, Muir and her colleagues ran weekly Bible schools and Sunday school classes in rented rooms in downtown Osage. By 1927, they had built a settlement house to serve the residents of Scotts Run.42 That same year, the Presbyterian Church, U. S. A. joined the Methodist Episcopals. Frank Losa and Frank Svoboda, colporteurs of the churchs Board of National Missions, undertook a social and religious survey of the communities along the creek and reported that it was "almost obligatory to start mission work." In this investigation, Losa and Svoboda described the ethnic and racial demographics of the communities. They did not report on the physical well-being of the people, sanitary conditions, or the need for health care.43
With the early focus on spiritual pursuits and basic social work, the churches' efforts to uplift the miners and their families encouraged them to assume more traditionally middle-class American attitudes and behaviors. These ventures in Americanization, like most progressive programs, were aimed at improving the individual without altering the system which produced poverty and its accompanying evils. Mary Behner set up programs to teach sewing, canning, and gardening at the Scotts Run Community Center, later known as The Shack. From these mundane activities, programs expanded to include a charm school, drama club, and frequent Bible schools.44
Limited by the expectations of the Presbyterian Church's Board of National Missions, Behner was restricted in the programs she could introduce. While frequent informal efforts were made to aid families in need of health care,45 little official attention was given to the issue. The Shack's budget during these years discloses that minimal funding was expended on medical services for the community's residents. According to these records, no money was spent on health programs from the beginning of the settlement's work until the summer of 1931, when $5.10 was spent on a children's clinic. Compared to the $161.53 allocated for staff travel, this expenditure was insignificant.46 Community center records reflect no disbursements for health care again until 1933. Medical services remained minor items in the budget; the approximately two hundred dollars spent on travel that year was twice the allotment paid to assistants and ten times the amount used for medical services.47
The Presbyterians were not unique in their lack of systematic attention to health concerns. The Methodist Episcopals also placed greater emphasis on spiritual and social matters than on medical necessities. The mandate for this agenda came from the Woman's Home Missionary Society, the national agency which oversaw the work on Scotts Run. Monthly and yearly reports, completed by the deaconess in charge of the Scotts Run Settlement House, were submitted on generic forms provided by the home office. These forms indicate that the duties of settlement workers were to address religious and social needs. Reports did not cover health care. Assisting the community in acquiring medical service was simply not a priority in the early days of the settlement house.48
Although their lack of attention to health care delivery appeared to be more formally institutionalized, it was actually the Methodist Episcopals who first began to offer substantive public health care services. In 1933, responding to the economic and social devastation of the Great Depression, the Woman's Home Missionary Society expanded its focus to include health care issues and began reporting their coordination with local health care agencies. By 1936, the Scotts Run Settlement House hosted well-baby and preschool clinics, which provided facilities for public health nurses to screen children and teach maternal and infant care. To protect their relationship with the county medical society, the nurses carefully avoided providing any service which might resemble free curative medical care.49
The Presbyterians at The Shack also began to respond to the physical needs of the residents in the late 1930s. Under the direction of the Reverend Frank Trubee, who arrived in 1937, The Shack established a self-help cooperative called the Scotts Run Reciprocal Economy to assist the residents by encouraging self-sufficiency and skill building. Reverend Trubee also solicited the assistance of the elderly Dr. Stonestreet to provide health care in emergency situations. The Shack sponsored bimonthly well-baby clinics run by public health nurses, exhibiting the more pragmatic agenda assumed by both religious groups during this time.50
This new perspective of the settlement workers demonstrated a growing concern for the community's practical needs. Unlike earlier workers, these new missionaries focused more on material improvements than religious conversion and Americanization. This shift, reflecting the professionalization of social work and the effect of that movement on missionary work, was a watershed in the development of health services on Scotts Run.
The willingness of the settlement house and the community center to open their doors and assist with health care made the work of the public health department much easier. As residents of the community remember, attending clinics at both facilities were normal activities by 1940.51 In addition, government funds made available during the Depression by the Federal Emergency Relief Administration enabled public health nurses to visit homes along the Run to provide maternal and infant care.52
Cooperation between religious groups and the public health department enabled residents of Scotts Run to acquire some preventive and educational services from public health nurses. Access to a physicians care was still limited, however. Financially disadvantaged and sometimes without transportation, miners and their families were compelled to rely on company doctors. Improved social services provided by local branches of New Deal agencies and the growing power of the UMWA inspired the residents of Scotts Run to demand increased control over their direct provider care. Empowered by advancements in public health services, they sought similar revisions in their relationship with local physicians.
Frustrated by the perception of company doctors as agents of the mine owners and by the frequent incompetence of some company physicians, miners expressed their exasperation by seeking new arrangements with medical practitioners. Some UMWA locals attempted to form their own insurance programs or to negotiate contracts with doctors without going through the mine operators.53 Both methods were attempted on Scotts Run during the 1930s.
In 1934, the Monongalia County Medical Society discussed the possibility of doctors accepting employment from the union rather than mine operators. Although such contracts might have been quite lucrative, they were rejected on the principle that only the mine owner could engage the doctor. The society's members, uninterested in working for the union, contended that employment as a company physician "boils down to whether the company or the union employs the physician."54
Events in 1938 demonstrated that, while the company doctor system was in decline, many physicians continued to oppose collective methods to manage health care payments. Employees at one Scotts Run mine approached Dr. E. F. Heiskell about setting up a standardized hospitalization fee. Heiskell reported the offer to the medical society and a discussion ensued. The doctors agreed that standardized fees were unacceptable, an interesting observation from men who had been working under the check-off system for years and who, in the 1920s, had discussed the establishment of a uniform fee system. The society rejected the offer, stating "the fee schedule given by the [union] committee is not approved by the County Medical Society and Dr. Heiskell is to set his own fees."55
The company doctor system did not completely collapse on Scotts Run until after the establishment of the UMWA Welfare Fund in 1946. The extended coverage provided miners with new choices in health care. Physicians who lost their monopoly with the companies began to terminate services on the Run, expecting miners and their families to travel to Morgantown for treatment. The fund eased the economic burden of miners who needed health care, but, on Scotts Run, it also contributed to physical separation from medical care providers.
Continuing tensions between the mine workers and medical practitioners were illustrated in an exchange which took place in the spring of 1947. Members of the union local were concerned because many Morgantown physicians closed their offices on Thursday afternoons. Fearful of being unable to locate a physician, the local requested that the medical society encourage doctors to keep their offices open, to which the medical society drafted a scathing response.
The physicians of Monongalia County have been interested in the health and welfare of the people of the county before organized labor was ever dreamed of. . . . The mine contract medical practice is one which the United Mine Workers Union and the Coal Companies are responsible for. . . . The Monongalia County Medical Society claims no responsibility for this type of practice. . . . It is believed generally that you get about what you pay for and medical practice is in that respect no different from any other service. . . . You will have to pay more money, hire more doctors to get more service. This it seems to us is your problem and not the problem of the Monongalia County Medical Society.56
A number of trends came together in this era to both improve and diminish the quality and quantity of health care available. Seeking complete dominance over health care delivery, medical practitioners struggled to enhance their professional status through increased specialization and a reliance upon hospitals and improved technology. Centralization of care in hospitals and in modern offices discouraged house calls and the practice of medicine in ill-equipped coal camp offices. In addition, physicians strove to insure their preeminence in the relationship between public health work and private practice. Treatment of illness, the basic tenet of the physician's work, required the existence of sickness, the eradication of which was the goal of preventive public health care. In Scotts Run, and across the United States, supporters of these conflicting issues attempted to reach a middle ground.
Achieving minimal preventive health care for the residents of Scotts Run has been a dilemma throughout most of the twentieth century. While in the 1920s the problems were just being recognized and labeled, the 1930s saw religious groups and public healthofficials successfully bring limited care to the community. The creation of the UMWA Welfare Fund in the 1940s made paying for medical services easier for many miners but removed the incentive for physicians to practice in the mining communities. After the fund was enacted, transportation to services became an even more significant issue.
Efforts to bring medical care to Scotts Run continued after the UMWA Fund was created. In the late 1960s a free health clinic was established at the Scotts Run Settlement House. This endeavor, which lasted into the 1970s, reminds us that the challenge to provide health care to Scotts Run and to other isolated rural communities in the state has never fully been met.57
Notes
1. Helen B. Hiscoe, Appalachian Passage (Athens: Univ. of Georgia Press, 1991) and Claude A. Frazier, Miners and Medicine: West Virginia Memories (Norman: Univ. of Oklahoma Press, 1992). See, for example, Richard Mulcahey, "Serving the Union: The United Mine Workers of America Welfare and Retirement Fund, 1946-1978" (Ph. D. diss., West Virginia University, 1988).
2. While these issues have received little attention in historical literature, they have been examined by sociologists and political scientists. See Richard Couto, "Appalachian Innovation in Health Care," in Appalachia and America: Autonomy and Regional Dependence, ed. by Allen Batteau (Lexington: Univ. Press of Kentucky, 1983), 168-88.
3. Miscellaneous Orders, Monongalia County Courthouse, Morgantown, Book 11, 111, all county court records cited herein are at the Monongalia County Courthouse.
4. Interview by the author, Sara Boyd Little, Chaplin, 23 October 1992.
5. Ibid.
6. William Brooks, "The Proposed Upper Monongahela Valley Planning Board Report with Respect to Social Conditions and Problems," Moreland Family Papers, West Virginia and Regional History Collection, West Virginia University, Morgantown, hereafter referred to as Moreland Family Papers.
7. Frazier, Miners and Medicine, 20.
8. Nettie McGill, The Welfare of Children in Bituminous Coal Mining Communities in West Virginia, U. S. Department of Labor, Children's Bureau (Washington, DC: GPO, 1923), 14, 16, 47.
9. American Friends Service Committee, Report of the Child Relief Work in the Bituminous Coal Fields (Philadelphia: Engle Press, 1932), 5.
10. Brooks, "The Proposed Upper Monongahela Valley Planning Board Report," 1.
11. "North American Hill and Jew Hill Survey," North American Hill and Jew Hill Survey Collection, West Virginia and Regional History Collection.
12. The Welfare Board's survey reflected the middle-class bias of the women who conducted it. Each family in North American Hill and Jew Hill was evaluated on its moral behavior, cleanliness, intelligence, and history of involvement with the legal system.
North American Hill and Jew Hill Survey.
13. American Friends Service Committee, Report of the Child Relief Work, 5.
14. Interview by the author, Joseph Trischler, Osage, 12 October 1992; interview with Sara Boyd Little.
15. Miscellaneous Orders, Book 9, 346.
16. Monongalia County Medical Society, "Minutes of Business Meeting," 3 April 1934, Monongalia County Medical Society Papers [Closed Collection], Health Sciences Library, West Virginia University, Morgantown, hereafter referred to as Medical Society Minutes.
17. Richard Couto, "Appalachian Innovation in Health Care," 169-70.
18. Paul Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (New York: Basic Books, 1982), 224-25.
19. Eugene Elkins and Larry Young, Public Health Administration in West Virginia (Morgantown: West Virginia Univ. Bureau for Government Research, 1956), 5.
20. Medical Society Minutes, 3 May 1921.
21. Ibid., 14 August 1925.
22. Barbara Melosh, "The Physicians's Hand": Work, Culture and Conflict in American Nursing (Philadelphia: Temple Univ. Press, 1982), 130-31.
23. Clarence Meadows, Attorney General of the State of West irginia, to Thomas Parran, Surgeon General of the United States, 29 June 1939, United States Public Health Service Collection, Box 119, National Archives, Washington, DC.
24. Morgantown New Dominion, 1 August 1929.
25. Ibid., 31 July 1929.
26. Ibid., 7 August 1929.
27. Monongalia County Medical Society, "Legislative Committee Report," 13 August 1929, Monongalia County Medical Society Papers.
28. Morgantown New Dominion, 2 August 1929.
29. Ibid., 7 August 1929.
30. Ibid., 14 August 1929.
31. Medical Society Minutes, 6 December 1923 and 11 December 1930.
32. Ibid., 5 December 1922.
33. Ibid., 16 May 1923.
34. Reverend Frank Trubee Papers, Scotts Run Community Center Collection, West Virginia and Regional History Collection, hereafter referred to as Community Center Coll.
35. West Virginia State Health Department, Biennial Report, 1928-1930 (Charleston: Jarrett Printing, 1931), 156.
36. Morgantown New Dominion, 1 and 8 April 1929; American Friends Service Committee, Report of the Child Relief Work, 27.
37. Medical Society Minutes, 5 December 1933.
38. Ibid., 13 December 1932.
39. Ibid., 7 June 1938.
40. Ibid., 2 January 1934.
41. Julian Tudor Hart, "The Inverse Law of Care," The Lancet (27 February 1971): 405-06.
42. Interview by the author, Violet Petso, Morgantown, 25 November 1992; Scotts Run Settlement House Collection, West Virginia and Regional History Collection, hereafter referred to as Settlement House Coll.
43. Frank Losa and Frank Svoboda, "Report of Missionary Survey in Scotts Run, West Virginia, 1927," Community Center Coll.
44. "Scotts Run Community Center Scrapbook," Community Center Coll.
45. Bettijane Burger, "Mary Elizabeth Behner Christopher, 1906- ," in Missing Chapters II: West Virginia Women in History, ed. by Frances S. Hensley (Charleston: WV Womens Commission, 1986), 49.
46. "Scotts Run Community Center Scrapbook," Community Center Coll.
47. Ibid.
48. "Annual Reports of the Womans Home Missionary Society," Settlement House Coll.
49. Ibid.
50. Reverend Frank Trubee Papers, Community Center Coll.
51. Interview with Joseph Trischler; interview with Sara Boyd Little; interview by the author, Clifford Winston, Osage, 23 October 1992.
52. "Federal Emergency Relief Administration Records, Monongalia County, West Virginia," Moreland Family Papers.
53. Marlene Huff, "The Effects of the UMWA upon the Reform of the Company Doctor System," unpublished paper presented at the Appalachian Studies Association Conference, East Tennessee State University, 21 March 1993.
54. Medical Society Minutes, 3 April 1934.
55. Ibid., 5 April 1938.
56. Monongalia County Medical Society, "Proposed Letter to Union Concerning Recommendations of Union Made by Special Committee," 1 April 1947, Monongalia County Medical Society Papers.
57. Interview with Violet Petso.
Sandra Barney is a doctoral student at West Virginia University. Her dissertation focuses on the role of women in the development of modern health care institutions in the Progressive Era.