The Role of Women in Cancer Control and Cancer Care in the Early 20th Century

Abstract

In the early 20th century, thousands of women in the United States were involved in the cancer control movement as volunteers in the Women’s Field Army and as professional social workers caring for patients living with the disease. Yet their stories are largely untold in the social welfare literature. Using primary archival data and published writings from the era, this article examines the parallel and complementary work of these women and describes how these early efforts shaped the way we approach cancer care today.

At the dawn of the 20th century, cancer was shrouded in mystery and fear. It was described in both the scholarly and popular literature of the time as a “sinister menace” (The Control of Cancer, 1913). It was widely believed that cancer was an automatic death sentence and not considered fit for civilized public conversation. Although the exact cause of the disease continued to elude scientists, by the beginning of the 20th century, there was a growing recognition that cancer could be successfully treated if detected early. In fact the literature, both popular and scientific, began to practically guarantee a cure if the cancer was discovered early enough (Gardner, 2006). As a result, there was a sense of urgency to disseminate this information to both the physicians and the laity of the nation. These factors fed a burgeoning movement in the United States to control this disease and determine a way to care for those living with cancer. Women played a pivotal role in this early cancer work in both a voluntary and professional capacity, yet their work is largely excluded from the social welfare and cancer care literature. Much of the existing literature has minimized the efforts of the women volunteers. In the case of professional social workers, the literature rarely notes cancer work prior to the 1970s. The result is a historical gap in our understanding of the important contributions these women made to our current system of cancer control and care.

The purpose of this article is to address this gap by examining the parallel and complementary work of these women as volunteers through their involvement in the Women’s Field Army (WFA) and as social work professionals caring for those affected by the disease in the United States, tracing their involvement from the birth of the cancer control movement focusing primarily on the 1930s and 1940s. This article begins with a brief description of the historical context of cancer leading up to and including the period of focus. What follows is a description of the American Society for the Control of Cancer (ASCC) and the work of the WFA. While the efforts of the WFA were underway, social workers began to wrestle with how to meet the unique needs of people diagnosed with cancer. A description of these contributions are then explicated. The efforts of the women of the WFA and the professional social workers set the stage for cancer control and cancer care today and warrant scholarly attention.

Method

This study analyzed primary data from the Social Welfare History Archives of the University of Minnesota including the collections of Savel Zimand, United Way of Minneapolis, Louis W. Hill, Jr., Ollie Randall, and Harriett Bartlett. The collections of Zimand and Hill included numerous primary source documents from the ASCC, the New York Committee on Cancer (NYCC), and the American Cancer Society (ACS) including ASCC Bulletins, minutes of meetings, and other correspondence between the Minnesota Society for Cancer Control and the NYCC and the ASCC during the 1920s through the 1960s. In addition, the Medical Social Service section of the Board of Governors’ Annual Reports were reviewed at the Historical Archives at the Mayo Clinic in Rochester, MN, as well as a historical summary of the work of the social service department at the Mayo Clinic from the 1920s through the 1940s. In addition, a collection of the Wisconsin Division of the Women’s Field Army (WDWFA) Bulletins from this period were examined.

Background

It is helpful to appreciate both the public and the scientific understanding of cancer as a disease that precedes the work of the women in this article. In the early part of the 1900s, cancer was commonly referred to as “one of the greatest of modern scourges” (Mayo, 1918, p. 4). There was a lack of consensus among medical professionals as to the nature and cure of this disease. Although a definitive cause continued to elude the medical establishment, there seemed to be consensus growing as to potential causes of this disease. Some of those dominant theories connected the development of cancer in an individual to diet, age, heredity, gender, injury, and personal behaviors (excessive smoking or alcohol consumption (Hamilton, 1915). There was a growing opinion that cancer occurred more often among those who were affluent and white (Mayo, 1918). One publication referred to cancer as a disease of the “civilized and cultured” (Waldenberger, 1941, p. 1). This was unlike any of the communicable diseases addressed at this time such as tuberculosis or syphilis to which professionals tended to attribute higher incidence rates to those who were disadvantaged in terms of both their financial and social capital. There was also overall consensus that cancer incidence and mortality rates were increasing. Although Hamilton (1915) acknowledged that the increase was due in part to improved diagnostic efforts and an aging population, there seemed to be a sense that it was due to some other and more frightening reason. This fear appeared to stem from the inability of science to determine a definitive cause and thus a cure. While treatment continued to be elusive, there was a growing recognition (though not universally accepted) that those whose cancer was detected early and removed (by surgery) when small and contained had better cure rates (Hamilton, 1915; Mayo, 1918).

American Society For the Control of Cancer

It was against this backdrop that in 1913, a group of prominent doctors in New York City formed the ASCC (Shaughnessy, 1957). The ASCC envisioned its role primarily as that of “middlemen” sifting through the scientific and medical advances in cancer and disseminating those found to be credible to a national audience (Cancer, 1915). This vision revealed the primary motive for the establishment of the ASCC to be a recognition that a uniform approach to cancer was needed if there was to be any headway made against this enemy. Thus, the primary objective of the ASCC was to educate the public about cancer and instill hope in early detection and treatment. Initially, they pursued this goal primarily by writing articles for lay magazines, professional journals (medical and social), and holding lectures at medical conferences and medical schools (Stoddart, 1943b). In addition, they published their own monthly pamphlet, entitled Campaign Notes, summarizing the work of their organization and the latest advances on the cancer front. However, the ASCC needed to increase their national reach and Director Clarence Little decided women needed to lead this charge. At the time, cancer was regularly described as affecting women at greater rates than men (Cancer Army, 1937). “If we can get all the women talking about cancer, we will be in a fair way of controlling this tremendous cause of suffering and death,” stated Little (Cancer Army, 1937, p. 59). Women were considered by Little and his committee to be more sympathetic and have more patience and more time than men.

Women Volunteers

The directors of the ASCC needed an organized nationwide reach and wanted the “most promising group of intelligent adult women in America,” the General Federation of Women’s Clubs (GFWC) (The Women’s Field Army, Its Objectives and Present Status, n.d.). Little contacted Grace Morrison Poole with a request to enlist the support of the GFWC. Poole was the president of GFWC in 1932 and dean of Stoneleigh College in New Hampshire. After “careful consideration,” the GFWC endorsed the work of the ASCC (WDWFA, 1938a). Thus, began what would prove to be a pivotal relationship in the “war” on cancer with women on the front lines. The women hosted physician lectures and held parlor discussions that helped to spread the word about cancer through their network of women’s clubs across the nation (WDWFA, 1938a). These contributions expanded the reach of the ASCC and laid the groundwork for the Society’s foray into the public health domain of the laity—an arena dominated by women. These women were familiar with involvement in public health movements. The early decades of the 20th century found women playing chief roles in public health movements (Skocpol, 1992). Prior to their prominent role in the ASCC, the women of the GFWC had participated in earlier campaigns to address public health issues related to child and maternal health (Ladd-Taylor, 1994) as well as very successful campaigns against communicable diseases such as tuberculosis (Trattner, 1999). By 1929, cancer surpassed tuberculosis in the number of deaths caused annually (Adair, 1937). Thus, their involvement with this campaign was somewhat natural.

On the heels of these successes in the public health arena and buoyed by the support of the GFWC, the ASCC began a more ambitious campaign to spread the message of early detection, and it was decided that women would continue to play the starring role in this campaign. Eventually, Poole and Marjorie Illig, Chairman of Public Health for the GFWC, together with the current director of ASCC, Dr. Clarence Little, created and implemented the WFA (WDWFA, 1938a). The WFA was officially established in 1935 with Illig, a trained radiologist, appointed as the National Commander under the supervision of Little. The members of the GFWC formed the initial “nucleus” of this “great army” (Clausen, 1938).

From its inception, the WFA echoed the maternalist themes of the dominant women’s organizations involved in previous public health movements. Women were considered the guardians of their family’s health and logically, the nation’s as well. The women of the WFA embraced their maternal role:

As women, we are the natural protectors of health in the home and have repeatedly given of our time and strength to promote public health, the American Society for the Control of Cancer turned to the women of the country when they wished to institute a program of public education. (Clausen, 1938, p. 1)

Overall, the role did not challenge social norms of the day while providing the women with what epidemiologist Devra Davis (2007) described as a “unique vehicle for their political and social energies” (p. 115). As long as the women stayed within the boundaries of this role, their work was supported. However, if their actions pushed beyond the proscribed boundaries, the women met with some resistance. Some units of the WFA around the country were offering practical aid to indigent cancer patients. For example, some units offered free cancer screening and provided funds for treatment. Members of various medical societies expressed concern that these women were intruding on their terrain. Not only were doctors concerned about their professional domain, the American Medical Association expressed concern that this movement could lead to socialized medicine (Patterson, 1987). Dr. Little assured these physicians that he would closely supervise the women to ensure that they stayed within their domain of education and not attempt to offer medical advice or care.

In addition to the maternal themes undergirding the efforts of these women, military themes were pervasive in the WFA. The enlistment of women “into a militant organization to attack this deadly enemy” was described as their primary objective (Ten Years of Progress, 1946). Cancer was the defined enemy with fear and ignorance its “close allies” (Clausen, 1938, p. 1). As Clausen (1938) noted the name was chosen as their activities would bring them into “active contact and combat with the enemy” (p. 1). For example, in one article written by Illig (1942), the WFA is described as one of the “greatest defense units in the country—on all fronts, the units of the WFA are fighting heroically to defend the citizens of our great country against cancer.” The military themes were not only present in their written and spoken word but in their dress as well. Women, who could afford to, purchased khaki uniforms that included symbols of their rank or achievements (WDWFA, 1938b).

Beyond bringing their maternal instincts to the ASCC, the women of the WFA were an inexpensive labor force. This may help to explain why the ASCC was able to expand their programming despite a devastating financial climate in the nation that had resulted in the culling of “about one-third of the nation’s private agencies” due to “lack of funds” (Trattner, 1999, p. 259). In fact, the WFA was structured in such a way that it required women to pay an enlistment fee of US$1 for the benefit of volunteering (WDWFA, 1938b). This enlistment fee was reported to be a hardship for some women, demonstrating that membership extended beyond middle- and upper-class women (WDWFA, 1938b). Despite the difficult economic times across the country, women enlisted by the thousands. Consider the state of Wisconsin, for example, by 1938, there were 850 officers and approximately 1,800 enlisted women in this state alone (Illig, 1942). By 1943, nationwide membership in the WFA was reported to have reached 350,000 women (Ten Years of Progress, 1946). The women of the WFA approached this work very seriously and with a sense of urgency. Shaughnessy (1957) described the WFA as being infused with a mysterious “crusading quality” that was extremely efficacious. One member of the WFA summed up this crusading spirit:

Because women bear the pain and the burden of life-giving, they above all other should appreciate the value of life. Let us show that America battles for life not death. What higher mission could women ask than to participate in a war against ignorance and disease? What greater patriotic service need she seek?…It is our duty to join with the Field Army in its health crusade. (WDWFA, 1939, p. 4)

The members of the WFA recognized the value of early detection to save lives and embraced their role to teach women how to protect themselves from this “sinister menace.” The pamphlets they distributed contained information about the early signs of cancer including a sore that refused to heal, a lump that formed on a breast, or irregular bleeding from the uterus. These pamphlets also described what women could do to prevent cancer; recommended regular physical exams, and for women over 35, a semiannual breast and pelvic exam (The WFA, n.d.). The women had a very persuasive commander by Illig. As a radiologist, Illig had regularly witnessed that cervical abnormalities could be detected by regular physical exams prior to turning into cancer (Davis, 2007).

Beyond persuading women of the benefits of early detection, the women of the WFA were encouraged to fight this battle in the political arena. In these early decades of the 20th century, the U.S. federal government paid little or no attention to cancer. Cancer was not an infectious disease and federal policy was not inclined to fund the eradication of a disease that was not contagious (Gardner, 2006). Although historian James Patterson (1987) suggested there was no evidence that the WFA was involved in coordinated political advocacy for federal involvement, WFA historical documents suggest otherwise. In this crusade against cancer, the women were encouraged to advocate for increased attention to the control of the disease primarily through letter writing initiatives to both state and national officials. The lobbying efforts of these women were described at the time as vital to the establishment of the National Cancer Institute (NCI). Surgeon General Parran remarked that “the activities of the Women’s Field Army of the American Society for Cancer Control and the General Federation of Women’s Clubs have been influential in securing the Federal appropriation” (Ten Years of Progress, 1946, p. 6-7). The creation of the NCI was a result of unanimous support from members of the U.S. Senate (Harden, n.d.). In writing of this accomplishment in the WDWFA Bulletin, the women recognized the significance of the achievement. “Never in the history of the Republic had the entire membership of either body of congress sponsored a piece of legislation!” (WDWFA, 1943, p. 7).

The women of the WFA also successfully lobbied members of Congress as well as President Roosevelt to designate April as “Cancer Control Month.” This was a piece of legislation introduced in 1937 by one of their own members, Mrs. Edith Rogers, a representative from Massachusetts (Ten Years of Progress, 1946). Although strides were being made on this front as exemplified above, there was a lack of real funding for the cancer control movement from the federal government. In an article entitled “Democracy and Health,” Stoddart (1940) addressed the lack of attention to cancer by the federal government:

To the cancer patient, government says, in effect: You are welcome to keep your cancer if you like. You cannot give it to anyone else anyhow, and you are a menace to nobody except yourself. I am interested only in recording your death for statistical purposes. (p. 1)

This sense of frustration appeared to grow with the U.S. involvement in World War II. In the Bulletins and fund-raising letters, references were made to the fact that more American lives were lost because of cancer then were lost as a result of war. Frustration with the federal government’s spending priorities was frequently expressed: “Certainly, we in this country can well afford to spend more money on the discovery of the causes and cure of cancer than should be spent to develop death dealing instruments such as the atomic bomb” (Johnston, 1946). As the country shifted its attention to the U.S. involvement in World War II, the women recognized this might have a harmful effect on their fight. They decided it was even more vital to focus their work (The Women’s Field Army, Its Objectives and Present Status, n.d.). Unfortunately, there were other pressures influencing their longevity.

By the close of World War II, there was a campaign within the ASCC to shift its emphasis away from educating the lay public about early detection to advocating for increased financial support for research that focused on a cure. Driving this shift to prioritize research was a genuine sense that a cure was just around the corner. The pervading notion at this time was that the true obstacle to a cure was adequate funding for cancer research. This perception was based on earlier scientific success with research on such causes as atomic energy. Thus, if the nation committed a similar level resources to cancer research, the cure would quickly be found (On the Brink of Hope, 1949). This change to a primary focus on research was also fueled by the entry of wealthy socialite Mary Lasker. Lasker was the wife of advertising executive Albert Lasker who made much of his fortune marketing cigarettes. Frustrated by the lack of attention to research, Mary Lasker challenged the value of the WFA and the doctors who made up the leadership of the ASCC. She, together with her husband, successfully pushed for a change in ASCC leadership from physicians to laypersons. In this case, the laypersons were all men and all wealthy “titans of industry” with close ties to marketing, pharmaceutical, and insurance businesses, among others (Davis, 2007; Patterson, 1987).

This infusion of wealth and power led to a redefinition of the mission to focus on raising funds for research (Garner, 2006). Part of this reorganization included branding changes. The ASCC was renamed the American Cancer Society (ACS) and the WFA was renamed the Field Army. Little reported that the reason for the name change of the WFA was a “recognition of the fact that men as well as women are vitally concerned in the work” of cancer control (Stoddart, 1944, p. 9). However, when reporting the name change in the WDWFA Bulletin, the State Commander described this new initiative differently. She stated a new “objective has been presented to us this year—that of financing research” and that to meet this objective:

a men’s division of the ACS has been formed, headed by Mr. Eric Johnston, President of the US Chamber of Commerce. Many eminent men are now associated with him throughout the country and that group will soon be enlarged by the addition of prominent men in each state. (p. 4)

This expression reflected the gendered norms of the time with women ensconced in the arena of public health education and men dominating the scientific and business domains. Moreover, it was a reflection of how deeply rooted these gendered roles were in society and how these roles were valued. This new committee described the women of the WFA as “do-good amateurs” (Patterson, 1987, p. 174) and at their national convention in 1946 voted to discontinue the WFA (Davis, 2007). By 1951, the office of the national commander was officially dismantled. However, a new position was created in its place, a corporate vice presidency, and it was mandated that this position be held only by a woman (On the Brink of Hope, 1949). The trajectory of the experience of the women of the WFA mirrored the women involved in earlier public health movements. The women organized and informed the public, bringing the cause onto the national stage yet were excluded from official positions of leadership and as a result the major decision-making as well.

Social Work Professionals and Cancer Care

While the members of the WFA volunteered their time and expertise to spreading the word about early detection, professional social workers were striving to understand the unique skills needed to care for those diagnosed with cancer. There is a dramatic gap in the literature outlining what part social workers played in the growing cancer movement in the United States at this time. Furthermore, there are no identifiable social work journal articles or other scholarly writings prior to the 1970s that discuss social workers’ involvement with these early efforts. Yet it is clear that they were active on the front lines of cancer care. For example, there is reference to the efforts of social workers researching cancer trends as early as the 1920s at Pondville State Hospital (Pondville State Hospital, 1927) in Massachusetts. There are also references to social workers' public education efforts with the ASCC and the WFA. In one prominent publication of the ASCC from 1936, social workers were recognized as “significant actors in cancer awareness” campaigns conducted at this time (Gardner, 2006). As one example of this connection, the president of the Conference on Social Work was a captain in the WFA in Wisconsin (WDWFA, 1943). Another reference describes how social workers participated in a continuation study course in cancer education along with the Field Army leaders. The purpose of this program was to discuss the “story of cancer” and how to tell that story to more people (Stoddart, 1943a). In addition, social workers were part of symposiums held by the New York City Cancer Committee (NYCCC) of the ASCC to educate social workers about cancer and the benefits of early detection (Report on NYCCC Lecture and Film Series, 1948).

We know that social workers were actively engaged on the front lines of caring for those living with cancer. In the section on hospital social work in the Social Work Yearbook of 1929, mention is made of the “significant contributions” of hospital social workers in the departments of social service in cancer institutions (Estabrook, 1929). What follows on these next pages, then, is a description of the work of two prominent social workers, Harriett Bartlett and Ollie Randall, at the height of the first nationwide cancer campaign in the United States. Medical social workers practicing on the East Coast between the late 1930s to the early 1940s, they were also leaders and pioneers in medical social work. Randall was the president of the New York State Conference of Social work and Bartlett has been described as a role model to today’s oncology social workers (Fobair et al., 2009). Primary source material found in the archival collections of Bartlett and Randal demonstrates these social workers recognized that caring for people living with cancer was different and required an approach that was distinct from general medical social work. During this period, a shift was occurring within the medical establishment regarding the understanding of the relationship between psychological and biological aspects of illness. In a paper delivered at the University of Minnesota Center for Continuing Study in February 1939, Bartlett discussed the growing recognition of the intersection of “psychic” and “organic” aspects of illness that had occurred in recent years (Bartlett, 1939). She referred to the appearance of a new journal, Psychosomatic Medicine, as evidence that these two concepts had not only become integrated but that this hybrid perspective was valued enough to inspire the creation of a professional journal.

Both Bartlett and Randall in many ways mirrored the women who initiated the efforts of the WFA in that they were educated, white women of upper-class socioeconomic status. Like the early work of the women volunteers of the WFA, social work with cancer patients began on the East Coast but rapidly expanded across the country especially as cancer clinics and hospitals were developed. Social work with cancer patients ranged from acting as friendly visitors to more detailed casework (Annual Report, 1931). This casework focused primarily on securing financial assistance and providing what we now refer to as psychosocial support. While the cases contained in the collections offer illustrations of the financial burden associated with a cancer diagnosis, this was not always the case. Cancer was a disease that crossed income boundaries not as frequently penetrated by other diseases prevalent in the early decades of the 20th century. As a result, the psychosocial component of this casework was equally if not more prominent in this work.

It is helpful to have an understanding of the expectations of medical social workers in general during this time. At a meeting of the American Association of Medical Social Workers in Atlantic City, NJ, in 1941, Cohen (1936–1941) presented a paper in which she described the role of the medical social worker as such:

The function of medical social work is to help sick people with problems arising from their illness or medical care. It’s most characteristic feature is individualization of the patient, his particular needs, and his reactions to his illness, treatment, and his interpersonal relationships. (p. 13)

She continued to describe the challenges associated with working effectively with different professionals in a hospital setting. The hospital social worker had “the problem of interpretation of this patient’s need and of attempting to influence either directly or indirectly the activities of the physician, administration, and others” (p. 13).

It is evident in the documents included in these collections that the above descriptions of both the expectations and the challenges accurately depict the work of these women with cancer patients. At a time when medical social work had established itself, information about the full role of the social worker in cancer care was not yet developed. This makes sense, given the relatively recent entry of the cancer problem onto the national stage. The minutes from several meetings about cancer work with the elderly during a Conference for Old Age Problems in Long Island, NY, highlighted how social work with patients living with cancer was unique and required a professional and informed approach (Randall, 1943). Over the course of 3 years, under the tutelage of Dr. Morton Levin of New York State Department of Health, the social workers participating in these conferences attempted to define the role of the social worker in cancer care. Initially, these meetings appeared designed to inform the social worker about the basic characteristics of the disease, the resulting needs of the patients and their families, and ways that the social worker could support these clients.

The discussion about the needs of the cancer patients and their families illustrates difficulties that would fall under the category of survivorship issues today such as depression, pain, caregiver strain, and loss. There was a sense of compassion that permeated the minutes of these meetings. Depression was described as a common psychological effect of adjusting to the disease. Levin discussed the intense pain that is often associated with the progression of the disease and the limited methods available for controlling this pain. He also considered the impact on the family stating that the “family is severely taxed by taking care of” the patient (Randall, 1943, p. 2). Discussions were had about the need to support both the caregiver and the patient. Levin described certain side effects as an additional source of distress. For example, he described the difficulty some women have in adjusting to the removal of a breast and stated, “She may need assurance that men’s emotions are not affected by the loss of her breast” (p. 5).

After the first meeting, the emphasis shifted from one of gaining information about cancer to one of developing an understanding of what a social worker’s role was in caring for this specific population. At the second meeting, Levin began his discussion by updating the women on the latest medical understanding of cancer: causes, treatment, and the effects of the war on cancer. Then, he moved quickly into the role of the social worker. Throughout the training, these women combined the use of case examples and the opinions of medical experts and began to weave together a professional approach to working with cancer patients and their families. Levin described the primary roles of the social worker as an advocate, a powerline, and an authority.

Social Worker as an Advocate

The role of advocate was not new to social workers at this time. It was the extent to which they were to advocate for their clients who appeared somewhat unfamiliar. One of the more traditional definitions of advocating for cancer patients and their families was securing financial assistance for treatment. One case example from the Mayo Clinic in Rochester, MN, illustrates a typical way that social workers advocated for clients to receive funding for care. A fund had been established at Mayo to aid “self-supporting women” who were unable to cover hospital expenses (Annual Report, 1931). In this case, social workers successfully advocated for one woman to receive US$56.00 to cover the cost of her surgery for removal of a malignant tumor (Annual Report, 1931). Beyond advocating for financial support, the definition of advocacy included the social worker’s responsibility to act as a “stimulus” for the patient. In other words, the social worker was to stimulate the client to seek competent preventative care and treatment. Social workers were uniquely situated to take on this responsibility as they were in a “rare position” of intimacy with patients. They have the confidences of the patient and can be of

the greatest assistance in noting early lesions, in correctly interpreting symptoms, and insisting that the patient see a doctor. In fact, the nurse and the social worker must even go a step further, and go along with the patient to the doctor if the patient be so frightened that it is a question of her arriving at the doctor’s office. (Adair, 1937, p. 4)

Furthermore, they were to advocate for the client if the doctor showed no interest in providing an exam to screen for cancer. It was suggested that the social workers advocate for specific types of exams if doctors do not perform them, such as pelvic exams for women (Randal, 1943). This seemed to imply that not all doctors were on board with their role in cancer screening at this time. Therefore, it was the social worker’s responsibility to advocate for their clients by influencing the doctor in a way that went beyond current forms of general medical social work practice.

Social Worker as a Powerline

The second theme that emerged from the conference was the vision of the social worker as what was termed a “powerline” connecting the doctor, the patient, and the patient’s family (Randall, 1943). In this role, she was encouraged to act as the instrument that transmitted information the doctor wanted shared with the patient and the patient’s family regarding diagnosis, treatment, and prognosis. The maternalist beliefs, which so strongly permeated the work of the women of the WFA, were echoed in this interpretation of the social worker’s role. Levin stated that social workers were uniquely situated to be successful in their role as a “powerline” since they were more “psychologically attuned” to the patient than doctors, and therefore they should be responsible for interpreting medical findings of cancer to the patient (Randall, 1943). Despite this attunement to the patient, it was the doctor’s decision whether to reveal a cancer diagnosis to a patient or his family members. Dr. Rusk of New York University College of Medicine attempted to illustrate this perspective. He declared that by not revealing the prognosis, the patient avoided developing “anxiety neuroses” and that “keeping patients in doubt often saves them from total desolation” (ACS Campaign Bulletin, 1948, p. 5). Levin also advocated concealing from the patient the seriousness of their diagnosis, particularly in cases where “death and suffering are inevitable” (Randall, 1943, p. 4). This assumption that patients could not handle the truth of their cancer prognosis reflected a position commonly held by the medical establishment during this period.

As a powerline between the doctors, patients, and families, social workers were responsible to ensure that patients adhere to the physician’s instructions as to course of treatment and follow-up care. Apparently, there was a tendency for patients to not follow-up with their physicians after initial diagnosis at a rate of up to 50% (Randall, 1943) although there is no accurate way of verifying this percentage. There was no discussion noted in the data from these meetings about how a doctor's decision to conceal the true nature of the disease might have influenced the patient’s adherence to medical advice for care. From the perspective of the physicians leading this training, a patient’s failure to follow up on treatment recommendations was in part due to the social worker’s inability to convince the patient to pursue care as directed by the doctors.

Social Worker as an Authority

It was apparent from the minutes of these meetings between Levin and the medical social workers that casework was primarily initiated as a result of a patient experiencing difficulty over a particular step required in their medical care. It was as if a roadblock had risen up preventing them from moving forward with crucial decisions about their care. These roadblocks appeared to surface at a variety of intersections along their path to recovery from the point of diagnosis to end of life decisions. The primary obstacles impeding patient progress that emerged from these data included difficulty deciding whom to tell about their diagnosis and difficulty making decisions about treatment. It was considered the social worker’s role as an authority figure to assist the patient in overcoming these obstacles.

The summaries included in the Bartlett and Randall collections revealed a tension surrounding the role of the social worker as an authority. This tension seemed to arise primarily because of the differences between the way a doctor used his or her role as an authority in interactions with a patient and the manner in which a social worker engaged a patient with cancer. It appeared the social workers were somewhat resistant to this authority role as the medical establishment envisioned it. Bartlett stated that the “most important thing which the medical social worker can give may prove to be, not in the area of manipulating and arranging, but a point of view, [her emphasis] a perspective upon the needs of the patient” (Bartlett, 1939, p. 5). She continued, “The social worker wants to help the patient to move along on his problem as much as possible in his own way and on his own initiative.” This approach is “fundamental in the social case work process” and becomes more so when working with patients facing cancer (p. 5). To illustrate, she offered a case example of man who did not want to tell his wife he had cancer for fear she could not handle the news:

Through giving [him] perspective, more perspective…she [social worker] aided him to move toward the decision to tell her [the wife] himself…. In one sense, the social worker was fairly active here, and yet in another sense she really did not control the situation or take it out of his hands. (p. 6)

Bartlett’s statements above illustrated the emphasis in the social work training at that time which was a result of the influence of the “new psychology” being integrated into social casework. This “new psychology” had at its foundation the use of “nonauthoritarian direction” (Chambers, 1963). The use of nonauthoritarian direction in work with cancer patients appeared to require some refinement due to the belief that cancer was an emergent disease and early diagnosis and rapid treatment was the “difference between life and death” (Randall, 1943, p. 4). The use of authority was considered vital in work with cancer patients as there was not time for patients to move toward their decision about treatment at their own pace. The social worker, armed with information, should be clear in her own mind what the patient should do, then transfer that “earnestness and enthusiasm” to the patient (Randall, 1943, p. 6).

The following quote from a social worker participating in the discussion illustrates a willingness to refine the use of authority to meet the unique circumstances inherent in work with cancer patients, “Social workers are trained to not exercise authority but prefer the individual to exercise independence. But the urgency of cancer necessitates some firmness” (Randall, 1943, p. 1). The use of authority was defined by these women as “not dictatorial but as one of sharing our conviction which is based on our knowledge of the ‘facts’ of cancer” (Randall, 1943, p. 3). This knowledge was considered more sophisticated than the patient’s understanding of the disease. As a result, a patient’s compliance with treatment recommendations or follow-up care became the primary responsibility of the social worker. If patients did not understand the seriousness of their diagnosis, it was not the doctor’s fault. The social workers were to use their position of authority to convince the patient of the seriousness of their condition. That social workers were responsible for the patient’s compliance was ironic considering that the physician may decide not to inform the patient of the grave nature of their diagnosis as noted above. In these cases, the social worker was to “hint” at the seriousness of the prognosis if the patient appeared reluctant to proceed with the recommended medical care (Randall, 1943, p. 4). No doubt, this required a great deal of creativity on the part of the social worker in order to be effective in her or his task.

Lasting Legacies

While the women of the WFA engaged in battle with the enemy on the volunteer front, the social workers engaged the enemy on the professional stage. These efforts, both voluntary and professional, helped shape the way we understand cancer control and cancer care today in terms of public education, funding for cancer research, and oncology social work practice. The efforts of the women in the WFA succeeded in moving the topic of cancer from a dark corner in society to center stage not only in private homes but in professional and political conversations as well. While at the time, the women of the WFA celebrated their achievements, scholarly literature has largely ignored these efforts or belittled their work as “mundane” (Patterson, 1987). For example, in his Pulitzer Prize–winning biography of cancer, Mukherjee (2010) included a description of the WFA as a “Ladies’ Garden Club” focused on fund-raising (p. 113). The author relied on the papers of Mary Lasker as the source and not primary WFA documents in his analysis. As noted above, Lasker was a well-connected, wealthy woman who expressed frustration with the slow work of the ASCC and the WFA and viewed the women as amateurs. Yet, Illig was a trained radiologist, Rogers was a member of the U.S. House of Representatives, and Poole was a college dean and a former member of the Massachusetts Department of Health. The head of the Northeast Division of the WFA at the time was a physician. Historical evidence describes the vital role these women played in how we talk about cancer today. Moreover, their public education efforts have been described as a model for how to involve a target audience as messengers (Anderson, 2004).

While the members of the WFA were largely white Christian middle-class women, Jewish women and women of color also participated in the movement. There were Jewish divisions of the WFA in New York. There were divisions of the WFA in Harlem and Kentucky made up of African American women. However, these stories remain largely unexplored. Bringing these voices to light would offer a perspective that would enrich our historical understanding of the cancer experience across race and culture.

Social workers such as Randall and Bartlett contributed to the knowledge base of psychosocial cancer care. The social workers put forth enormous time and energy to begin to understand the unique needs of people living with cancer as they grappled with their role in addressing those needs. The social work skills described in these collections are still relevant today. For example, they recognized the importance of working effectively across professions by understanding their role and communicating with the physicians in order to best serve their patient. Today, interprofessional collaboration is considered a key strategy for optimizing patient care (Nester, 2016). The broader definition of the use of authority challenged the concept of “nonauthoritarian direction” common in social work at the time. Today, social workers recognize the importance of working with clients facing cancer whose prognosis may be impacted by how quickly decisions are made about interventions. If “oncology social work came to full blossom in the 1970’s…” as noted by Fobair and colleagues (2009, p. 156), perhaps the work of Randall, Bartlett, and the other social workers who attended the trainings planted the seeds.

The timing and the focus of these trainings on work with cancer patients described in the Randall and Bartlett collections occurred at the height of the activities of the WFA. This is hardly a coincidence and is likely the result of the overlapping spheres in which these two groups of women operated, spheres boundaried by traditional power structures. Women’s roles were primarily limited to homemaking, volunteering, or professional positions deemed appropriate for their gender such as secretaries, teachers, and social workers (Chafe, 1991). The full contribution of these women has not been written about in the cancer or social welfare literature. It is possible that the near silence in the literature reflects the inability of these women to challenge medical power structures or create an alternative vision of cancer control and care. Both groups of women were under the supervision of men and lacked any real authority for high-level decision-making. There was no evidence discovered that the women of the WFA challenged the decision to prioritize funding for research. Nor was there evidence that the social workers challenged the final authority of the physicians to decide what to disclose to patients about their disease. It was not until the 1970s that the feminist health movement broaden medical discussion to include women’s perceptions with publications such as Our Bodies, Ourselves. The 1970s also brought critique of conventional cancer care by women such as Rose Kushner and Audre Lorde among others (Gardner, 2006).

It is also possible these stories are not fully examined because historically this work was not considered worthy of publication. Davis (2007) contends that much of what we know “about cancer is profoundly economic and political and reflects the views and values” of those in power (p. 431). The cancer control efforts of the WFA did not have the successful conclusion of other public health campaigns. A “cure” for cancer was not discovered. The care provided by social workers was not as exciting as surgery, radiation, or the discovery of a new treatment. Although not glamorous, the vital work of educating the public about cancer and caring for those who face the disease continues. The early efforts by these women provided the groundwork that undergirds our ongoing efforts in cancer control and care today.