By Patricia D’Antonio, PhD, RN, FAAN
On August 19th, the Editorial Board of the New York Times noted the Obama administration’s commitment to expanding community health centers and stabilizing the funding streams that support the salaries of the doctors “and other health professionals” who work to bring high quality primary care to poor urban neighborhoods and isolated rural ones. These health centers are indeed a lifeline for so many individuals, families, and communities. But they have a history that pre-dates federal involvement either through President Lyndon Johnson’s war on poverty or President Barack Obama’s Affordable Care Act.
In the immediate aftermath of World War I – long before the legitimacy of federal involvement in health care had been established – private philanthropists, public health reformers, nurses and physicians came together to establish neighborhood-based centers that would provide coordinated, accessible, and high-quality care to the urban and rural poor. Health centers in the 1920s existed at an exciting moment in time when the emphasis was not just about care but also the structure within which care would be delivered. Be it the organization of one discipline’s work or questions about what kinds of workers should do what kinds of work, these earlier health centers tried to grapple with important issues. They left important questions for which our expanded commitment to community health centers can now tackle.
Why should we care about this earlier history? Because the historical distance of time allows us to see more clearly some of the strengths and weaknesses of this important innovation in health care. One strength of this earlier health center movement was that it acknowledged dependence on nurses – especially public health nurses – for community outreach and the adoption of healthier lifestyles, preventive physical exams, well-child care, and routine dental care. Their work established the norms of primary care now practiced in today’s primary care centers.
A clear weakness was that the work was highly labor intensive and depended on the breakdown of disciplinary boundaries among nurses, physicians, and social workers that had been painstakingly created in the decades before the War. This almost happened – until the ravages of the Great Depression of the 1930s forced retrenchments that stifled continued innovation. Without a secure funding base experiments in the delivery of health care took a back seat to the provision of more urgent and life-saving treatments.
My historical work includes studying the East Harlem Nursing and Health Service, what we might today call a nurse-managed health center located in what was in the early 1920s a large Italian-American neighborhood in New York City. With funding from the Rockefeller Foundation, nurses designed and implemented their own health center. They worked at a moment in time when the best in health care still centered on the home, and they provided bedside nursing to sick individuals and health teaching to those members of their families. Rates of infectious diseases were declining, but tuberculosis, diphtheria, typhus, and pneumonia still presented significant threats. The nurses in East Harlem knew how to handle these problems, but they needed to study the best organizational structure to provide their care in the most efficient and effective way possible.
Nurses . . . were simply the most trusted and most visible members of the health care team.
The burning question involved the organization of their own nursing knowledge. Was it better to move in the direction of more specialized knowledge, as were their physician colleagues, and nurse only individuals and families within their sphere of expertise? Or was it better to build a broad knowledge base in order to nurse all individuals and families within a smaller and more circumscribed community. East Harlem nurses provided data supporting the idea that nursing knowledge had its greatest impact on individuals, families and communities when drawn from the broadest base in natural and social sciences. Yet they also learned that knowledge and trust went hand-in-hand. Some newer public health practices – practices such as well child and adult physical exams, immunizations, vision and hearing tests that we now take for granted as integral to primary care – raised real suspicions that they were but a new way to part a patient from his money. Nurses, building on relationships forged when caring for an individual in the grip of a life-threatening illness, were simply the most trusted and most visible members of the health care team. They knew how to teach families to value health and not just illness care.
Yet knowledge is never static. In the 1920s, knowledge about ways to establish healthy mental (as well as physical) health increasingly became part of nurses’ professional armamentarium. Mental health knowledge had also been claimed by social workers. For instance, by the 1920s, social workers had developed a systematized technique called “case work” that enabled one to understand an individual or family in the context of developmental, social, and psychological factors. Nurses in East Harlem – as did others across the country – believed they could incorporate case work into their own illness and health care to enable a more comprehensive approach to the individuals, families, and communities with whom they worked. As I have written elsewhere, tensions blazed. By the end of the decades some reformers had made credible calls for a “new kind of health worker” – part nurse, part social worker – that could best address the complicated and multi-determined issues their patients faced.
And then the market crashed. Within a few short years, private philanthropists had fewer funds; and city and state governments faced dramatic tax shortfalls. Public health nurses – what few remained – had to nurse the sick and social workers – whose ranks dramatically expanded – had to determine relief eligibility alone. Federal dollars through the 1930s provided some assistance, and the post-World War II commitment to hospital-centered health care shielded attention from real needs in primary care.
The recent announcement of an expansion of support today’s for community health centers will strengthen the role of primary care. But by looking back to an earlier history we can think about an organizational structure of primary care that remains built around the traditional health care disciplines of nursing, medicine, and social work. History tells us it is not only necessary to provide a site for high-quality care; we must also provide one that has deep connections with the families it serves.
Patricia D’Antonio is a nurse and historian whose body of scholarship situates the profession’s work and worth in both American hospitals and health care agencies and in the fabric of families and communities. Dr. D’Antonio is also the editor of the Nursing History Review, the official journal of the American Association for the History of Nursing