THE NURSE AND THE COMMUNITY
The work begun from the top floor of the tenement comprised, in simple
forms, those varied lines of activity which have since been developed
into the many highly specialized branches of public health nursing now
covering the United States and engaging thousands of nurses.[2]
In trying to forestall every obstacle to the establishment of our nursing
service on the East Side, it seemed desirable to have some connection
with civic authority. Through a mutual friend I met the President of the
Board of Health and, I fear rather presumptuously, asked that we be given
some insignia. Desirous of serving his friend and tolerant of my intense
earnestness, he sanctioned our wearing a badge which had engraved on its
circle, “Visiting Nurse. Under the Auspices of the Board of Health.”
As it transpired, we did not find it necessary or always felicitous
to utilize this privilege, but our connection with the Board of Health
was not a perfunctory or merely complimentary one. We found from the
beginning an inclination on the part of the officials of the department
to treat us more or less like comrades. Every night, during the first
summer, I wrote to the physician in charge, reporting the sick babies
and describing the unsanitary conditions Miss Brewster and I found,
and we received many encouraging reminders that what we were doing was
considered helpful.
[Illustration]
In the new activity for the promotion of public health many campaigns
have been waged to popularize the study of social diseases. Education
is the watchword, and where emphasis is laid upon the preservation of
health rather than upon the treatment of disease, the nurses constitute
an important factor. Appreciation of this is recorded by the Commission
which drafted the new health law for New York State (1913). “The advent
of trained nursing,” says its report, “marks not only a new era in the
treatment of the sick, but a new era in public health administration.”
This Commission also created the position of Director of the Division of
Public Health Nursing in the state department of health.
* * * * *
I had been downtown only a short time when I met Louis. An open door in a
rear tenement revealed a woman standing over a washtub, a fretting baby
on her left arm, while with her right she rubbed at the butcher’s aprons
which she washed for a living.
Louis, she explained, was “bad.” He did not “cure his head,” and what
would become of him, for they would not take him into the school because
of it? Louis, hanging the offending head, said he had been to the
dispensary a good many times. He knew it was awful for a twelve-year-old
boy not to know how to read the names of the streets on the lamp-posts,
but “every time I go to school Teacher tells me to go home.”
It needed only intelligent application of the dispensary ointments to
cure the affected area, and in September I had the joy of securing the
boy’s admittance to school for the first time in his life. The next
day, at the noon recess, he fairly rushed up our five flights of stairs
in the Jefferson Street tenement to spell the elementary words he had
acquired that morning.
It had been hard on Louis to be denied the precious years of school,
yet one could sympathize with the harassed school teachers. The classes
were overcrowded; there were frequently as many as sixty pupils in a
single room, and often three children on a seat. It was, perhaps, not
unnatural that the eczema on Louis’s head should have been seized upon
as a legitimate excuse for not adding him to the number. Perhaps it was
not to be expected that the teacher should feel concern for one small
boy whom she might never see again, or should realize that his brief
time for education was slipping away and that he must go to work fatally
handicapped because of his illiteracy.
The predecessor of our present superintendent of schools had apparently
given no thought to the social relationship of the school to the pupils.
The general public, twenty years ago, had no accurate information
concerning the schools, and, indeed, seemed to have little interest
in them. We heard of flagrant instances of political influence in the
selection and promotion of teachers, and later on we had actual knowledge
of their humiliation at being forced to obtain through sordid “pull”
the positions to which they had a legitimate claim. I had myself once
been obliged to enter the saloon of N⸺, the alderman of our district,
to obtain the promise of necessary and long-delayed action on his part
for the city’s acceptance of the gift of a street fountain, which I had
been indirectly instrumental in securing for the neighborhood. I had
been informed by his friends that without this attention he would not be
likely to act.
Louis set me thinking and opened my mind to many things. Miss Brewster
and I decided to keep memoranda of the children we encountered who had
been excluded from school for medical reasons, and later our enlarged
staff of nurses became equally interested in obtaining data regarding
them. When one of the nurses found a small boy attending school while
desquamating from scarlet fever, and, Tom Sawyer-like, pulling off the
skin to startle his little classmates, we exhibited him to the President
of the Department of Health, and I then learned that the possibility of
having physicians inspect the school children was under discussion, and
that such evidence of its need as we could produce would be helpful in
securing an appropriation for this purpose.
I had come to the conclusion that the nurse would be an essential
factor in making effective whatever treatment might be suggested for
the pupils, and, following an observation of mine to this effect, the
president asked me to take part, as nurse, in the medical supervision in
the schools. This offer it did not seem wise to accept. We were embarking
upon ventures of our own which would require all our faculties and all
our strength. It seemed better to be free from connections which would
make demand upon our energies for routine work outside the settlement.
Moreover, the time did not seem ripe for advocating the introduction of
both the doctor and the nurse. The doctor himself, in this capacity,
was an innovation. The appointment of a nurse would have been a radical
departure.
[Illustration]
In 1897 the Department of Health appointed the first doctors; one hundred
and fifty were assigned to the schools for one hour a day at a salary of
$30 a month. They were expected to examine for contagious diseases and
to send out of the classrooms all those who showed suspicious symptoms.
It proved to be a perfunctory service and only superficially touched the
needs of the children.
In 1902, when a reform administration came into power, the medical
staff was reduced and the salary increased to $100 a month, while three
hours a day were demanded from the doctors. The Health Commissioner of
that administration, an intelligent friend of children, now ordered an
examination of all the public school pupils, and New York was horrified
to learn of the prevalence of trachoma. Thousands of children were
sent out of the schools because of this infectious eye trouble, and in
our neighborhood we watched many of them, after school hours, playing
with the children for whose protection they had been excluded from
the classrooms. Few received treatment, and it followed that truancy
was encouraged, and, where medical inspection was most thorough, the
classrooms were depleted.
The President of the Department of Education and the Health Commissioner
sought for guidance in this predicament. Examination by physicians
with the object of excluding children from the classrooms had proved a
doubtful blessing. The time had come when it seemed right to urge the
addition of the nurse’s service to that of the doctor. My colleagues
and I offered to show that with her assistance few children would lose
their valuable school time and that it would be possible to bring under
treatment those who needed it. Reluctant lest the democracy of the
school should be invaded by even the most socially minded philanthropy,
I exacted a promise from several of the city officials that if the
experiment were successful they would use their influence to have the
nurse, like the doctor, paid from public funds.
Four schools from which there had been the greatest number of exclusions
for medical causes were selected, and an experienced nurse, who possessed
tact and initiative, was chosen from the settlement staff to make the
demonstration. A routine was devised, and the examining physician sent
daily to the nurse all the pupils who were found to be in need of
attention, using a code of symbols in order that the children might be
spared the chagrin of having diseases due to uncleanliness advertised to
their associates.
With the equipment of the settlement bag and, in some of the schools,
with no more than the ledge of a window or the corner of a room for the
nurse’s office, the present system of thorough medical inspection in
the schools and of home visiting was inaugurated. Many of the children
needed only disinfectant treatment of the eyes, collodion applied to
ringworm, or instruction as to cleanliness, and such were returned at
once to the class with a minimum loss of precious school time. Where more
serious conditions existed the nurse called at the home, explained to the
mother what the doctor advised, and, where there was a family physician,
urged that the child should be taken to him. In the families of the poor
information as to dispensaries was given, and where the mother was at
work, and there was no one free to take the child to the dispensary, the
nurse herself did this. Where children were sent to the nurse because
of uncleanliness, the mother was given tactful instruction and, when
necessary, a practical demonstration on the child himself.
[Illustration: A SHORT CUT OVER THE ROOFS OF THE TENEMENTS]
One month’s trial proved that, with the exception of the very small
proportion of major contagious and infectious diseases, the addition
of the nurse to the staff made it possible to reverse the object of
medical inspection from excluding the children from school to keeping the
children in the classroom and under treatment. An enlightened Board of
Estimate and Apportionment voted $30,000 for the employment of trained
nurses, the first municipalized school nurses in the world, now a feature
of medical school supervision in many communities in this country and in
Europe.
The first nurse was placed on the city payroll in October, 1902, and
this marked the beginning of an extraordinary development of the public
control of the physical condition of children. Out of this innovation New
York City’s Bureau of Child Hygiene has grown.
The Department of Health now employs 650 nurses for its hospital and
preventive work. Of this number 374, in the year 1914, were engaged for
the Bureau of Child Hygiene.
Poor Louis, who all unconsciously had started the train of incidents that
led to this practical reform, has long since moved from his Hester Street
home to Kansas, and was able to write us, as he did with enthusiasm, of
his identification with the West.
* * * * *
Our first expenditures were for “sputum cups and disinfectants for
tuberculosis patients.” The textbooks had said that Jews were practically
immune from this disease, and here we found ourselves in a dense colony
of the race with signs everywhere of the white plague, which we soon
thought it fitting to name “tailors’ disease.”
Long before the great work was started by the municipality to combat its
ravages through education and home visitation, we organized for ourselves
a system of care and instruction for patients and their families, and
wrote to the institutions that were known to care for tuberculosis cases
for the addresses of discharged patients, that we might call upon them to
leave the cups and disinfectants and instruct the families.
Since 1904 the anti-tuberculosis movement has been greatly accelerated,
and although it is pre-eminently a disease of poverty and can never
be successfully combated without dealing with its underlying economic
causes—bad housing, bad workshops, undernourishment, and so on—the most
immediate attack lies in education in personal hygiene. For this the
approach to the families through the nurse and her ability to apply
scientific truth to the problems of human living have been found to be
invaluable.[3]
Infant mortality is also a social disease—“poverty and ignorance, the
twin roots from which this evil springs.” There is a large measure of
preventable ignorance, and in the efforts for the reduction of infant
mortality the intelligent reaction of the tenement-house mother has been
remarkably evidenced. In the last analysis babies of the poor are kept
alive through the intelligence of the mothers. Pasteurized or modified
milk in immaculate containers is of limited value if exposed to pollution
in the home, or if it is fed improperly and at irregular periods.
[Illustration]
The need of giving the mother training seemed so evident that, in the
course of lessons given on the East Side antedating our nursing service,
I had demonstrated with a primitive sterilizer a simple method of
insuring “safe” milk for babies.
The settlement established a milk station in 1903, when one of its
directors began sending milk of high grade from his private dairy.
Following our principle of building up the homes wherever possible, the
modification of the milk has always been taught there. The nurses report
that it is very rare to find a woman who cannot learn the lesson when
made to understand its importance to her children.
[Illustration]
Children under two years who show the greatest need are given the
preference in admission to our clinic. Excellent physicians practicing
in the neighborhood have contributed their services as consultants, and
conferences are held regularly. In 1914 the number of infants cared for
was 518 and the mortality 1.8 per cent. The previous year, with 400
infants, the mortality was one-half of one per cent.
The Health Commissioner of Rochester, N. Y., a pioneer in his specialty,
founded municipal milk stations for that city in 1897. He states that
the reduction of infant mortality that followed the establishment of the
stations was due, not so much to the milk, but to the education that went
out with the milk through the nurse and in the press.
In 1911 New York City authorized the municipalization of fifteen milk
stations, and so satisfactory was the result that the next year the
appropriation permitted more than the trebling of this number. A nurse
is attached to each station to follow into the homes and there lay the
foundation, through education, for hygienic living. A marked reduction in
infant mortality has been brought about and, moreover, a realization, on
the part of the city, of the immeasurable social and economic value of
keeping the babies alive.
The Federal Children’s Bureau in its first report on the study of infant
mortality in the United States showed that, in the city selected for
investigation, the infant death rate, in those sections where conditions
were worst, was more than five times that in the choice residential
sections.
This report constitutes a serious indictment of society, and should goad
civic and social conscience to aggressive action. But there are evidences
(and, indeed, the existence of the Bureau is one) that the public is
beginning to realize the profound importance in our national life of
saving the children that are born.
* * * * *
Perhaps nothing indicates more impressively our contempt for alien
customs than the general attitude taken toward the midwife. In other
lands she holds a place of respect, but in this country there seems to
be a general determination on the part of physicians and departments of
health to ignore her existence and leave her free to practice without
fit preparation, despite the fact that her services are extensively used
in humble homes. In New York City the midwife brings into the world over
forty per cent. of all the babies born there, and ninety-eight per cent.
of those among the Italians.
We had many experiences with them, beginning with poor Ida, the
carpenter’s wife, and some that had the salt of humor. Before our first
year had passed I wrote to the superintendent of a large relief society
operating in our neighborhood, advising that the society discontinue its
employment of midwives as a branch of relief, because of their entire
lack of standards and their exemption from restraining influence.
To force attention to the harmful effect of leaving the midwife without
training in midwifery and asepsis free to attend women in childbirth, the
Union Settlement in 1905 financed an investigation under the auspices of
a committee of which I was chairman.
A trained nurse was selected to inquire into and report upon the
practice of the midwives. The inquiry disclosed the extent to which
habit, tradition, and economic necessity made the midwife practically
indispensable, and gave ample proof of the neglect, ignorance, and
criminality that prevailed; logical consequences of the policy that
had been pursued. The Commissioner of Health and eminent obstetricians
now co-operated to improve matters, and legislation was secured making
it mandatory for the Department of Health to regulate the practice of
midwifery. Five years later the first school for midwives in America was
established in connection with Bellevue Hospital.
[Illustration]
Part of the duty assigned to nurses of the Bureau of Child Hygiene is
to inspect the bags of the midwives licensed to practice, and to visit
the new-born in the campaign to wipe out _ophthalmia neonatorum_, that
tragically frequent and preventable cause of blindness among the new-born.
These are a few of the manifestations of the new era in the development
of the nurse’s work. She is enlisted in the crusade against disease and
for the promotion of right living, beginning even before life itself is
brought forth, through infancy into school life, on through adolescence,
with its appeal to repair the omissions of the past. Her duties take
her into factory and workshop, and she has identified herself with the
movement against the premature employment of children, and for the
protection of men and women who work that they may not risk health and
life itself while earning their living. The nurse is being socialized,
made part of a community plan for the communal health. Her contribution
to human welfare, unified and harmonized with those powers which aim at
care and prevention, rather than at police power and punishment, forms
part of the great policy of bringing human beings to a higher level.
With the incorporation of the nurse’s service in municipal and state
departments for the preservation of health, other agencies, under
private and semi-public auspices, have expanded their functions to the
sick.
I had felt that the American Red Cross Society held a unique position
among its sister societies of other nations, and that in time it might
be an agency that could consciously provide valuable “moral equivalents
for war.” The whole subject, in these troubled times, is revived in
my memory, and I find that in 1908 I began to urge that in a country
dedicated to peace it would be fitting for the American Red Cross to
consecrate its efforts to the upbuilding of life and the prevention of
disaster, rather than to emphasize its identification with the ravages of
war.
The concrete recommendation made was that the Red Cross should develop
a system of visiting nursing in the vast, neglected country areas. The
suggestion has been adopted and an excellent beginning made with a
Department of Town and Country Nursing directed by a special committee.
A generous gift started an endowment for its administration. Many
communities not in the registered area and remote from the centers of
active social propaganda will be given stimulus to organize for nursing
service, and from this other medical and social measures will inevitably
grow. It requires no far reach of the imagination to visualize the
time when our country will be districted from the northernmost to the
southernmost point, with the trained graduate nurse entering the home
wherever there is illness, caring for the patient, preaching the gospel
of health, and teaching in simplest form the essentials of hygiene. Such
an organization of national scope, its powers directed toward raising
the standard in the homes without sacrifice of independence, is bound to
promote the social progress of the nation.
* * * * *
In the year 1909 the Metropolitan Life Insurance Company undertook
the nursing of its industrial policyholders—an important event in the
annals of visiting nursing. I had suggested the practicality of this
to one of the officials of the company, a man of broad experience, and
he, immediately responsive, provided opportunity for me to present to
his colleagues evidence of the reduction of mortality, the hastening of
convalescence, and the ability to bring to sick people the resources that
the community provides for treatment through the institution of visiting
nursing.
The company employed our staff to care for its patients, and the
experiment has been extended until a nursing service practically covers
its industrial policyholders in Canada and the United States. The company
thereby gave an enormous impetus to education and hygiene in the homes
and treatment of the sick on the only basis that makes it possible for
persons of small means to receive nursing without charity—namely, through
insurance.
The demand for the public health nurse coming from all sides was so great
that for a time it could not be adequately met. Women of initiative
and personality with broad education were needed, for much of the work
required pioneering zeal. Instructive inspection, on the nurse’s part,
like other educational work, requires suitable and sound preparation, a
superstructure of efficiency upon woman’s natural aptitudes.
[Illustration]
The Henry Street Settlement and other groups with well-established
visiting nursing systems responded to the need by offering opportunities
for post-graduate training and experience in the newly opened field of
public health nursing, and sought co-ordination with formal educational
institutions for instruction in social theories and pedagogy. In 1910
the Department of Nursing and Health was created at Teachers College,
Columbia University, embracing in its completed form the Department
of Hospital Economics established there in 1899 by the efforts of
training-school superintendents. This department is in affiliation with
the settlement. At least four important training-schools for nurses are
now working under the direction of universities, and other provision has
been made to give education supplementary to the hospital training.
Nurses themselves have taken the initiative in securing the means for
equipping women in their profession to meet the new requirements. They
are providing helpful literature and finding stimulating associations
with others enlisted in similar efforts for human welfare. I had the
honor to be elected first president of the National Organization for
Public Health Nursing. At the conference held in 1913 (less than a year
after the formation of the society) an assemblage of women gathered from
all parts of the country to seek guidance and inspiration for this work,
and something that was very like religious fervor characterized their
meetings.
The need of consecration to the sick and the young that has touched
generation after generation with new impulse was manifested in their
eagerness to serve the community. From the root of the old gospel another
branch has grown, a realization that the call to the nurse is not
only for the bedside care of the sick, but to help in seeking out the
deep-lying basic causes of illness and misery, that in the future there
may be less sickness to nurse and to cure.
A pleasant indication that the academic world reached out its fellowship
to the nurses in their zeal for public service was given some months
later when Mt. Holyoke College, at the commemoration of its seventy-fifth
anniversary, honored me by conferring on me the LL.D. degree.