Early colonial public health efforts included the collection of vital statistics, improvements to sanitation systems, and control of any communicable diseases introduced through seaports. Colonists lacked a continuing and organized mechanism for ensuring that public health efforts would be supported and enforced. Epidemics intermittently taxed the limited local organization for health during the seventeenth, eighteenth, and nineteenth centuries (Rosen, 1958).

After the American Revolution, the threat of disease, especially yellow fever, brought public support for establishing government-sponsored, or official, boards of health. New York City, with a population of 75,000 by 1800, had established basic public health services, which included monitoring water quality, constructing sewers and a waterfront wall, draining marshes, planting trees and vegetables, and burying the dead (Rosen, 1958).

Increased urbanization and beginning industrialization in the new United States contributed to increased incidence of disease, including epidemics of smallpox, yellow fever, cholera, typhoid, and typhus. Tuberculosis and malaria remained endemic at a high incidence rate, and infant mortality was about 200 per 1000 live births (Pickett and Hanlon, 1990). American hospitals in the early 1800s were generally unsanitary and staffed by poorly trained workers; institutions were a place of last resort. Physicians received a limited education through proprietary schools or simple apprenticeship. Medical care was difficult to secure, although public dispensaries (similar to outpatient clinics) and private charitable efforts attempted to address gaps in the availability of sickness services, especially for the urban poor and working classes. Environmental conditions in urban neighborhoods, including inadequate housing and sanitation, were additional risks to health. Table 2-1 presents milestones of public health efforts that occurred during the seventeenth, eighteenth, and nineteenth centuries.

During the early 1800s, experiments in providing nursing care at home focused on moral improvement and less on illness intervention. The Ladies’ Benevolent Society of Charleston, South Carolina, provided charitable assistance to the poor and sick beginning in 1813. In Philadelphia, lay nurses after a brief training program cared for postpartum women and newborns in their homes. In Cincinnati, Ohio, the Roman Catholic Sisters of Charity began a visiting nurse service in 1854 (Rodabaugh and Rodabaugh, 1951). Although these early programs provided services at the local level, they were not adopted elsewhere, and their influence on later public health nursing is unclear.

During the mid-nineteenth century, national interest increased in addressing public health problems and improving urban living conditions. New responsibilities for urban boards of health reflected changing ideas of public health, as the boards began to address communicable diseases and environmental hazards. Soon after it was founded in 1847, the American Medical Association (AMA) formed a hygiene committee to conduct sanitary surveys and to develop a system to collect vital statistics. The Shattuck Report, published in 1850 by the Massachusetts Sanitary Commission, called for major innovations: the establishment of a state health department and local health boards in every town; sanitary surveys and collection of vital statistics; environmental sanitation; food, drug, and communicable disease control; well-child care; health education; tobacco and alcohol control; town planning; and the teaching of preventive medicine in medical schools (Kalisch and Kalisch, 1995). However, these recommendations were not implemented in Massachusetts until 1869, and in other states much later.

In some areas, charitable organizations addressed the gap between known communicable disease epidemics and the lack of local government resources. For example, the Howard Association of New Orleans, Louisiana, responded to periodic yellow fever epidemics between 1837 and 1878 by providing physicians, lay nurses, and medicine. The Association established infirmaries and used sophisticated outreach strategies to locate cases (Hanggi-Myers, 1995).

The origins of professional nursing are found in the work of Florence Nightingale in nineteenth-century Europe. With tremendous advances in transportation, communication, and other forms of technology, the Industrial Revolution led to deep social upheaval. Even with the advancement of science, medicine, and technology in the two previous centuries, nineteenth-century public health measures continued to be very basic. Organization and management of cities improved slowly, and many areas lacked systems of sewage disposal and depended on private enterprise for water supply. Previous caregiving structures, which relied on the assistance of family, neighbors, and friends, became inadequate in the early nineteenth century because of human migration, urbanization, and changing demand. During this period, a few groups of Roman Catholic and Protestant women provided nursing care for the sick, poor, and neglected in institutions and sometimes in the home. For example, Mary Aikenhead, also known by her religious name Sister Mary Augustine, organized the Irish Sisters of Charity in Dublin (Ireland) in 1815. These sisters visited the poor at home and established hospitals and schools (Kalisch and Kalisch, 1995).

In nineteenth-century England, the Elizabethan Poor Law continued to guarantee medical care for all. This minimal care, provided most often in almshouses supported by local government, sought as much to regulate where the poor could live as to provide care during illness. Many women who performed nursing functions in almshouses and early hospitals in Great Britain were poorly educated, untrained, and often undependable. As the practice of medicine became more complex in the mid-1800s, hospital work required skilled caregivers. Physicians and hospital administrators sought to advance the practice of nursing. Early experiments yielded some improvement in care, but Florence Nightingale’s efforts were revolutionary.

Florence Nightingale’s vision of trained nurses and her model of nursing education influenced the development of professional nursing and, indirectly, public health nursing in the United States. In 1850 and 1851, Nightingale had carefully studied nursing “system and method” by visiting Pastor Theodor Fliedner at his School for Deaconesses in Kaiserwerth, Germany. Pastor Fliedner also built on the work of others, including Mennonite deaconesses in Holland who were engaged in parish work for the poor and the sick, and Elizabeth Fry, the English prison reformer. Thus mid-nineteenth century efforts to reform the practice of nursing drew on a variety of interacting innovations across Europe.

The Kaiserwerth Lutheran deaconesses incorporated care of the sick in the hospital with client care in their homes, and their system of district nursing spread to other German cities. American requests for the deaconesses to respond to epidemics of typhus and cholera in Pittsburgh provided only temporary assistance since local women were uninterested in the work. The early efforts of the Lutheran deaconesses in the United States ultimately focused on developing systems of institutional care (Nutting and Dock, 1935).

Nightingale soon found a way to implement her ideas about nursing. During the Crimean War (1854–1856) between the alliance of England and France against Russia, the British military established hospitals for sick and wounded soldiers at Scutari (in modern Turkey). The care of the sick and wounded soldiers was severely deficient, with cramped quarters, poor sanitation, lice and rats, insufficient food, and inadequate medical supplies (Kalisch and Kalisch, 1995; Palmer, 1983). When the British public demanded improved conditions, Nightingale sought and received an appointment to address the chaos. Because of her wealth, social and political connections, and knowledge of hospitals, the British government sent her to Asia Minor with 40 ladies, 117 hired nurses, and 15 paid servants.

In Scutari, Nightingale progressively improved soldiers’ health outcomes using a population-based approach that strengthened environmental conditions and nursing care. Using simple epidemiological measures, she documented a decreased mortality rate from 415 per 1000 at the beginning of the war to 11.5 per 1000 at the end (Cohen, 1984; Palmer, 1983). Paralleling Nightingale’s efforts in Scutari, public health nurses typically identify health care needs that affect the entire population, mobilize resources, and organize themselves and the community to meet these needs.

Nightingale’s fame was established even before she returned to England in 1856 after the Crimean War. She then organized hospital nursing practice and established hospital-based nursing education to replace the untrained lay nurses with Nightingale nurses. Nightingale also emphasized public health nursing: “The health of the unity is the health of the community. Unless you have the health of the unity, there is no community health” (Nightingale, 1894, p. 455). She differentiated “sick nursing” from “health nursing.” The latter emphasized that nurses should strive to promote health and prevent illness. Nightingale (1946, p. v) wrote that nurses’ task is to “put the constitution in such a state as that it will have no disease, or that it can recover from disease.” Proper nutrition, rest, sanitation, and hygiene were necessary for health. Nurses continue to focus on the vital role of health promotion, disease prevention, and environment in their practice with individuals, families, and communities.

Nightingale’s contemporary and friend, British philanthropist William Rathbone, founded the first district nursing association in Liverpool, England. Rathbone’s wife had received outstanding nursing care from a Nightingale-trained nurse during her terminal illness at home. He wanted to offer similar care to relieve the suffering of poor persons unable to afford private nurses. With Rathbone’s advocacy and economic support between 1859 and 1862, the Liverpool Relief Society divided the city into nursing districts and assigned a committee of “friendly visitors” to each district to provide health care to needy people (Kalisch and Kalisch, 1995). Building on the Liverpool experience, Rathbone and Nightingale recommended steps to provide nursing in the home, and district nursing was organized throughout England. Florence Sarah Lees Craven shaped the profession through her book A Guide to District Nursing, which recommended, for example, that nursing care during the illness of one family member provided the nurse with influence to improve the health status of the whole family (Craven, 1889).

The care of the sick poor at home was made economical by having home-visiting nurses attend several families in a day rather than attend only one client as the private duty nurse did. In 1877 the Women’s Board of the New York City Mission hired Frances Root, a graduate of Bellevue Hospital’s first nursing class, to visit sick poor persons to provide nursing care and religious instruction (Bullough and Bullough, 1964). In 1878 the Ethical Culture Society of New York hired four nurses to work in dispensaries, a type of community-based clinic. In the next few years, visiting nurse associations (VNAs) were established in Buffalo, New York (1885), Philadelphia (1886), and Boston (1886). Wealthy people interested in charitable activities funded both settlement houses and VNAs. Upper-class women, freed of some of the social restrictions that had previously limited their public life, became interested in the charitable work of creating, supporting, and supervising the new visiting nurses. Public health nursing in the United States began with organizing to meet urban health care needs, especially for the disadvantaged.

The public was interested in limiting disease among all classes of people not only for religious reasons as a form of charity, but also because the middle and upper classes feared the impact of communicable diseases believed to originate in the large communities of new European immigrants. In New York City in the 1890s, about 2.3 million people lived in 90,000 tenement houses. Deplorable environmental conditions for immigrants in urban tenement houses and sweatshops were common across the northeastern United States and upper Midwest. “Slum dwellers were ravaged by epidemics of typhus, scarlet fever, smallpox, and typhoid fever, and many of them died or developed tuberculosis” (Kalisch and Kalisch, 1995, p. 172). From the beginning, nursing practice in the community included teaching and prevention (Figure 2-1). Nursing interventions, improved sanitation, economic improvements, and better nutrition were credited with reducing the incidence of acute communicable disease by 1910.

New scientific explanations of communicable disease suggested that preventive education would reduce illness. The visiting nurse became the key to communicating the prevention campaign, through home visits and well-baby clinics. Visiting nurses worked with physicians, gave selected treatments, and kept temperature and pulse records. Visiting nurses emphasized education of family members in the care of the sick and in personal and environmental prevention measures, such as hygiene and good nutrition (Figure 2-2). Many early visiting nurse agencies employed only one nurse, who was supervised by members of the agency board, usually composed of wealthy or socially prominent ladies who were not nurses. These ladies were critically important to the success of visiting nursing through their efforts to open new agencies, financially support existing agencies, and render the services socially acceptable. The work of both visiting nurses and their lady supporters reflected changing societal roles for women as it became more acceptable for women to be active in public arenas than it had been earlier in the nineteenth century.

For example, in 1886 two Boston women approached the Women’s Education Association to seek local support for district nursing. To increase the likelihood of financial support, they used the term instructive district nursing to emphasize the relationship of nursing to health education. The Boston Dispensary provided support in the form of free outpatient medical care. In 1886 the first district nurse was hired, and in 1888 the Instructive District Nursing Association became incorporated as an independent voluntary agency. Sick poor persons, who paid no fees, were cared for under the direction of a trained physician (Brainard, 1922).

Other nurses established settlement houses—neighborhood centers that became hubs for health care, education, and social welfare programs. For example, in 1893 Lillian Wald and Mary Brewster, both trained nurses, began visiting the poor on New York’s Lower East Side. The nurses’ settlement they established became the Henry Street Settlement and later the Visiting Nurse Service of New York City. By 1905 the public health nurses had provided almost 48,000 visits to more than 5000 clients (Kalisch and Kalisch, 1995). Lillian Wald emerged as the established leader of public health nursing during its early decades (Box 2-1; Figure 2-3). Other settlement houses influenced the growth of community nursing including the Richmond (Virginia) Nurses’ Settlement, which became the Instructive Visiting Nurse Association; the Nurses’ Settlement in Orange, New Jersey; and the College Settlement in Los Angeles, California.

BOX 2-1

LILLIAN WALD: FIRST PUBLIC HEALTH NURSE IN THE UNITED STATES

Beyond New York City, Lillian Wald took steps to increase access to public health nursing services through innovation. She persuaded the American Red Cross to sponsor rural health nursing services across the country, which stimulated local governments to sponsor public health nursing through county health departments. Beginning in 1909, Wald worked with Dr. Lee Frankel of the Metropolitan Life Insurance Company (MetLife) to implement the first insurance payment for nursing services. She argued that keeping working people and their families healthier would increase their productivity. MetLife found that nursing care for communicable diseases, injuries, and mothers and children reduced mortality and saved money for this life insurance company. MetLife nursing services continued for 44 years, yielding accomplishments in (1) providing home nursing services on a fee-for-service basis, (2) establishing an effective cost-accounting system for visiting nurses, and (3) reducing mortality from infectious diseases.

Convinced that environmental conditions as well as social conditions were the causes of ill health and poverty, Wald became actively involved in using epidemiological methods to campaign for health-promoting social policies. She advocated for creation of the U.S. Children’s Bureau as a basis for improving the health and education of children nationally. She fought for better tenement living conditions in New York City, city recreation centers, parks, pure food laws, graded classes for mentally handicapped children, and assistance to immigrants. She firmly believed in women’s suffrage and considered its acceptance in 1917 in New York State to be a great victory. Wald supported efforts to improve race relations and championed solutions to racial injustice. She wrote The House on Henry Street (1915) and Windows on Henry Street (1934) to describe this public health nursing work.

Backer BA: Lillian Wald: connecting caring with action, Nurs Health Care 14:122, 1993;

Cristy TE: Lillian D. Wald: portrait of a leader. In Kelly LY: Pages from nursing history, New York, 1984, American Journal of Nursing Co., pp 84-88;

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Zerwekh JV: Public health nursing legacy: historical practical wisdom, Nurs Health Care 13:84, 1992.

Jessie Sleet (Scales), a Canadian graduate of Provident Hospital School of Nursing (Chicago), became the first African-American public health nurse when she was hired by the New York Charity Organization Society in 1900. Although it was hard for her to find an agency willing to hire her as a district nurse, she persevered and was able to provide exceptional care for her clients until she married in 1909. At the Charity Organization Society in 1904 to 1905, she studied health conditions related to tuberculosis among African-American people in Manhattan using interviews with families and neighbors, house-to-house canvases, direct observation, and speeches at neighborhood churches. Sleet reported her research to the Society board, recommending improved employment opportunities for African-Americans and better prevention strategies to reduce the excess burden of tuberculosis morbidity and mortality among the African-American population (Buhler-Wilkerson, 2001; Hine, 1989; Mosley, 1994; Thoms, 1929).

In 1909 Yssabella Waters published her survey titled Visiting Nursing in the United States, which documented the concentration of visiting nurse services in the northeastern quadrant of the nation. In 1901 New York City alone had 58 different organizations with 372 trained nurses providing care in the community. However, nationally, 68% of visiting nurses were employed in single-nurse agencies. In addition to VNAs and settlement houses, a variety of other organizations sponsored visiting nurse work, including boards of education, boards of health, mission boards, clubs, churches, social service agencies, and tuberculosis associations. With tuberculosis then responsible for at least 10% of all mortality, visiting nurses contributed to its control through gaining “the personal cooperation of patients and their families” to modify the environment and individual behavior (Buhler-Wilkerson, 1987, p. 45). Most visiting nurse agencies depended financially on the philanthropy and social networks of metropolitan areas. As today, fund-raising and service delivery in less densely populated and rural areas was challenging.

WHAT DO YOU THINK?

Lillian Wald demonstrated an exceptional ability to develop approaches and programs to solve the health care and social problems of her times. How would you apply this creativity to today’s health care challenges? If Lillian Wald were looking over your shoulder, what would she recommend?

The American Red Cross, through its Rural Nursing Service (later the Town and Country Nursing Service), provided a framework to initiate home nursing care in areas outside larger cities. Wald secured initial donations to support this agency, which provided care of the sick and instruction in sanitation and hygiene in rural homes. The agency also improved living conditions in villages and isolated farms. The Town and Country nurse dealt with diseases such as tuberculosis, pneumonia, and typhoid fever with a resourcefulness born of necessity. The rural nurse might use hot bricks, salt, or sandbags to substitute for hot water bottles; chairs as back-rests for the bedbound; and boards padded with quilts as stretchers (Kalisch and Kalisch, 1995). In the 2 years after World War I, the 100 existing Red Cross Town and Country Nursing Services expanded to 1800, and eventually to almost 3000 programs in small towns and rural areas. This service demonstrated the importance and feasibility of public health nursing across the country at local and county levels. Once firmly established by the Red Cross, ongoing responsibilities for these new agencies were passed on to local voluntary agencies or local government.

Occupational health nursing began as industrial nursing and was a true outgrowth of early home visiting efforts. In 1895 Ada Mayo Stewart began work with employees and families of the Vermont Marble Company in Proctor, Vermont. As a free service for the employees, Stewart provided obstetric care, sickness care (e.g., for typhoid cases), and some post-surgical care in workers’ homes. Unlike contemporary occupational health nurses, Stewart provided very few services for work-related injuries. A graduate of the Waltham (Massachusetts) Training School, Stewart continued to wear the Waltham nursing student uniform, and added a plain coat and hat. Although her employer provided a horse and buggy, she often made home visits on a bicycle. Before 1900 a few nurses were hired in industry, such as in department stores in Philadelphia and Brooklyn. Between 1914 and 1943, industrial nursing grew from 60 to 11,220 nurses, reflecting increased governmental and employee concerns for health and safety at work (AAIN, 1976; Kalisch and Kalisch, 1995).

Lina Rogers, a Henry Street Settlement resident, became the first school nurse. She worked with the children in New York City schools and made home visits to instruct parents and to follow up on children excluded or otherwise absent from school. The school nurses found that “many children were absent for lack of shoes or clothing, because of malnourishment, or because they were serving their families as babysitters” (Hawkins, Hayes, and Corliss, 1994, p. 417). The school nurse experiment made such a significant and positive impact that it became permanent, with 12 more nurses appointed 1 month later. School nursing was soon implemented in Los Angeles, Philadelphia, Baltimore, Boston, Chicago, and San Francisco.

Established by the Cleveland Visiting Nurse Association in 1909, the Visiting Nurse Quarterly initiated a professional communication medium for clinical and organizational concerns. In 1911 a joint committee of existing nurse organizations convened, under the leadership of Wald and Mary Gardner, to standardize nursing services outside the hospital. Recommending formation of a new organization to address public health nursing concerns, 800 agencies involved in public health nursing activities were invited to send delegates to an organizational meeting in Chicago in June 1912. After a heated debate on its name and purpose, the delegates established the National Organization for Public Health Nursing (NOPHN) and chose Wald as its first president (Dock, 1922). Unlike other professional nursing organizations, the NOPHN membership included both nurses and their lay supporters. The NOPHN sought “to improve the educational and services standards of the public health nurse, and promote public understanding of and respect for her work” (Rosen, 1958, p. 381). With greater administrative resources than any of the other national nursing organizations existing at that time, the NOPHN was soon the dominant force in public health nursing (Roberts, 1955).

The NOPHN sought to standardize public health nursing education. Visiting nurse agencies found that graduates of the hospital schools were unprepared for home visiting. It became apparent that the basic curriculum of many schools of nursing was insufficient. Because diploma schools of nursing emphasized hospital care of clients, public health nurses would require additional education to provide services to the sick at home and to design population-focused programs. In 1914, in affiliation with the Henry Street Settlement, Mary Adelaide Nutting began the first post-training-school course in public health nursing at Teachers College in New York City (Deloughery, 1977). The American Red Cross provided scholarships for graduates of nursing schools to attend the public health nursing course. Its success encouraged development of other programs, using curricula that might seem familiar to today’s nurses. During the 1920s and 1930s, many newly hired public health nurses had to verify completion or promptly enroll in a certificate program in public health nursing. Others took leave for a year to travel to an urban center to obtain this further education. Correspondence courses (distance education) were even acceptable in some areas, for example, for public health nurses in upstate New York.

Public health nurses were also active in the American Public Health Association (APHA), which was established in 1872 to facilitate interprofessional efforts and promote the “practical application of public hygiene” (Scutchfield and Keck, 1997, p. 12). The APHA targeted reform efforts toward contemporary public health issues, including sewage and garbage disposal, occupational injuries, and sexually transmitted diseases. In 1923 the Public Health Nursing Section was formed within the APHA to provide nurses with a forum to discuss their concerns and strategies within the larger context of the major public health organization. The Section continues to serve as a focus of leadership and policy development for public health nursing.

Public health nursing in voluntary agencies and through the Red Cross grew more quickly than public health nursing sponsored by state, local, and national government. In the late 1800s, local health departments were formed in urban areas to target environmental hazards associated with crowded living conditions and dirty streets, and to regulate public baths, slaughterhouses, and pigsties (Pickett and Hanlon, 1990). By 1900, 38 states had established state health departments, following the lead of Massachusetts in 1869; however, these early state boards of health had limited impact. Only three states—Massachusetts, Rhode Island, and Florida—annually spent more than 2 cents per capita for public health services (Scutchfield and Keck, 1997).

The federal role in public health gradually expanded. In 1912 the federal government redefined the role of the U.S. Public Health Service, empowering it to “investigate the causes and spread of diseases and the pollution and sanitation of navigable streams and lakes” (Scutchfield and Keck, 1997, p. 15). The NOPHN loaned a nurse to the U.S. Public Health Service during World War I to establish a public health nursing program for military outposts. This led to the first federal government sponsorship of nurses (Shyrock, 1959; Wilner, Walkey, and O’Neill, 1978).

During the 1910s, public health organizations began to target infectious and parasitic diseases in rural areas. The Rockefeller Sanitary Commission, a philanthropic organization active in hookworm control in the southeastern United States, concluded that concurrent efforts for all phases of public health were necessary to successfully address any individual public health problem (Pickett and Hanlon, 1990). For example, in 1911 efforts to control typhoid fever in Yakima County, Washington, and to improve health status in Guilford County, North Carolina, led to establishment of local health units to serve local populations. Public health nurses were the primary staff members of local health departments. These nurses assumed a leadership role on health care issues through collaboration with local residents, nurses, and other health care providers.

The experience of Orange County, California, during the 1920s and 1930s illustrates the role of the public health nurse in these new local health departments. Following the efforts of a private physician, social welfare agencies, and a Red Cross nurse, the county board created the public health nurse’s position, which began in 1922. Presented with a shining new Model T car sporting the bright orange seal of the county, the nurse focused on the serious communicable disease problems of diphtheria and scarlet fever. Typhoid became epidemic when a drainage pipe overflowed into a well, infecting those who drank the water and those who drank raw milk from an infected dairy. Almost 3000 residents were immunized against typhoid. Weekly well-baby conferences provided an opportunity for mothers to learn about care of their infants, and the infants were weighed and given communicable disease immunizations. Children with orthopedic disorders and other disabilities were identified and referred for medical care in Los Angeles. At the end of a successful first year of public health nursing work, the Rockefeller Foundation and the California Health Department recognized the favorable outcomes and provided funding for more public health professionals.

The personnel needs of World War I in Europe depleted the ranks of public health nurses, even as the NOPHN identified a need for second and third lines of defense within the United States. Jane Delano of the Red Cross (which was sending 100 nurses a day to the war) agreed that despite the sacrifice, the greatest patriotic duty of public health nurses was to stay at home. In 1918 the worldwide influenza pandemic swept the United States from the Atlantic coast to the Pacific coast within 3 weeks and was met by a coalition of the NOPHN and the Red Cross. Houses, churches, and social halls were turned into hospitals for the immense numbers of sick and dying. Some of the nurse volunteers died of influenza as well (Shyrock, 1959; Wilner, Walkey, and O’Neill, 1978).

Problems of maternal and child morbidity and mortality spurred the passage of the Maternity and Infancy Act (often called the Sheppard-Towner Act) in 1921. This act provided federal matching funds to establish maternal and child health divisions in state health departments. Education during home visits by public health nurses stressed promoting the health of mother and child as well as seeking prompt medical care during pregnancy. Although credited with saving many lives, the Sheppard-Towner Program ended in 1929 in response to charges by the AMA and others that the legislation gave too much power to the federal government and too closely resembled socialized medicine (Pickett and Hanlon, 1990).

Some nursing innovations were the result of individual commitment and private financial support. In 1925 Mary Breckinridge established the Frontier Nursing Service (FNS) to emulate systems of care used in the Highlands and islands of Scotland (Box 2-2; Figure 2-4). The unique pioneering spirit of the FNS influenced development of public health programs geared toward improving the health care of the rural and often inaccessible populations in the Appalachian region of southeastern Kentucky (Browne, 1966; Tirpak, 1975). Breckinridge introduced the first nurse-midwives into the United States when she deployed FNS nurses trained in nursing, public health, and midwifery. Their efforts led to reduced pregnancy complications and maternal mortality, and to one-third fewer stillbirths and infant deaths in an area of 700 square miles (Kalisch and Kalisch, 1995). Today the FNS continues to provide comprehensive health and nursing services to the people of that area and sponsors the Frontier School of Midwifery and Family Nursing.

BOX 2-2

MARY BRECKINRIDGE AND THE FRONTIER NURSING SERVICE

Born in 1881 into the fifth generation of a Kentucky family, Mary Breckinridge devoted her life to the Frontier Nursing Service (FNS) and to promoting the health care of disadvantaged women and children. Educated by tutors and in private schools, Breckinridge considered becoming a nurse only after her first husband died. In 1907 she entered St. Luke’s Hospital School of Nursing in New York City. She later married for a second time, but her daughter died at birth and her son died at age 4 in 1918. In post–World War I France, Breckinridge administered maternal/child and public health programs, including a “goat crusade” in which Americans donated goats to provide milk for hungry European infants. In Great Britain, she became one of the first Americans to receive a nurse-midwifery certificate. At this time, nurse- midwifery training was not available in the United States. Breckinridge returned to the United States to take the 1-year public health nursing course at Teacher’s College of Columbia University in New York.

Passionate about helping the children of rural America and prepared to begin her life’s work, Breckinridge returned to Kentucky early in 1925. She had determined that Kentucky’s mountain region was an excellent place to demonstrate the value of public health nursing to improving the health of disadvantaged families living in remote areas. She thought that if it were possible to establish a nursing center in rural Kentucky, the program could be duplicated anywhere. Breckinridge used her family inheritance to start the Frontier Nursing Service. Establishing the first FNS health center in a five-room cabin in Hyden, Kentucky, required not only nursing skills, but also construction of the cabin, other buildings, and later the FNS hospital. Each step was difficult, including securing a water supply, electric power, and sewage disposal, and stabilizing a mountain terrain prone to landslides. Despite these obstacles, six outpost nursing centers were built between 1927 and 1930. When the FNS hospital in Hyden was completed in 1928, physicians began providing service. Financial support for FNS nursing and medical care ranged from client families’ labor exchange and farm product donation to fund-raising through annual family dues, philanthropy, and direct fund-raising by Breckinridge herself.

Serving nearly 10,000 people distributed over 700 square miles, the FNS provided nursing and midwifery services 24 hours a day and established medical, surgical, and dental clinics. Reduced death rates were especially remarkable considering the environmental conditions these rural Kentuckians faced. Many area homes lacked heat, electricity, and running water. During the 1930s, nurses lived in one of the six outposts. Transportation was difficult, as nurses, midwives, and couriers climbed mountains by foot and rode horses great distances. Like her staff, Breckinridge traveled through the remote mountains of Kentucky on her horse, Babette, providing food, supplies, and health care to mountain families. Breckinridge documented her experiences in the book Wide Neighborhoods, a Story of the Frontier Nursing Service.

Over the years, hundreds of nurses have worked with the FNS. Since Breckinridge died in 1965, FNS has continued to grow and provide needed services to people in the mountains of Kentucky. FNS remains a vital means to providing health services to rural families and as a creative model for nursing service delivery through its home health agency, outpost clinics, primary care centers, the Frontier School of Midwifery and Family Nursing, and the Mary Breckinridge Hospital.

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