Nursing with a Message

Front matter

NURSING

— witha =-

MESSAGE

Introduction

The Houses That Health Built Practicing Nursing Knowledge Shuttering the Service

Notes Bibliography ix

Xi

XV vii

Illustrations

Illustrations

Table

Map of the East Harlem Health and the East Harlem Nursing and Health Demonstration Projects Neighborhoods

. Map of the Bellevue-Yorkville Health Demonstration

Project Neighborhoods

Locations of All of Manhattan’s Health Demonstration Projects and Clinics circa 1925

The Parents Conference Room at the East Harlem Nursing and Health Service

The Children’s Play Room at the East Harlem Nursing and Health Service

. A Puerto Rican Family in the East Harlem Nursing and Health Service’s Care

. Key Features and Funders of the Health Demonstration

Projects and Health Clinics in Manhattan

Acknowledgments

Nursing with a Message was never meant to be a book-length project. Its origins lay in a long-ago request that I present a paper on some aspect of the history of women’s health at the 2010 Congress of the International Council on Women’s Health Issues hosted by my School of Nursing in Philadelphia. I knew the Barbara Bates Center for the Study of the History of Nursing, my intellectual home for the past thirty years, held Susan Reverby’s anthology of pamphlets written by public health nurses involved in an interesting maternal-child health project in the East Harlem section of New York City in the 1920s. I saw this as an opportunity to dive more deeply into these materials. Paper written, paper presented, and then paper put aside.

Until a short time later when my friend and colleague, Julie Fairman, and I visited the Rockefeller Archive Center, successfully persuading the Center to fund a third, but now international, conference on the history of nursing. While there, James Allen Smith—the Center’s vice president, its director of Education and Research, and a staunch proponent of the importance of the history of nursing to the Foundation’s own history—gave us a tour of its archives. Before me lay boxes upon boxes, row after row, of materials related to the Rockefellerfunded East Harlem Health Demonstration Project and, a short time later, the East Harlem Nursing and Health Demonstration Project whose nurses actually wrote my above referenced pamphlets. Now, I thought, I have access to the materials I needed to return to my paper and turn it into an article-length manuscript. A generous grant-in-aid from the Center allowed me to spend two weeks in Sleepy Hollow, New York, slowly realizing I now had a story that could not be contained by the conventions of a thirty-page manuscript. I thank Jim for believing this project was broader than just the history of nursing—that it was also about the history of public health. And I thank archivist Bethany Antos for constantly steering me in the direction of even more letters and documents.

While in Sleepy Hollow I came to understand the intense optimism that public health reformers of the immediate post-World War I era who believed that they could now put health—health promotion and disease prevention— into public healthcare. This drew me to the collection of the Milbank Memorial Fund that supported its own health demonstration project in what was then the Bellevue-Yorkville section of midtown Manhattan. This has not been a journey of archival hardship. Funding from Penn’s own University Research Foundation xi xii Acknowledgments

(URF) allowed several extended trips to Yale’s magnificent Sterling Memorial Library. I admit that my most vivid memory of those visits will remain that of sitting in that appropriately named “cathedral of learning” and feeling the aftershocks of the earthquake that rumbled through the East Coast in 2011.

The URF and the H-15 grant for faculty members from the American Association for the History of Nursing allowed more trips to New York City than I can remember to explore the archives of all the other associations involved with the demonstration projects, particularly those of the Association for Improving the Conditions of the Poor that administered the demonstration projects for both the Rockefeller Foundation and the Milbank Memorial Fund. The staff at Columbia University’s Rare Books and Manuscript Library never tired of my repeated requests. I am particularly grateful to Stephen Novak, the head of Archives and Special Collections at the Augustus C. Long Health Sciences Library at Columbia University’s Medical Center. He brought to my attention records I would never have found on my own: those of the public health nurses’ own Citizen’s Protective Society, otherwise known as the Manhattanville project.

There are some very practical debts I need to repay. Most universities, like Penn, have efficient book or article retrieval systems that literally place such requests on your desk or desktop within days. But the staff at Penn Libraries outdid themselves when, three days after I requested that twenty years of the nondigitized journal Public Health Nursing be retrieved from storage, two young work-study students arrived at my office with suitcases full of all twenty old and dusty volumes. And as chair of a very large department during the entire life of this story, I would also like to thank my successive assistants, Kristen Nestor, Erica Hildenbrand, and, now, Jake Rutkowski for assiduously protecting the time I had set aside for research and for writing. My thanks also to Lisa Hilmi for her beautiful maps that locate the health clinics and demonstration projects in Manhattan.

I am especially grateful for the community of scholars who have surrounded this story and have helped me develop context, sharpen arguments, and, although I own any remaining errors, save me from some dreadful mistakes. Theodore Brown pushed hard and helped me improve the clarity of some fundamental tensions that ran through the East Harlem Nursing and Health Demonstration Project. Karen Flynn, as always, helped me talk and think through the intersections of race and gender in these demonstration projects, in the larger city, and in the discipline of nursing. David Rosner’s, Gerry Oppenheimer’s, Daniel Fox’s, and James Colgrove’s feedback after a seminar at Columbia’s Mailman School of Public Health immeasurably strengthened the ending. I am also so thankful to those who have read earlier versions of

Acknowledgments xiii this story in its entirety: Susan Reverby, Jennifer Gunn, and Cynthia Connolly. Their extraordinarily generous critiques, insights, and advice have made this overall story so much stronger.

The Barbara Bates Center’s faculty, staff, and students continuously provided support, collegiality, good council, and friendships. Julie Fairman, Cynthia Connolly, Barbra Mann Wall, Joan Lynaugh, and Jean Whelan have patiently (and sometimes painfully) heard—in formal and informal discussions—about this story since its inception. I owe a special debt to Cynthia Connolly for her strategic advice that constantly moved this story along. Finally, our doctoral students, Kathleen Nishida, Katharine Smith, Amanda Mahoney, and Briana Ralston, sat through a rather muddled presentation of what would become chapter 1. Their advice helped make it chapter 1 and, in return, I hope they learned that historical writing is not a linear process.

I have been very self-conscious during the life of this project that I have been standing on the shoulders of a giant in the history of public health nursing, the late Karen Buhler-Wilkerson. Karen, my dear friend and mentor, set the standard for rigorous scholarship and uproarious fun. I can only aspire to meet her high expectations. And I have always known of my good fortune to sit in a School of Nursing that values history and historical thinking. Both my former dean, Afaf Meleis, and my current dean, Antonia Villarruel, have been unwavering in their support of an intellectual climate that supports the ambitions of the Bates Center faculty and students.

As this story now closes, I thank Janet Golden and Rima Apple, the editors of Rutgers University Press’s series on Critical Issues in Health and Medicine, for believing in the importance of this story from the beginning. I also thank Peter Mickulas, senior editor at the Press, for shepherding the story through to publication. As always, my husband, Joseph, and my son, Frank, deserve my eternal gratitude for their patience and pride in my work.

Portions of the following articles are used with the permission of the publishers: “Cultivating Constituencies: The Story of the East Harlem Nursing and Health Service, 1928—1941,” American Journal of Public Health 103, no. 6 (2013): 988—996; and “Lessons Learned: Nursing and Health Demonstration Projects in New York City, 1920-1935,” Policy, Politics, and Nursing Practice 14, no. 3—4 (2014): 133—141.

Abbreviations

AICP ARC CSS

CUMC

Association for Improving the Conditions of the Poor

American Red Cross

Community Service Society, Columbia University Rare Book and Manuscript Library

Health Sciences Library Archives and Special Collections, Columbia University Medical Center

Historical Society of Philadelphia

Henry Street Settlement

Laura Spelman Rockefeller Memorial

Maternity Center Association

Metropolitan Life Insurance Company

Milbank Memorial Fund, Sterling Memorial Library, Yale University Rockefeller Archive Center

Rockefeller Foundation

Tuberculosis

Henry Street Settlement and Visiting Nurse Service xv

Introduction

On March 10, 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act (ACA). Seven months later a key feature of the bill, the Center for Medicare and Medicaid Innovation (Innovation Center), opened its doors. While the ACA looks to restructure key features of the US healthcare payment systems, the Innovation Center serves as an incubator of new ideas to deliver and pay for care that will improve quality and decrease costs. To this end, its $10 billion budget sets in motion demonstration projects to increase access to high-quality, cost-effective, and coordinated healthcare for beneficiaries of Medicare, Medicaid, and state children’s health insurance programs. Its charge is to rigorously and rapidly assess the progress of these demonstrations, and to replicate those with a “high return on investment” in communities across the country. Its first initiative, Strong Start for Mothers and Newborns, has now funded 182 demonstration projects to improve the health of mothers and babies. The intent is that the more successful of these demonstrations can be scaled up to national initiatives that will reduce early elective deliveries, decrease preterm births, test new approaches to prenatal care, and improve outcomes for mothers and babies.

The Center for Medicare and Medicaid Services (CMS) has a thirty-year history of supporting such demonstration projects, most recently in value-based payment systems and disease management and care coordination.” Yet demonstration projects in healthcare in the United States predate the CMS’s initiatives. Nursing with a Message examines the history of the first such demonstration projects in New York City in the 1920s and 1930s, a period commonly referred to as the interwar years. Surprisingly, historians have yet to look systematically at these health demonstration projects that were testing new models of healthcare delivery in selected urban and rural communities throughout the country. The brief accounts that do exist are embedded in the histories of the foundations and philanthropies that supported the projects or in the histories of city and state public health departments that looked to them for their policy and practice implications.* The East Harlem Nursing and Health Demonstration Project, one of New York City’s signature demonstration projects, has had some recognition for its seeming success in settling long-simmering debates about the best organizational structure for public as well as private public health nursing.* But this book approaches these demonstrations in New York City as they relate to each other rather than, as in prior work, in isolation.

We need to do this for two reasons. First, there exists an entrenched, yet erroneous, belief that public health prevention and treatment services had their roots in the community health movement of the 1960s. Second, and even more significantly, the United States stands ready to commit significant resources to bolster and expand the capacity of community health centers to provide comprehensive, high-quality, and coordinated care that will target health disparities for low-income individuals, racial and ethnic minorities, rural communities, and other underserved neighborhoods. It is as committed—as in the past—to identifying and using key quality improvement data to disseminate best practice models to hospitals and healthcare systems throughout the country. It is urgent that we understand the history of an earlier movement also committed to access, quality, care coordination, and data to more fully understand all the possibilities and the problems of a national agenda rooted in the needs of particular families and communities.

Three threads, mirroring those of other health demonstration projects throughout the country, ran through all of New York City’s projects. The first involved a commitment to broaden public health initiatives to pregnant women and preschool children. These populations had been overlooked in the prewar emphasis on infants and school-aged children. Yet, both mothers and their very young children had, as so many do today, appalling rates of morbidity and mortality. The second centered on initiatives that would teach individuals and families to demand health as well as illness care from their own private physician or, if unable to afford such medical care, from publicly funded clinics. The third was the central place of the public health nurse as the agent who would deliver these messages in her daily rounds in neighborhoods and homes. This last thread seemed self-evident. Public health nurses had long considered themselves and had been considered by others as the

“connecting link”—between patients and physicians, between and among

Introduction 3 institutions, and between scientific knowledge and its implementation in the homes they visited. But the nurses in New York City’s demonstration projects, like progressive urban colleagues throughout the country, went one step further. They used their experiences in the three demonstration projects to work toward identifying the whole families of their mothers and preschool children as their practice domain.

As historians have long argued, these nurses worked within the interwar years’ new constellation of ideas, practices, actions, and actors that shifted the structure of initiatives that might improve the health of women and children in particular, and that of the public in general. The quest to infuse “science” and “scientific meaning” into reasoned, scholarly investigations and also into everyday practices created a new “science of childhood” that emphasized careful developmental studies, on the one hand, and a renewed drive to translate the implications of these results to those individual mothers most responsible for rearing a new generation of upstanding citizens, on the other. Historian Rima Apple’s construction of the idea of “scientific motherhood” captures perhaps the strongest impulse to teach mothers the latest science behind such issues as proper prenatal care, infant feeding, and the psychological and environmental requirements to ensure their children’s normal growth and development. This impulse, Apple argues, constructed mothers as dependent and passive learners from expert physicians, psychologists, nutritionists, and nurses. But even if believed to be dependent and passive, such mothers were, in fact, quite eager consumers of the literature, lectures, well-baby clinics, and individual conferences that came to large cities and small rural hamlets throughout the country in the 1920s.° Most financial support for these came from the unwieldy titled federal legislation, the “Promotion of the Welfare and Hygiene of Maternity and Infancy Act,” passed in 1921, that quickly became more popularly known as the “Sheppard-Towner Act” in honor of its legislative sponsors. And while Sheppard-Towner monies did not provide any direct support in New York City’s health demonstration projects, it did place nurses in a very direct role in implementing what historians Barbara Beatty, Emily Cahan, and Julie Grant have described as an “empire of child services” created through the 1920s.’

This same quest also created a new impulse to, in historian Jodi Vandenberg-Daves’s words, “medicalize the maternal body” itself. The timeless debate about whether the process of childbirth required patient watching and waiting as part of a normal experience shared by women across generations or if it needed active and expert intervention by specially trained physicians tipped in the 1920s in favor of skilled medical attendance. Historian Jacqueline

Wolfe locates this change in the introduction of obstetrical anesthesia to the birthing process, a change that predated but certainly supported the accelerating 1920s movement to move births from homes into hospitals.” And the quest also medicalized—or psychologized—a new framing of how to think about the misbehaviors of children and, especially, adolescents. Historian Kathleen Jones’s work on the origins of the “child guidance” movement in the 1920s extended an emphasis on the “whole child” to include his or her emotional as well as physical and developmental life.

Nursing with a Message places New York City’s nurses in the middle of this turn toward science. It centers on the power of nurses—too often invisible in histories of healthcare—to also shape the public health messages of the interwar years. These nurses do provide a different lens with which to view this turn: in their day-to-day work with individuals, families, and communities they had to make their own decisions about what aspects of science seemed most relevant, at any one point in time and over the longer time frame within which they envisioned their work. This book draws on Steven Luke’s understanding of power as dispositional—that is, it focuses on what these women believed to be their capacity to influence both those they worked for and those they served. The nurses in New York City’s health demonstration projects truly occupied a place in the “middle” of the goals of public health reformers, physicians, and patients, and this study shows how they strategically navigated often-rocky shoals. It foregrounds the ideas, the practices, and the effects of the work of these public health nurses as they negotiated their roles within this matrix of competing agendas.

On a broader level, Nursing with a Message explores the day-to-day processes involved in the coming together and moving apart of different organizations, disciplinary interests, knowledge domains, and spheres of public and private responsibilities involved in caring for those in need at the point of delivery of service. More specifically, it uses the public health nurses involved in New York City health demonstration projects in the 1920s and the 1930s as a case study of disciplinary tensions inherent in projects with various constituents and invested in multiple and sometimes contradictory outcomes. It shows how one central public health discipline searched for better ways to care for the people it served even as it attended to its own advancement, place, and power in a very complicated space of ideas, practice, action, and actors.

Nursing with a Message centers on three seminal health demonstration projects in New York City in the 1920s and 1930s. Most of its analysis focuses on the East Harlem Nursing and Health Demonstration Project, reconstituted as the East Harlem Nursing and Health Service in 1928. This particular demonstration and later nursing service was completely managed by its public health

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Introduction 7 nurses and independent governing board. But it also uses both the Bellevue- Yorkville Health Demonstration Project and, reflecting the city’s segregated public health system, the black nurse-managed Columbus Hill Health Clinic, to enlarge, compare, or contrast the ideas and practices developed in East Harlem. Each of these projects had a distinct focus; yet all were linked through the officers of the city’s venerable Association for Improving the Conditions of the Poor (AICP), a private charity devoted to providing health and social welfare services to the city’s poor and immigrant families, that funneled the philanthropic and foundation monies that made the services possible.

This book is grounded in three central arguments. First, while it is undoubtedly useful to think of these demonstration projects in terms of traditional metrics of successes and failures, such metrics obscure the day-to-day practices and processes involved in turning ideals about health into normative values shared (and performed) by communities. Change did come: New York City’s health demonstration projects eventually established what are now the norms for primary, pregnancy, dental, and pediatric care. But, as I argue, it came almost painfully slowly through the day-to-day work of public health nurses going door to door, street to street, school to school, neighborhood to neighborhood, preaching the gospel of good health to those without access to the resources that class, race, ethnicity, and financial stability provided others their messages. Their messages were certainly reinforced by a new group of public health workers called “health educators.” But health educators concentrated on crafting messages for groups—of schoolchildren, church members, or club participants. Nurses focused on individuals and families and, conceptually, on those most difficult to reach.

As importantly, change also came through the efforts of families to first incorporate and then normalize these messages of health by removing them from stigmatizing sites of health and social welfare (in which the public health nurses were located) and placing them within the schools that the community embraced. The nurses in New York City’s health demonstration projects slowly moved from understanding their role as bringing “medicine and a message” of middle-class values to immigrant families they wished to assimilate, to conceiving of it as being “more than just a messenger” as they sought to be embodiments of a new emphasis on sound mental as well as physical health. Support for public health nursing did decline in the 1930s as nurses painfully realized that it was “not enough to be a messenger.” But the decline was less about no longer serving families who needed to assimilate, as other historians have suggested. The decline, I argue, was as much about families taking responsibility for their health and thereby setting limits on the intrusiveness of the increasingly intimate public health education that came with the public health turn toward mental health.

I also argue that situating nurses as the focal point of a matrix of competing public health agendas in the interwar year brings into sharper relief the porousness of professional boundaries in times of intellectual as well as social change. While traditional histories of public health nursing have highlighted tensions with physicians, the experiences of nurses in New York City’s health demonstration projects suggest those with female social workers held much more salience. In Nursing with a Message I chart the how the interwar period’s shift of the mental hygiene movement from psychiatry to public health forced nurses and social workers to rethink both their disciplinary practices and their relationships with each other. Social workers, not nurses, had developed the “case work” method for systematically understanding an individual in his or her environment." But nurses, not social workers, had the experience and the expertise in the kinds of neighborhood engagement and family outreach necessary for widespread mental health education. What historian Robert Kohler describes as the war-born enthusiasm for science challenged disciplines, foundations, and clinicians to rethink norms about what constituted accepted knowledge and valid evidence.’? While both nursing and social work drew on the gendered settlement house traditions of simultaneously incorporating research and action in their real-world practices, nursing’s claim to science— claims forged in their training school experiences—ultimately strengthened their place in the increasingly medicalized public health hierarchy.’ As other historians have argued, faith in science to find solutions to discrete problems, the self-proclaimed “new public health” that now focused on the individual rather than on the environment, as well as the conservative political climate of the 1920s created a perfect storm that decoupled providing healthcare from issues of social justice.* In ways we have yet to recognize, public health nurses actively participated in this decoupling process and, I argue, were also central to the success of this refocused and narrower agenda.

Finally, Nursing with a Message argues that history is a valid albeit underutilized lens with which to understand current health policy and the processes of health policy changes. In ways that predate what we now describe as the social determinants of health, New York’s public health leaders, including nurses, 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 health and social services necessary to allow mothers to raise healthy infants, to help children achieve in school, and to enable breadwinners

Introduction 9 to remain productive at work—issues that sound frighteningly similar to those experienced by today’s families from vulnerable backgrounds—remained highly problematic." As this story ends in the late 1930s, migrant Puerto Rican and southern black families—experiencing rampant tuberculosis and soaring maternal and infant mortality rates—had moved into the East Harlem neighborhoods. But they also moved into a more medically driven model of public health that nurses actively built. This new public healthcare model did address the healthcare needs of these new constituents. But it also abandoned issues of housing, education, and employment to the more stigmatized domain of social welfare.

The chapters in this book organize these arguments both chronologically and thematically. Chapter 1 maps the social, political, and public health landscape of New York City as it planned to meet the twin challenges of a new health center movement and more effective tuberculosis control and treatment in the aftermath of the First World War. Prominent social workers and physicians found support from the Rockefeller Foundation to create a health center in East Harlem to test the idea that bringing the twenty-three separate agencies that served the neighborhood into one central building could more efficiently coordinate the delivery of health and welfare services to its Italian and Italian American families. These men also found Foundation support for a public health nursing demonstration within a smaller area in East Harlem that would move beyond voluntary care coordination, as would be demonstrated at the health center, to one of care control. All the nurses in the private agencies working in East Harlem would pool their resources, personnel, and dollars into one controlling organization with its own governing board. This particular demonstration would test some of the more vexing issues in the organization and delivery of public health nursing. At the same time, many of these same men found support from the Milbank Memorial Fund for a “monumental enterprise” that included a health center in the Bellevue-Yorkville neighborhood of the city that would provide a model for how to finally eradicate tuberculosis. The city’s most prominent public health nurses knew of these plans, and some strongly opposed these ideas. But, in the end, I argue, they felt quite comfortable ignoring them. Leading public health nurses were more concerned about education for practice rather than practice itself.

Chapter 2 delves more deeply into the day-to-day realities of the city’s health demonstration projects. It situates these realities amid the tensions between the city’s Department of Health and private agencies and associations over who controlled the public health agenda. Both the Rockefeller Foundation and the Milbank Memorial Fund knew that both the private public health nurses working in East Harlem and the city’s own public health nurses working in Bellevue-Yorkville were critical to the demonstrations’ successes. Indeed, the involvement of the city’s own public health nurses working in East Harlem’s schools had been a central element of the Rockefeller Foundation’s support. The Foundation’s policy, both in the United States and abroad, was one of only working through official governmental public health authorities to ensure the sustainability of its initiatives. It hoped to use a consolidated private and public nursing system in East Harlem to ultimately do the same for the city. But, I argue, leading public health nurses shared no interest in this initiative because, in the end, these women won what they had always wanted. By 1928, public health nurses in New York City—not, as in the past, physicians—supervised the independent practices of other public health nurses. They considered this a substantive achievement.

Chapter 3 focuses on the knowledge needed for what contemporaries recognized as “a new approach to health work” among public health nurses. But it is also about how ideas regarding health circulated between and among constituents, how they were implemented, and how their implementation fed back into new policies and practices. It focuses specifically on the complicated and contingent relationships between nurses, social workers, and families at the newly reconstituted East Harlem Nursing and Health Service. Nurses there, like progressive colleagues throughout the country, used their practice experiences to legitimize claims to families as their exclusive domain. They built knowledge that bridged the biological sciences that supported their traditional public health nursing with the new social sciences that buttressed their work with families. This practice, however, brought them out of their traditional disciplinary interests and into a place at the center of their own and also others’ agendas. Foundations, families, physicians, and other public health workers all had particular ideas about what nurses should and could do as they delivered their messages of health. As this chapter argues, nurses practiced in a very complicated space of ideas, practice, action, and actors. The knowledge they needed for practice was, in the end, determined not just by the sciences. It was also determined by the demands of the community they sought to serve.

And, as we see in chapter 4, the community around them was changing. The Great Depression had hit East Harlem families early and hard. Its nurses knew about their economic vulnerability, but they thought little of the larger and changing social and healthcare landscape that surrounded them. Through the 1930s Puerto Rican families increasingly settled in neighborhoods of East Harlem. Moreover, these families were moving into a healthcare system increasingly dominated by hospitals and outpatient clinics. I argue that the nurses at East Harlem paid little attention to warnings about the implications

Introduction 11 of these new clinical sites for healthcare. They steadfastly maintained the site of their practices to that place where it could be most effectively and independently exercised: with cooperative families in their own homes, in the clinics the nurses controlled, and in the classrooms they created. Despite their commitment to maternal-child health initiatives, this narrow focus allowed them to professionally ignore one of the most pressing public health issues in the city in the early 1930s: the newly rising rates of maternal mortality attributed by both the New York Academy of Medicine and the Maternity Center Association to poor obstetrical practices in hospitals that women were increasingly choosing as sites of their infants’ births. These nurses could not see or take responsibility for solving problems that lay inside public health policies but outside their defined disciplinary purviews and sites of practice.