Pubc T 0k, Health Thenand Now

Public Health : In Sickness or in Health? KAREN BUHLER-WILKERSON, RN, PHD

Abstract: nursing began in the United States as a sick nursing would increasingly become the sole domain of the small undertaking in which a few wealthy women hired one or two voluntary organizations, while the teaching of prevention would nurses to visit the sick poor in their homes. By 1910, the work of become the responsibility of public agencies. By examining the these nurses had expanded to include a variety of preventive history of public health nursing between 1900-30, this article con- programs. While most preventive programs originated with volun- siders why a movement that might have been significant in deliver- tary organizations, such as the visiting nurse societies, they were ing comprehensive to the American public failed to reach eventually taken over either by boards of education or health its potential. (Am J Public Health 1985; 75:1155-1161.) departments. As a consequence of the new division that resulted,

Introduction character to the homes of the sick poor.' As was the case with so many philanthropic activities, these nurses were By the last decade of the nineteenth century, American expected to bring a message with their medicine. Disciplined cities were experiencing a major transformation. Those first and well-bred women, they were to raise the "household affected were the northern coastal cities where the concen- existence" with their "delicate instruction and firm convic- tration of immigrants and industry linked poverty to disease tions," and to protect the public from the spread of disease and dirt. Population growth alone required major adjust- with forceful, yet tactful lessons in physical and moral ments in the lives of most city dwellers. With immigration . The image of the visiting nurse climbing the tene- accounting for much of this urban growth, ethnic, cultural, ment stairs to save the indigent from illness and bad habits religion, and economic differences accentuated the separa- struck the fancy of a wide variety of social reformers.5 tion between old and new inhabitants.1"2 As knowledge of these visiting nurses' work spread, the For many, the advent of the number of agencies organized to provide their services simply heightened these concerns. Realizing, that individual rapidly increased. These early visiting nurse associations, as health depended to some extent on the health of the popu- they were called, began as small undertakings in which a few lation generally, the hazards of infectious diseases become wealthy "lady managers" financed and supervised the work an increasingly tangible concern. The knowledge that the ofone or two nurses. In most associations the nurses worked diseases of workers-who sewed clothes in their filthy six days a week, eight to ten hours a day, and were able to tenement homes or who processed food-could spread to visit daily eight to twelve patients. The ailments they en- decent, clean, and respectable citizens served as powerful countered were commonly infectious, often acute, and al- incentive for renewed efforts to eliminate the menace of ways complicated by the families' social and economic illness among the poor.3 circumstances. 1,5 Like most city dwellers, the urban poor usually chose to Usually, after only a brief interval of tension, even the stay at home during illnesses, relying on traditional healing dispensary and private physicians, who cared for the sick methods or, perhaps, the services of a dispensary physi- poor in their homes, came to appreciate the work of visiting cian.4 Compared to the middle and upper classes whose nurses. In the context of a widespread debate on "charity diseases were supervised by the frequent visits from the abuse" of health care facilities, the rapid acceptance of the family physician either in their homes or, to a lesser extent, visiting nurse may have been based on the rising cost of in the well-ordered surroundings of a hospital's pay ward or hospital care and the effort to reduce the number of charity private rooms, treatment of the sick poor during illness patients seeking hospitalization.6 In their search for paying seemed careless at best. patients, hospitals valued any program that helped them A few lady philanthropists, in New York, Boston, shed their image as a "once charitable enterprise."7 Obvi- Philadelphia and Buffalo, found these grim realities intoler- ously, one way to relieve hospital burdens-caused by what able. Motivated by their shared "vision" of the good soci- some contemporary spokesmen asserted was excessive and ety, they hired trained nurses to bring care, cleanliness, and indiscriminate charity-was to provide the poor with more Address reprint requests to Karen Buhler-Wilkerson, RN, PhD, Assis- care in their homes, while simultaneously teaching them how tant Professor of Clinical Nursing, University of Pennsylvania, School of to stay healthy.8 From the perspective of the sick poor, the Nursing, Philadelphia, PA 19104. This article, invited as part of the Journal's visiting nurse brought much needed care and relief from the 75th anniversary series, was accepted for publication on January 8, 1985. Editor's Note: See also related article p 1162 this issue. often extreme burdens of illness. Thus, as the result of a complex set of social, medical, and economic needs, the C 1985 American Journal of Public Health 0090-0036/85$1.50 visiting nurse, seemingly assured of success, entered the

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Visiting Nurse caring for an elderly patient at home. (Photo credit: Philadelphia Staff of the Visiting Nurse Society of Philadelphia in front of the Nurses Home, Visiting Nurse Society) on Lombard Street, 1907. (Photo credit: Philadelphia Visiting Nurse Society) If public health was indeed an increasingly private twentieth century with a clear sense of purpose, backed by a matter, then the task ahead required translating the knowl- supportive constituency anxious to promote what appeared edge of scientific medicine into terms of personal effort and to be an unambiguously valuable undertaking. responsibility. Education, declared C.-E.A. Winslow, a leading proponent of this view, was a keynote of the modern campaign for public health. The "new idea" of this cam- The New Public Health Campaign paign was to bring "hygienic knowledge right to the individ- ual in his home," where the information taught could be It was the changing emphasis of the "public health adapted to the particular circumstances of each individual campaign" that would, within the first decade of the 20th and presented in the words of the kitchen or the sitting century, create a bond between these visiting nurses and room. 14 public health.9 By 1910, death rates, especially for infectious In actuality, this idea of a "" originated disease, were declining and public officials showed no hesi- with Florence Nightingale and was first discussed in this tation in claiming their share of the success. Many others country in 1893 at the International Congress of Charities, agreed, that it was through public hygiene that these diseases Correction and Philanthrophy.'5 In her widely read paper, had been successfully combated: care of the water, food, "Sick Nursing and Health Nursing," she outlined the details and milk supply; removal of garbage, ashes, and dirt; the of this new scheme which she had helped initiate in England cleaning of streets; disposal of sewage; better housing; and in 1892. In the Nightingale .plan, these health missionaries the control of contagious disease. But freedom from disease were to be ladies with special training and practical instruc- no longer depended simply on community effort or the tion. 6"17 construction of more public works. Winning the fight against The only significant variation in the American version of disease now required moving from public hygiene to per- the Nightingale plan was to make the teacher of positive sonal hygiene. This new campaign would focus on the affairs health the visiting nurse, not a lady health missionary. of the household and conduct of the individual's life. There Already well established in the homes of the poor, the was nothing to be gained by uplifting the masses, it was visiting nurse was the logical choice, as one medical author- argued, unless each individual in the mass was to lift him/ or ity suggested, to serve as "the relay station, to carry the herself."-3 power from the control stations of science, the hospital, and

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The busy nurse, giving care to a newborn, had little time to remove her hat. With sleeves roUled up, she demonstrated proper care to the older sisters of the infant. (Photo credit: Phikadelphia Visiting Nurse Society) Having improvised a sick bed, the nurse encourages the child to eat, 1907. (Photo credit: Phikadelphia Visiting Nurse Society) requiring diagnosis, sending them where this might best be accomplished. the university to the individual homes of the community."'8 In the case of the tuberculosis patient, for example, the She was "preeminently fitted" for this function, explained nurse was, according to Ellen LaMotte, an early leader in C.-E.A. Winslow, because she was a woman and therefore the field, "singularly independent." There were no special possessed the patience and tact necessary to bring hygiene orders; the doctor knew what should be done and the nurse into the life of the tenements. Unlike the social worker, she knew what to do. Further words were, she claimed, unnec- knew the human body and what he described as its reaction essary. Patients could go for months without seeing the to external conditions and to the hygienic conduct of life. doctor or even change physicians, and it would have no Her approach was far superior to that of the physician significant impact on their daily regimen. It was the nurse because she was trained to see the body as a whole, while who was in charge of the patient's care, who was there the physician's vision was distorted by a preoccupation with through the long months of illness, and who moved the special pathological conditions.'9 patient from doctor to doctor. Some exploitative or ignorant Most nurses shared this viewpoint, and some even went physicians reacted to such behavior on the part of nurses so far as to suggest that this new field of health nursing with antagonism and opposition, but, according to LaMotte, differed so greatly from sick nursing that it might one day they were simply "holdovers from a passing regime." In constitute a distinct profession. Why not, queried one edi- such cases the nurse simply proceeded with her duty even if torial in the Public Health Nurse, "come boldly forth, one at seemingly cross purposes with the physician.23 As those and all, and claim the right to exercise the promotion of nurses entering this new field suggested, what they intended health as a profession?"20 to do was certainly not, in the words of nursing leader Asserting their independence, these nurses declared an Adelaide Nutting, "nursing in the ordinary sense of that end to "the old teaching" of the nurse as the handmaiden of term. "25 the physician. She was instead an associate or co-worker of the physician who helped him produce results he could never Prevention Programs, Services accomplish alone. While some physicians still expected to find the nurse waiting "at his elbow," more progressive Visiting nursing willingly added these new preventive physicians could be counted on, stated nursing leader Mary tasks to their traditional responsibilities of caring for the sick Gardner, to gladly give these nurses "a helping hand" by at home. By 1910, the majority, of the large urban visiting strengthening their new position with the patient.2124 nurse associations had initiated preventive programs for Health nursing seemed particularly well suited for those school children, infants, mothers, and patients with tuber- nurses seeking the opportunity for autonomous practice. culosis. While pleased by this sudden growth of their new Although these nurses still carried out the doctors' orders, enterprises, the ladies who managed these associations their new working conditions made it possible to discrimi- found themselves overwhelmed by the need for correspond- nate as to doctors, cooperating with those working for "a ingly rapid increases in their sources of support. As a result, higher standard of public welfare" while standing in but not only was the focus of these programs a radical departure, "remote and casual relation with those who have no such but the methods used by the lady managers to finance them aims or desire.'"23 These nurses appeared to be crossing the were equally unprecedented. Unable to finance any large invisible and ill-defined line between medicine and nursing, new programs, the ladies used two methods to entice others as they believed it their business to select those cases to pay for these new works-the joint venture and the

AJPH October 1985, Vol. 75, No. 10 1157 PUBLIC HEALTH THEN AND NOW

sis. 23 Many quickly found, however, that this was their most expensive program, since the patients tended to be poverty stricken and often required much time-consuming teaching. Recognizing the magnitude of this undertaking, visiting nurse societies were careful, as one Boston lady manager put it, to "avoid allowing anyone to place respon- sibility for the whole tuberculosis movement with their organization.""30,3 The glory of the visiting nurse associa- tion, would come, they hoped, from initiating the work, not in bearing its long-term financial burden. Financing this educational campaign was, from these lady managers' per- spective, the responsibility of the growing number of volun- tary societies for the prevention of tuberculosis and, ulti- mately, the city government. Thus, the role of visiting nurse associations in the development of the campaign against tuberculosis was most frequently that of partners in a joint venture. Typical of this approach was the work initiated by John and Isabel Lowman in Cleveland. John Lowman was a member of the Western Reserve Medical School faculty, and Isabel Lowman an active member of the Board of the Cleveland Visiting Nurse Association. Concerned about the lack of services for tuber- culosis patients, the Lowmans went to Germany and France in 1903 to study treatment of consumption. Following their School nurse treating an eye condition, 1907. (Photo credit: Philadelphia Visiting trip, John Lowman began to open tuberculosis dispensa- Nurse Society) ries-four by 1905-while Isabel Lowman and her commit- tee on tuberculosis began to raise money to provide Visiting Nurse Association staff to visit the dispensary's patients. demonstration. In the joint venture, the visiting nurse asso- With the help of the Lowmans, the Cleveland ciation provided the nurses while some other voluntary Anti-tuberculosis League was organized in 1905, and by 1908 organization provided the money. Demonstrations were a bit was able to assume all expenses for these tuberculosis more risky, since in those instances the visiting nurse nurses. In September 1910, the League's report to the mayor association initiated the program on a small-scale, experi- on tuberculosis conditions in the city resulted in the creation mental basis, assuming that when its worth was clear to "the of a Bureau of Tuberculosis within the Department of public", the necessary funds would be provided.26 Health. By 1913, all tuberculosis nursing was being financed best illustrates the demonstration ap- by the city, which saw itself, as one health officer suggested, proach to expansion. In many cities, physicians had been as having "come to the rescue and provided funds for the hired by the city to inspect school children and to exclude support of the work. '32 those with contagious diseases. Initially, this approach pre- For the visiting nurse, these circumstances created a sented few problems, but as the number ofchildren excluded time of unlimited possibilities. Visiting nurses could be grew rapidly, many boards of education began to seek other found working for department stores, factories, insurance solutions. By 1902, the situation in the New York City companies, boards of health and education, hospitals, set- schools was out of control with 15 to 20 children per school tlement houses, milk and baby clinics, playgrounds, and being sent home daily. At the suggestion of Lillian Wald, a hotels, as well as for visiting nurse associations. Not sur- nurse from the Henry Street Settlement House was sent to prisingly, the number of agencies seeking their services had four schools to demonstrate how, through home visiting, the increased from only 58 in 1901 to nearly 2,000 by 1914. illnesses of these children could be cured. The experiment was successful, and at the end of a month the Board of Voluntary vs Official Health Agencies Health hired 12 nurses to continue this work. The efficiency of the program was further documented by a dramatic The outcome of this rapid growth in preventive services decrease in absenteeism.' 27'28 varied from city to city with voluntary and "official" gov- Visiting nurse associations also assumed an important ernment agencies assuming essentially unpredictable, often role in the campaign against tuberculosis. Tuberculosis was overlapping, responsibilities. As the confusion grew so did seen as a "house disease" if the very poor, and its elimina- the debate as to the relative functions of the voluntary or tion required the personal cooperation of patients and their "nonofficial" versus the official health agencies. The central families. By the turn ofthe century, it had become clear that, concern was one of control.22'35 As Haven Emerson, a although medical science was now able to provide a great former Health Commissioner of New York City, later re- deal of information about tuberculosis and specific guidance membered, "competition and rivalry in methods, resources as to its prevention, no prompt or simple medical solution and accomplishments became as keen as in selling soup or was forthcoming. The campaign would need many more advertising tooth paste."12 clinics and sanatoriums, but more importantly any progress While locally voluntary and public agencies negotiated required overcoming of public apathy and ignorance.' 29 their rather idiosyncratic relationships, publicly the struggle The visiting nurse seemed ideally suited for this task for consensus continued in the journals. The views of the and, not surprisingly, visiting nurse associations were among public health nursing leadership and their predominately the first voluntary societies working to combat tuberculo- voluntary organizations most commonly appeared in the

1158 AJPH October 1985, Vol. 75, No. 10 PUBLIC HEALTH THEN AND NOW

existence of their non-official agencies.38'39 According to such public health officials, private health organizations had "mistaken their functions and misunderstood their relation- ship to government." Such organizations needed to be put in their proper place: "standing back of and helping the official agencies, placing themselves at the disposal of the health officer and permitting him to direct their activities according to his plan.' '38,39 As might be expected, debate over the proper domain of public health practice was not confined to these struggles between voluntary and public organizations. Attempts by health departments to extend the focus of their concerns also often resulted in conflict with the medical profession. Inev- itably, most health officers found themselves forced to abandon claims to any curative activities that might be construed as threatening the economic well-being of private physicians. Consequently, despite much ongoing discussion, health department and school health services become in- creasingly preventive.4042 What they chose for themselves, they not surprisingly chose for their employees and, accordingly, many health officers believed the work of the public health nurse was hygienic, not therapeutic. Thus, an inescapable, though seemingly unexpected, consequence was the limitation of Visiting nurse comforts mother as police officer aids her in removing sick baby the activities of these publicly supported nurses to the to the hospital. (Photo credit: National Library of Medicine) prevention of disease, leaving the care of the sick to the visiting nurse associations. Some health officers even went so far as to suggest that nurses who spent any significant Public Health Nurse, while those of the public health amount of their time providing bedside care should not even physicians and their official agencies were usually expressed be classified as public health nurses.24'43 in the American Journal of Public Health. of them superintendents In these articles, voluntary organizations characterized The nursing leadership, many themselves as fulfilling a set of responsibilities that they of visiting nurse associations, were outraged by such asser- could accomplish with "peculiar fitness and effectiveness." tions. Visiting nurses, they insisted, had always been teach- They saw their purpose as assisting or supplementing official ers of prevention and hygiene and had in fact "blazed the activities through education, research, demonstration, and trail" for all of the health departments' new preventive standardization. Health officers, they claimed, could not programs. But, unlike their narrowly focused critics, they attend to the details of their administrative work and simul- had possessed the wisdom to see the value of caring for the taneously conduct the needed investigations. Nor could the sick as a means of gaining access to families in greatest need health department be justified in using tax money to test new of . Were the assertions of health officers methods of work. It was therefore the task of the voluntary that visiting nurses were not public health nurses made, they agency to conduct these experimental programs. Once the wondered, "to keep the visiting nurse in her place, outside work of a particular program was established, public interest the sphere of public health work?" If so, these efforts were aroused, and the most effective methods established, the in vain, for the visiting nurse was as much a public health official agency could, they argued, easily obtain expansion nurse as any nurse employed by the health departments."44 funds for their continuation as part of a governmental By the 1920s, many nursing leaders were campaigning program. 36,37 for the creation of an institutional framework that would Thus voluntary agencies saw themselves as a corner- allow the public health nurse to care for both the healthy and stone of public health work. As Isabel Lowman described it, the sick. Realizing that separating the curative and preven- they were "an experimental laboratory whose cost in energy tive functions of the public health nurse had been a mistake, and money must ever be a surtax on the good will of the they argued for an "amalgamated" organization that would private individual."36 While admitting that at some point all health activities might conceivably be taken over by public unite both the voluntary and publicly funded agencies.26 health departments, the voluntary agencies claimed that the Even though these views were substantiated in numerous time had not yet come. Organizations for demonstration projects and major reports throughout the were far from complete and health officers were far from 1920s and 1930s, nurses gained few allies in their efforts to wise, contended these voluntary agencies, while the public create such agencies. In most communities, relationships was not educated to the point of recognizing the need to between these organizations remained haphazard, with gaps provide sufficient money for health programs.37 and duplication in services the inevitable outcome.33'48'49 In contrast, some health officers tended not to see the With health departments, school health services, and activities of voluntary health organizations as supportive or visiting nurse associations providing a perplexing assortment cooperative, but as competitive and self-serving. The grow- of both curative and preventive nursing services, the mean- ing popularity of public health, declared Francis Curtis, ing of public health nursing became increasingly obscure to Chairman of the Newton, Massachusetts Board of Health, both its practitioners and the public.48 50 The legacy of this causes clever people to see it as a means for justifying the dilemma still haunts contemporary public health nursing.5"

AJPH October 1985, Vol. 75, No. 10 1159 PUBLIC HEALTH THEN AND NOW

ued its campaign for the creation of a publicly funded comprehensive nursing service, the concerns of nurses in most official agencies were confined to the teaching of

.. prevention.48 _1_...... Thus, within both public and voluntary organizations, public health nurses found it increasingly difficult to create the kind of institutional setting that would allow them to offer every kind of nursing service to patients in their homes. Despite their failed ideal, public health nurses went on caring for at least some of the public-in sickness or in health-but rarely the same nurse for both.

ACKNOWLEDGMENTS This study was supported in part by American Nurses' Foundation, Nurses' Educational Funds, Inc., and the Division of Nursing of the US Department of Health and Human Services, grant #NU-05087. Photographs, o~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-7- except where noted otherwise, were provided by the Board of Managers of the Visiting Nurse Society of Philadelphia, founded in 1886 and the antecedent of Community Home Health Services of Philadelphia. I wish to thank Charles Rosenberg and Joan Lynaugh for their critical review of this manuscript. I am especially grateful to Susan Reverby for her '~~~~~~~~~~~~~~~~~~~~~~~.support and comments. REFERENCES The nurse's visit often caused a gathering of neighbors. (Photo credit: Philadel- I. Brainard A: The Evolution of Public Health Nursing. Philadelphia: W.B. phia Visiting Nurse Society) Saunders, 1922. 2. Boyer P: Urban Masses and Moral Order in America. Cambridge: Harvard University Press, 1978. 3. Duffy J: Social impact of disease in the late 19th century. In: Leavitt J, Domain ofPublic Health Nursing Numbers R (eds): Sickness and Health in America. Madison: University of Wisconsin Press, 1978; 395-402. Thus, during its first 50 years, the domain of the 4. Rosenberg C: Social class and medical care in 19th century America. J public Hist Med Allied Sci 1974: 29:32-54. health nurse came to include almost every health aspect of 5. Fulmer H: History of visiting nurse work in America. Am J Nurs 1902: life from the care of the sick to the prevention of disease. 2:411-425. Unmistakably, to the public and voluntary agencies who 6. Rosner D: Health care for the 'truly needy': nineteenth century origins of sought their services, these nurses seemed an economical the concept. Milbank Mem Fun Q 1982; 60:355-385. 7. Rosner D: A Once Charitable Enterprise: Hospitals and Health Care in and appropriate way to help the poor. By the late 1920s, Brooklyn and New York, 1885-1915. 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Boston: Little Brown, 1934. health nurse in these organizations reflected more the policy 22. Gardner M: Public Health Nursing. New York: MacMillan, 1916. of their organization or desires of the health officer than the 23. La Motte E: The Tuberculosis Nurse: Her Function and Her Qualifica- "visions" of the nurses. This break with custom and loss of tions. New York: Putnum's Sons, 1915. 24. Royer BF: Public health nursing vs. bedside work. Public Health Nurse authority was, not surprisingly, of great concern to many 1923; 15:231-234. leading public health nurses.26 While the leadership contin- 25. Nutting A: Nursing and health. Visiting Nurse Q 1910; 2:10-13.

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26. Buhler-Wilkerson K: False Dawn: The Rise and Decline of Public Health 41. Rosen G: The Structure of American Medical Practice: 1875-1941. Nursing, 1900-1930. PhD dissertation, University of Pennsylvania, 1984. Philadelphia: University of Pennsylvania Press, 1984. 27. Struthers (Rogers) L: The School Nurse. New York: Putnum, 1917. 42. Duffy J: The American medical profession and public health: from 28. Dock LL: The school nurse experiment in New York. Am J Nursing 1902; support to ambivalence. Bull Hist Med 1979; 53:1-22. 3:108-110. 43. Hill HW: Is the visiting nurse a public health nurse? Public Health Nurse 29. Shryrock R: National Tuberculosis Association 1904-1954: A Study of the 1923; 15:231-234. Voluntary Health Movement in the United States. New York: National 44. For an interesting discussion of these developments see, Melosh B: The Tuberculosis Association, 1957. Physician's Hand: Work, Culture, and Conflict in American Nursing. 30. Visiting Nurse Society of Philadelphia: Annual Report, 1907. Philadelphia: Temple University Press, 1982. 31. Graves S: Instructive Association: 1885-1912. MSN thesis, 45. Tucker K: Whither? Public Health Nurse 1919; 11:700-702. Boston University, 1970. 46. Fox E: Is a visiting nurse a public health nurse? Public Health Nurse 1919; 32. Bower I: Public Health Nursing in Cleveland, 1895-1928. Cleveland: 11:575-578. Western Reserve University, 1930. 47. Theory or experience? Public Health Nurse 1919; 11:579-581. 33. Goldmark J: Nursing and Nursing Education in the United States. New 48. National Organization for Public Health Nursing: Survey of Public Health York: MacMillan, 1923. Nursing: Administration and Practice: New York: Commonwealth Fund, 34. Waters Y:Visiting Nursing in the United States. New York: Charities 1934. Publication, 1909. 49. East Harlem Nursing and Health Service: A Comparative Study of 35. See for example the series of articles: Relative functions of official and Generalized and Specialized Health Services, 1926: New York: Garland non-official agencies: a symposium. Am J Public Health 1920; 10:940-972. Publishing Company, 1984 (reprint edition). 36. Lowman I: The relation of private and municipal antituberculosis activi- 50. Welch M: What is public health nursing? Am J Nursing 1936; 36:452-456. 51. Williams C: Community health nursing-what is it? Nursing Outlook ties. Public Health Nurse Q 1914; 6:40-51. 1977; 25:250-254. 37. Hatsfield C: Relative functions of health agencies: viewpoint of the 52. Reverby S: Something besides waiting: the politics of non-official agency. Am J Public Health 1920; 10:948-952. reform in the depression. In: Lagemann E (ed): Nursing History; New 38. Curtis FG: Relative functions of health agencies: relation between official Perspectives, New Possibilities. New York: Teachers College Press, and non-official health agencies. Am J Public Health 1920; 10:956-960. 1983; 133-156. 39. McCombs CE: Public health and private health agencies. Am J Public 53. Davis M: Nursing service measured by social needs. Am J Nursing 1939; Health 1919; 9:951-955. 39:35-40. 40. Rosenkrantz BG: Public Health and the State: Changing Views in 54. Tattershall L: Census of public health nursing in the United States. Public Massachusetts, 1842-1936. Cambridge: Harvard University Press, 1972. Health Nurse 1926; 18:266.

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AJPH October 1985, Vol. 75, No. 10 1161 This article has been cited by:

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