CHAPTER XIX_The Tuberculosis Nurse: Her Function and Her Qualifications A Handbook for Practical Workers in the Tuberculosis Campaign

Municipal Control—The Danger of “Political” Control—“Politics” in the

Co-operating Divisions—Results in Baltimore—Tuberculosis and

Poverty.

=Municipal Control.= Tuberculosis is a communicable disease in which the

patient himself must be relied upon to protect the community. We depend

upon him for whatever protection he chooses to give, and whether this is

much or little is determined by his circumstances, temperament, and

environment. Whenever his ability or good-will breaks down, we are at

his mercy. We may try to overcome his ignorance by education; to

substitute ethical for unethical standards, and in a more or less

unsatisfactory way to reconstruct his immediate surroundings. But the

success of these efforts depends, in the last analysis, upon the patient

himself. The public is exposed to a communicable disease, the control of

which lies with the transmitter.

For this reason, a disease which may be contracted by a neighbour

becomes as much his affair as it is that of the patient or possessor.

Should the interests of the two conflict, it is obvious that we must

have some impartial arbiter to decide between them. At such a point—the

right of one person to transmit, of another to acquire an infectious

disease—the matter becomes one of public as well as private concern. The

arbiter between these two interests should be the Health Department of a

community, and the control of all infectious diseases should be placed

completely under the municipality.

In the first chapters of this book, we considered the special nurse as

supported by a group of private individuals, in connection with some

privately maintained association. Social experiments frequently begin in

this way; when their value is proved, it should be the aim of the

promoters to transfer this special work to the department of the

municipality in which it belongs. Upon looking over the various

municipal departments, we realize that much of what is now freely

recognized to be municipal work, was originally carried on through

private enterprise and initiative. This is the case with school nursing,

playground work, juvenile court and probation work; which in many cities

has passed through the stage of private enterprise and become firmly

incorporated into the city machinery. In all public health nursing, the

aim of the founders should be, first to prove its worth to the

community, and then make the community (municipality) assume full charge

of it as soon as possible. It is particularly necessary to transfer

tuberculosis work from private to municipal control.

=The Danger of “Political” Control.= The question of doing this,

however, is often a matter of great concern to the founders. They are

usually deeply interested in the work, and have maintained it upon a

basis of efficiency, in spite of many obstacles. They fear, and often

rightly, that to transfer it to the municipality will be to transfer it

from the basis of efficiency in its own line, to the basis of politics,

and they dread that sinister condition known as “political control.” And

yet the administration of public affairs is not necessarily “political”

in the bad sense of the term. On the contrary, municipal control may,

and in many cities does mean, that work is conducted with the force,

authority, and financial backing of a great department, such as the

Health Department. Under such conditions, it can attain a far greater

degree of efficiency than could ever have been reached through private

administration. Under municipal control, it is possible to have a large

staff of nurses and pay them good salaries—which latter always means a

wide choice of applicants. It is also possible to establish many and

well equipped dispensaries, in charge of salaried, qualified physicians.

Money will be forthcoming for all necessary expenses connected with the

development and extension of the work—in short, the financial handicap

will be removed, and the work can go forward with increased facilities,

enlarged opportunities, and heightened dignity and authority.

On the other hand, if the administration of the Health Department is “in

politics,” the reverse of this will take place. Unfortunately, in many

American cities, the business of “politics” is the business of providing

people with jobs at the taxpayers’ expense, regardless of the fitness of

the applicant. Many of our cities are managed in this way. Moreover, in

the same city, this corruptness may affect certain departments only,

some being negligently and dishonestly conducted, others cleanly and

efficiently. Or we may find both conditions existing in a single

department, some of whose branches or divisions may be well conducted

and on a high level, while other divisions may be grossly mismanaged and

worthless. If a Health Department is hampered by politics, either as a

whole or in certain mismanaged branches or divisions, it is useless to

expect results. Placed under such a handicap, tuberculosis work would

fail. Not only would the taxpayers’ money be wasted, but the community

would suffer through a false sense of security, gained through its faith

in, or rather its ignorance concerning, a badly conducted department. To

trifle with the health of a community is a criminal act, and a Health

Department which is “in politics” is the most immoral of all corrupt

city departments.

Evil results of a Health Department being “in politics” may be of

several sorts. For example: the Superintendent of Nurses may be an

inexperienced, incapable woman, appointed by a ward politician to clear

off political debts. A ward politician is hardly one whose judgment—in

nursing matters at least—should be relied upon.

On the other hand, the Superintendent herself may be capable and

efficient, but she may not be permitted to select the members of her

staff. Instead of being able to choose them herself, according to their

fitness and ability, she must accept any unqualified woman whom the ward

boss may appoint. A staff of incompetent nurses, appointed without

regard to character or education, is not a force from which to expect

results. Moreover, nurses chosen in this manner feel that they are

“protected” and can do as they like, subject to neither restraint nor

discipline. This means that their work cannot be controlled, corrected,

or directed in any way. Dismissal can be made only for the most flagrant

offences—not for any such trifle as incompetence, laziness, or

stupidity. When the Superintendent’s hands are thus tied—when she cannot

select her nurses, cannot control them, and cannot dismiss the worthless

as well as the unscrupulous, the result is a low grade of work. No able

and self-respecting woman could hold the position of superintendent

under such circumstances, thereby making herself responsible for work

which she cannot control.

The acceptance of registered nurses only, and the requirement of Civil

Service Examination in addition, would do much to raise the level of

efficiency. These requirements, however, valuable as they are, would by

no means ensure the suitability of the applicant, or guarantee the

selection of nurses best adapted to public health work. Over and above

this, the Superintendent should have free choice in selecting her

workers, not only from the point of view of education, but also that of

personal worth.

=“Politics” in the Co-operating Divisions.= Sometimes the Tuberculosis

Division itself may not be on a political basis, but the various other

divisions of the Health Department may be conducted in such a manner as

to nullify much of the nurses’ work. For example: much depends upon the

co-operation of the Fumigation Division. If the men employed to fumigate

houses do their work badly or improperly—if they are too lazy to stop

chinks and crevices, thus permitting the disinfectant to leak out; if

too ignorant to properly measure the rooms, and unable to calculate the

necessary amount of formaldehyde, this work will be valueless. Worse

still if they are the kind that can be “bought off” and so shirk work

entirely.

Or the trouble may be with the Sterilization Division, where the duty of

the employees is to carry mattresses, etc., from the patient’s home to

the city sterilizer. When there is no law compelling this sterilization,

and it is an optional matter with the householder, if done, its doing is

altogether the result of the nurse’s teaching and advice. If the waggon

drivers are lazy and do not wish to carry the heavy mattresses, they can

shirk work by means of false excuses often difficult to detect. For

example: they can report that when a certain mattress was called for,

the family had changed their minds about having it sterilized and

refused to have it done. Upon investigation, we find that this refusal

was at the instigation of the waggon driver himself—he had assured the

family that sterilization was an unnecessary and stupid proceeding. To

ignorant minds, one Health Department employee is as good as another,

and when the advice is conflicting, they choose that which best pleases

them.

Again, the fumigators or drivers may report that they cannot get into a

certain house; the key could not be found; there was no one to admit

them, or give them the articles to be removed. In innumerable ways they

may compel the nurse to return again and again to the same house, to

make arrangements which they try to frustrate by every conceivable

device.

If, therefore, the employees of the various co-operating divisions are

mere jobholders—if they are neither honest nor intelligent, nor

interested in anything but pay-day—it is a heartbreaking task for the

honest and efficient division to work with them. All of these activities

interlock, and must work together to gain a common goal. If all are

operated at their highest level, working in close and intelligent

accord, then indeed we may expect results. But if the reverse is the

case—if the co-operating divisions are a drag and a hindrance—then the

task is overwhelming. The weak are corrupted and the strong discouraged.

Those responsible for placing tuberculosis work under the city’s

administration—where it rightfully and logically belongs—should continue

their interest still further. It is not enough to transfer it from

pioneer, private control, and then drop the responsibility.

If a Health Department is clear of politics, and all its divisions work

together harmoniously, magnificent results may be obtained. Power,

prestige, and efficiency is a combination which results in forceful

work.

=Results in Baltimore.= Results have been achieved in Baltimore by

reason of a well-managed Health Department, acting in close co-operation

with the institutions of both city and state. The tuberculosis machinery

consists of a staff of seventeen special nurses; three special

dispensaries with a physician in charge; a laboratory for sputum

examinations; a fumigation corps and a steam sterilizer. With this

force, we work in connection with three other tuberculosis dispensaries,

and six institutions for the care of early and advanced cases. Some of

these institutions are maintained by state appropriations, others by

both public and private funds. The co-operation between these

institutions and the Health Department is absolute; if the control was

all through one, instead of a dozen different centres, it could not be

more complete or harmonious. Failure in any one direction is felt down

the line, consequently each is stimulated to its best effort. Thus, the

nurse knows that if she fails to persuade her patient to enter the

hospital, the hospital is useless, or that if the bad food of the

hospital drives the patient back again to his home, the nurse’s work

goes for nothing. Each reacts upon the other, and as all are working for

the same end, there is constant incentive to become a strong, rather

than a weak link in the chain. The results obtained cannot be measured

in terms of individuals—we cannot point to so many patients improved, so

many working, and so forth. Individual welfare is too shifting and too

questionable a standard by which to judge. The only absolute standard is

that afforded by the death-rate. A declining death-rate means also a

decreasing morbidity—fewer people die of tuberculosis and fewer are

infected. While our tuberculosis death-rate is still enormously high, it

is nevertheless falling year by year. Thus we see:

Deaths

from

Pulmonary

Tuberculosis:

1909 1400

1910 1234

1911 1165

1912 1189

1913 1129

There is nothing spectacular about this. It is heartbreakingly

slow—needlessly, uselessly slow work. Yet it is progressing in the right

direction.

=Tuberculosis and Poverty.= Throughout the foregoing pages we have

considered the direct method of dealing with tuberculosis—the removal or

segregation of the distributor. But there is also an indirect method of

dealing with tuberculosis, namely the abolishment of poverty.

Tuberculosis recruits full fifty per cent. of its ranks from people of a

certain social level—the very poor. This class is composed of people

habitually overworked, underpaid, and subject to all the deteriorating

influences of unsanitary and vicious environment, and to the ignorance

and degradation which follow in the wake of extreme distress. The root

cause of these conditions is our present unjust economic system, which

produces an excess of luxury and frivolity on the one hand, and on the

other an army of people who must forego the barest necessities of life.

One class is maintained at the expense of the other. Every movement

which seeks to abolish this injustice, and to substitute a fairer and

more equable system, is a movement which at the same time tends to raise

the standard of public health. Any legislation, social or revolutionary,

which makes for the improvement of industrial conditions, raises the

level of public health through raising the welfare (_i.e._, resistance)

of the individual. Therefore, sweeping readjustment of social and

economic conditions would automatically eliminate an enormous amount of

disease, by reducing the number of highly susceptible individuals. To

increase the number of people with high resistance—or to decrease the

number of people with low resistance, whichever way one chooses to put

it—would probably diminish the amount of tuberculosis by about one half.

This indirect method—the readjustment of social conditions and the

abolishment of poverty—valuable as it would be, would still leave the

problem unsolved. Even diminished by one half, the amount of

tuberculosis would still be formidable, and we should have to attack it

as vigorously as ever, if not to the same extent. The disease would

still exist, just as it now exists in well-to-do families in small

towns, in rural districts, and in other circumstances attributable to

neither poverty nor bad industrial conditions.

A thousand years ago, industrial conditions were as distressing as those

which exist to-day—yet in those days the poor staggered under the

additional burden of leprosy. A hundred and fifty years ago poverty was

complicated by smallpox, the scourge of Europe. The rigid segregation of

lepers in the Middle Ages relieved the situation of leprosy, while the

discovery of vaccine has practically eliminated smallpox. The submerged

classes, while their economic condition remained unchanged, were at

least relieved of the added weight of these two great diseases. So in

our present fight against tuberculosis. An aggressive campaign against

this disease will not necessarily improve industrial conditions, but

those who suffer most from these conditions will be relieved of one more

handicap.

In our present warfare against tuberculosis we are not impelled by the

blind fear that made society in the Middle Ages demand segregation, and

refuse to tolerate an infectious disease at large in the community. Nor

has any vaccine or similar agent been discovered by which the disease

may be wiped out. Instead, we must depend upon a campaign of

education—wholesale, widespread education, conducted amongst all classes

of society. We know the path to be travelled, and the machinery by which

we may gain our ends. If at any time we become impatient with our slow

rate of progress, we can accelerate our speed by the extension and

multiplication of the three fundamental agencies in the

anti-tuberculosis campaign—the Hospital, the Dispensary, and the Public

Health Nurse.

INDEX

Advanced cases, 46–47, 119, 145, 223, 224–227;

see _Patients_ and _Segregation_

Air, fresh, 145–147

Alcohol, 151

Ambulatory cases, 33, 34, 38, 79–80;

see _Patients_

Anti-tuberculosis campaign, 1–3;

fundamental agencies in, 286

Anti-tuberculosis Society, 5–6

Arrested cases, 2;

nursing as work for, 13–14;

see _Patients_

Bacilli, tubercle, articles infected by, 253;

distribution of, 169, 262–266;

presence or absence in sputum, 107–108, 111;

tenacity of, 170

Badges, 31

Bag, nurse’s, 41;

supplies carried in, 42–46, 108

Baltimore, branch offices for tuberculosis nurses, 39;

co-operation of nurses with institutions, 202, 204–205, 281–282;

dispensaries, 92, 151, 186–187, 192, 198–199, 201–202;

examination of nurses, 12;

forms used for charts, etc., 50–59;

Health Department, 42, 157, 170–171, 174, 176, 183–192, 204, 206,

250, 256, 267–268, 279–282;

milk and eggs for patients, 250;

nurse’s bag, 41;

nurses’ districts, 39 _note_;

occupations of patients, 253, 261–263;

ordinance in regard to selling milk, 255–256;

organization of tuberculosis work, 200–202;

poverty, 231–232;

registration of cases, 112;

salary of tuberculosis nurse, 21;

sick-leave, 28;

supplies for patient, 42;

Tuberculosis Division, 171, 183, 201–202, 250;

uniforms, 30–31;

vacations, 28;

Visiting Nurse Association, 8, 39, 42, 65, 201, 202

Bed, for advanced cases, 145;

placing of, 144

Bed clothing, 144

Bedding, disinfection of, 175, 176

Bedroom, patient’s, 137–140

Board of examiners for nurses, 11

Board of Health of Maryland, 42;

furnishes formaldehyde, 173

Books of instruction, 44

Cabot, Doctor, quoted, 70

Calls, night, 16;

sources from which received, 121

Calmette test, 111

Card index, 53–54

“Careful consumptive,” the, 220–223

Carpets, infected, 178–179

Cases, tuberculosis, see _Advanced_, _Ambulatory_, _Arrested_, and

_Discharged cases_; and _Patients_

Cases, undiagnosed, 63, 99–101

Charity Organization Society (or Federated Charities), 39, 66, 98, 108,

109, 176, 210, 236–237, 239, 241, 242, 245;

rules for agents of, 237–241

Charts, patients’, 49–54, 58–60

Children, care of tuberculous, 163;

diagnosing, 161–162;

infection of, 95, 111, 151–152, 159–164;

open-air schools for, 163–165;

sending to school, 162–163;

pre-tuberculous, 163

Classes, tuberculin, 196–197

Cleaning should be compulsory, 182–183;

see _Disinfection_

Clothing for tuberculous patients, 142–143, 211–212

Cooking, supervision of, and instruction in, by nurse, 149–151

Cooks, infection from, see under _Infection_

Co-operation, between institutions and nurse, 203, 205–208;

of newspapers in tuberculosis work, 5;

of organizations for social work and nurse, 35–36, 143, 156–157,

176–177, 182, 210;

wrong methods of, 33–34;

see also _Charity Organization Society_ and _Social Workers_

Country, the, for tuberculous patients, 165–168

Cullen, Doctor Victor F., quoted, 108

Cure of tuberculosis, 4, 125–127, 208–209

Daily reports, 55–57

Day sheet, 57

Death of patient, 49, 119, 120;

reporting, 53, 171

Diagnoses, erroneous, 92–97, 101;

lack of, 63;

“lay,” 68–69, 100;

necessity for formal, 115–116;

obtaining, 105–107, 184–185;

from sputum, 107–109;

value of recording, 114–115;

volunteered by physicians, 106

Diet of patients, 147–150, 249–251

Discharged cases, 204–205, 207, 209;