Nursing with a Message

Patricia D'Antonio

• Publisher: Rutgers University Press
• Year: 2017
• ISBN:
  9780813575247
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Mandated by the Affordable Care Act, public health demonstration projects have been touted as an innovative solution to the nation’s health care crisis. Yet, such projects actually have a long but little-known history, dating back to the 1920s. This groundbreaking new book reveals the key role that these local health programs—and the nurses who ran them—influenced how Americans perceived both their personal health choices and the well-being of their communities.    Nursing with a Message transports readers to New York City in the 1920s and 1930s, charting the rise and fall of two community health centers, in the neighborhoods of East Harlem and Bellevue-Yorkville. Award-winning historian Patricia D’Antonio examines the day-to-day operations of these clinics, as well as the community outreach work done by nurses who visited schools, churches, and homes encouraging neighborhood residents to adopt healthier lifestyles, engage with preventive physical exams, and see to the health of their preschool children. As she reveals, these programs relied upon an often-contentious and fragile alliance between various healthcare providers, educators, social workers, and funding agencies, both public and private. Assessing both the successes and failures of these public health demonstration projects, D’Antonio also traces their legacy in shaping both the best and worst elements of today’s primary care system.   

Chapter 1

Medicine and a Message

Public health reformers had every reason for optimism at the dawn of the 1920s. Two seminal events had set grand plans in motion. The first, the decision of the American Red Cross (ARC) that its newly reconfigured peace-time mission would concentrate on the more effective organization of health and social services through neighborhood health centers, promised to solve the knotty problem of care coordination among the myriad of public and private entities operating in large urban areas like New York City. The second, the release of data from the Metropolitan Life Insurance Company’s intensive tuberculosis (TB) case finding and treating study in Framingham, Massachusetts, suggested a direct path to bring the “white plague” under control at last.

Yet, New York City’s leading public health nurses looked askance at the developing plans to establish the city’s own health center and to eradicate tuberculosis—at least as it involved them. They believed they had already solved their discipline’s organizational issues with a private system that brought bedside nursing and health teaching to the individual homes of the sick poor and a public system that provided broader communities with health education, immunizations, communicable disease control and quarantines, and the oversight of the health of school-aged children. The city’s Henry Street Settlement and Visiting Nurse Service (VNS) was world-renowned for its ability to bring “medicine and a message” of health and American values into the homes of working-class and immigrant families. Its Department of Health, under the tutelage of Lillian Wald, the founder of Henry Street, had the first and now had the largest numbers of nurses working with children in the city’s schools.1

This chapter maps the social, political, and public health landscape of New York City as it planned to meet these challenges in the aftermath of the First World War. It explores how a small group of white, middle-class, and well-educated public health nursing leaders worked among themselves and with other reformers to consolidate the disciplinary power they gained in their effective work bringing “medicine and a message” of American values to the working, poor, and often immigrant families they served prior to the war. It situates these women within the compromise brokered between public health and private medicine. Bruising battles between public health reformers and representatives of medical practitioners had established firm boundaries regarding who should treat the poor. Those nurses working in public agencies in large urban areas could only teach mothers and children about health and only rarely provided actual home bedside nursing care. In New York City, those working for private agencies like the VNS, the Association for Improving the Conditions of the Poor (AICP), and the Maternity Center Association (MCA) had more latitude. They provided bedside nursing care to sick individuals and prenatal care to mothers even as they taught their families the principles of health and hygiene. They also had a history of strong financial support from the Rockefeller Foundation.

Yet, like their colleagues in other large urban cities, these nurses worked within a complicated matrix that also supported the work of hundreds of other public health nurses employed by small, private neighborhood settlement houses, churches, welfare associations, and community organizations in the city. The proliferation of such agencies across the United States drove the national postwar emphasis on care coordination as a central element of the ARC’s commitment to health demonstration projects. In New York City, the problem of so many clinicians working to solve the same kinds of problems brought together the same prominent male social workers and sympathetic physicians to consult with the Rockefeller Foundation and the Milbank Memorial Fund. They successfully found Foundation funding to create a community-based health center in the East Harlem neighborhood of the city that could more efficiently coordinate the delivery of health and social welfare services to those in need; and they dreamed with the Fund’s officers of constructing a “monumental enterprise” in the Bellevue-Yorkville districts of the city that would eradicate TB, compel the attention of “scientific men,” and force action among communities of voters that seemed far too complacent about the need to increase tax dollars to pay for public healthcare.

The city’s leading public health nurses were not invited to these philanthropic tables, although they were aware of the plans. On the one hand, this omission reeked of the privilege of alliances among powerful white men who were comfortable in viewing public health nurses as the veritable foot soldiers of their reform army. But it also kept at a distance those who were not engaged in their vision. Lillian Wald, the most powerful nursing leader in the city, if not the world, wanted no part of any planned demonstration either at East Harlem or Bellevue-Yorkville. East Harlem seemed particularly troubling. In addition to demonstrating the value of health and social welfare, the second demonstration that involved nurses would be one of care control. The East Harlem Nursing and Health Demonstration Project intended to pool all neighborhood nursing personnel and financial resources into one centralized organization to reduce nursing redundancies and clinical overlaps.

Wald and her public health nursing colleagues centered at the VNS felt quite comfortable ignoring the plans of other public health reformers. They believed themselves to be very secure in the putative empire they had built in New York City, an empire created by well-educated nurses adhering to the highest public health nursing standards when nursing the sick poor in their homes. But they were well aware that their nurses were an anomaly, not the norm. Wald and her colleagues were preoccupied with issues surrounding the education for practice of all public health nurses, not public health practice itself.

Planning for Nursing

Both contemporaries and historians recognized New York City’s place at the epicenter of the public health world in the aftermath of the First World War. Under the prewar leadership of Hermann M. Biggs, the city attracted international attention for its school health, immunization, tuberculosis, scientific laboratories, and clean milk reform initiatives. They also recognized the city’s place at the epicenter of the nursing world. Service institutions such as the VNS at Henry Street and educational initiatives such as those at Teachers College at Columbia University attracted and trained public health nursing leaders from around the globe.2

But for all its successes, postwar New York City still faced seemingly intractable health issues among its poor, working-class, and immigrant families—those most vulnerable to the rising costs of living in the postwar city, labor strikes, and, as the Department of Health reported, the “unstable economic conditions.”3 These health issues included high infant mortality rates, poor prenatal care, and insufficient attention to the prevention and treatment of tuberculosis. Established philanthropies, such as the venerable AICP, the largest and most influential private social service organization in New York City, provided important financial and social welfare assistance to the city’s own public health initiatives, particularly for families that included a member with tuberculosis. All New York City public health leaders clearly understood the relationships among the conditions in which families lived, the material resources available to them, the access to education available to their children, and their health status. But issues of access and equity to the essential social and health services necessary to allow mothers to raise healthy infants, to help children achieve in school, and to enable breadwinners to remain productive at work remained highly problematic.4

The city’s nursing leadership, joined by other public health reformers, believed they had another, more vexing, problem to solve in the early 1920s: how would middle-class families who needed care be nursed? In New York City, as in other parts of the country, the working and immigrant poor had access to the services of privately funded visiting nurse services who sent skilled nurses into their homes for short, often daily visits and charged fees that were heavily subsidized by donors. The rich had access to private-duty nurses, graduates of hospital-based training schools, who stayed by their patients’ bedsides for the entire illness experience and charged concomitantly higher fees that were beyond the reach of most middle-class Americans. As one commentator noted in 1921, “the great problem” is “the problem of providing adequate nursing service for the community at a rate within the means of those who must pay for such services.”5 Ideas for solving this problem abounded: Have visiting nurse societies engage in the “hourly nursing” of middle-class families at rates greater than those charged the poor but less than the cost of continuous private-duty nursing; have nursing registries—employment agencies that matched a family in need of service with a private-duty nurse in need of work—seek opportunities for nurses who wanted less than continuous employment at prorated fees less than that usually charged; and, to the chagrin of nursing leaders, create a new category of a subsidiary nurse or nurse attendant who had a much shorter period of training.6

But in New York City there was cause for some optimism. Nurses Annie Goodrich, who had become head of Henry Street, and Anne Stevens of the Maternity Center Association proposed yet another alternative. They turned to two allies and strong supporters of nursing at the Metropolitan Life Insurance (MLI) Company, Lee Frankel and Louis Dublin. Frankel, the vice president of the company’s industrial insurance division, had a long-standing history of collaboration with Lillian Wald at her Henry Street Settlement and Visiting Nurse Service in the early decades of the twentieth century. Wald, known for her innovative approaches to public health nursing, had identified the possibilities of MLI’s “penny policies” that—for the penny a week collected door to door, a price within the budget of working-class New Yorkers—policyholders would be eligible for a death benefit that covered funeral expenses. In 1909, Wald had proposed inclusion of an additional benefit. When a policyholder or covered member of his family became ill, Wald would send one of her Henry Street visiting nurses into the home to provide the bedside nursing that could well be life-saving. Dublin was the MLI statistician who proved she was correct. Such nursing both saved lives (and—at 50 cents per visit—supported some of the operating costs of Henry Street) and decreased the dollars in death benefits the company would normally pay. By 1920, such policies had spread like wildfire throughout the country and within the insurance industry itself. Goodrich and Stevens proposed what was essentially a similar, private insurance program, but now for middle-class Americans, that would cover the costs of nursing care.7

The proposed Citizen’s Health Protective Society’s plan would also be much like prevailing mutual aid societies. These societies charged yearly dues and promised families help with medical bills when a member was ill and, most importantly, assistance with funeral expenses if the individual died. Like mutual aid societies, the goal of the Citizen’s Health Protective Society was to eventually become a self-reliant, self-governing entity run by its members. But, unlike mutual aid societies, the Citizen’s Health Protective Society would help with the costs of health, not illness care, and with the costs of nursing, not medical services. Its ambitious goals were to “work out” a self-supporting nursing service “within the means of the middle class.” Concretely, it would provide for the care of pregnant women, assistance at their delivery, and health work with their children until they reached school age. It would also arrange for a visiting nurse to provide bedside nursing when any member became ill. Dues would be $6 each year for an individual and $16 per year for a family.

By 1922, the nurses and their advisors had selected the Manhattanville neighborhood of the city, in the northwest section, from 122nd Street to 142nd Street and from 8th Avenue to the Hudson River because it was a “largely self-supporting neighborhood, not foreign in character and where the vital statistics conform closely to the general average of the city.” Manhattanville, in other words, was quite different from the poor, immigrant, and working-class neighborhoods that Henry Street nurses typically served in other Manhattan neighborhoods. It would allow nurses to broaden their reach to a white, middle-class constituency, who lived in newer apartments rather than older tenements, and who were young and newly married and ready to start their families. With the support of an anonymous philanthropist, the new Citizen’s Health Protective Society hired its director and set up its office in the heart of the neighborhood. Do you want, it now asked in handouts distributed to the community, a self-supporting nursing and health service?8

At the same time, New York City’s public health nursing leaders joined others across the United States in seeking answers to what they believed an equally vexing problem: What kind of education did nurses need for public health nursing practice? By the early 1920s, all nurses received their pre-licensure education in hospital-controlled training schools that depended largely on student labor for the care of patients. There, women traded three years of work on the inpatient wards for the knowledge, the clinical opportunities, the diploma they received at graduation, and, if they so chose, the right to sit for state licensing exams and earn the title of “registered nurse.”9

This training school experience emphasized medical science, skilled techniques, and discipline. Training school experiences varied widely even within New York City. At its worst it meant negligible time in lecture halls, absurdly strict discipline, blind loyalty, and rote obedience. But at its best—and New York City was home to some of the best (albeit segregated) training schools for both white and black nurses in the country—the experience provided the medical knowledge and the training that nurses needed to confront the most persistent challenge to their authority: mothers, drawing on their personal knowledge of their family members in their own homes. Medical knowledge—drawn from the new tenets of exciting developments in bacteriology, microbiology, physiology, and chemistry and learned in a hospital space far from the domestic spaces where they would eventually practice—invited women who would train as nurses to invest themselves with an objective and scientific authority that would more effectively compete with mothers’ more personalized and often quite powerful knowledge claims in both the tenements and the drawing rooms of New York City.10

Yet, this education and training was for the care of the acutely ill, those recovering from su...

Table of contents

• Cover
• Title Page
• Copyright Page
• Dedication
• Contents
• List of Illustrations
• Acknowledgments
• List of Abbreviations
• Introduction
• Chapter 1 Medicine and a Message
• Chapter 2 The Houses That Health Built
• Chapter 3 Practicing Nursing Knowledge
• Chapter 4 Shuttering the Service
• Chapter 5 Not Enough to Be a Messenger
• Notes
• Bibliography
• Index