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Lillian D. Wald: Pioneer of Public Health

Mary Ann Christopher, Regina Hawkey, and Mary Christine Jared

New York University Hall of Fame for Great Americans Medal, awarded in 1971, honoring Lillian D. Wald (front and back).

Long credited as a pioneer of public health nursing in America, Lillian D. Wald (1867–1940) personified the attributes of exemplary leadership in a way that transformed not only the nursing profession but society as a whole. Visionary, innovative, inspiring, passionate, and tenacious, she viewed the circumstances of her time not as obstacles to be overcome but as compelling catalysts for positive change. By harnessing the conditions of the late 1800s and early 1900s as the driving forces of her professional journey, she charted a course that would irrevocably alter the lives of individuals, the circumstances of both local communities and the broader U.S. population, and the future of professional nursing itself.

AN AGE OF TRANSFORMATION

From the 1890s to the 1920s, an unprecedented amount of political, social, and economic change was transforming the United States. Trumpeted as the Progressive Era by historians, the changes wrought during this time were so profound that their impact indelibly shaped life in the United States over the rest of the 20th century and into the new millennium (Gold, 2001).

The converging forces driving this change included public reaction and outrage to the problems that accompanied massive industrialism, urbanization, and immigration, as well as the promises ushered in by new advances in medicine and health care and expanding educational opportunities for both young people and adults. Women, for the first time in history, began to be full participants in driving change in both public and private domains (Muncy, 1998). The Progressive Movement veered away from the traditions of the past and America’s founding principles and “required the creation of a new order appropriate for the new Industrial Age” (West & Schambra, 2007, p. 1).

Other elements that factored into this revolution included a mounting anger over the treatment of poor and destitute immigrants who were flocking to the shores of the United States with no money, no health care, and no homes. Simultaneously, there was growing concern among the American elite that those living in poverty could spread diseases endemic in poor neighborhoods to anyone of any class. Men and women were also emerging who were uniquely motivated to take on the challenge of changing the fabric of society and leading the United States to become a nation in which the local, state, and federal government played a much more significant role in supporting its citizens—a role that included funding public health care and creating better educational systems.

One such person was the founder of public health nursing, Lillian D. Wald (1847–1940). Wald embodied a class of women who, because of their education, background, and social position, in combination with the cultural forces and changing attitudes of the Progressive Era, were able to make impressive contributions to “shaping public policy and creating public institutions” (Muncy, 1998, n.p.). Accomplished and often highly educated, these women were activists and leaders. These “new women,” in the words of Lillian Wald’s biographer Karen Buhler-Wilkerson, were “a revolutionary demographic and a political phenomenon.” “The new woman was typically single, educated, economically independent, a champion of professional visibility for women and an advocate of economic and social reform” (Buhler-Wilkerson, 1993, p. 1780).

The framework within which Wald’s contributions are perhaps best understood was captured poignantly in the words she herself offered to her staff in 1922: “The times call for the high spirit of the courageous pioneers among physicians, scientists, and nurses” (Buhler-Wilkerson, 2001, p. 113). A century before these concepts found their way into the health care landscape, Wald defined the criticality of patient and community engagement. In doing so, she distinguished herself first and foremost as a leader who enabled others to envision and create a better, bolder world. By modeling the way, Lillian Wald exhibited the attribute of exemplary leadership that creates and embodies standards of excellence, thus setting an example for others to follow. In Wald’s case, her example established the visionary framework for community-based nursing practice that has underpinned the U.S. health care system for over a century (Kouzes & Posner, 2012).

EARLY LIFE

The seeds of leadership acumen can be traced to a childhood that, in many ways, was emblematic of the American experience. Lillian Wald was born in Cincinnati, Ohio, on March 10, 1867, the second of four children of German immigrants, Max D. Wald and Minnie Schwartz. Her parents were descendants of rabbis and merchants from Germany and Poland, although Wald, herself, was not raised in a religiously observant household. Her father, an optical goods dealer, moved the family to Rochester, New York, when Wald was 11 years old and she would, from that point on, consider Rochester her home (Feld, 2009).

The same restlessness and adventurous spirit that inspired her parents to emigrate from Germany to Cincinnati and then move on to Rochester pervaded Wald’s personality. While she was afforded a private boarding school education and all the luxuries that money could buy during her childhood and adolescence, she also reacted to the shackles of a society that she felt offered limited opportunities for women. Rejected by Vassar College at the age of 16 because they considered her too young, Wald grew increasingly impatient with a life defined by the social circuit of Rochester (Lannon, 2006). Inspired by the home visit of a nurse to her then-pregnant older sister, Wald felt herself drawn to the care of the vulnerable and the sick. “In Lillian’s eyes everything noble and magnificent was embodied in the trained nurse who came to the house at the time” (Smith, 1929, p. 32). The seeds were thus sown for her life’s work.

Ambitious, intelligent, and talented, at age 22, Wald decided to leave her hometown to pursue a career in nursing. Given to rule breaking and risk taking, attributes often associated with exemplary leaders, Wald knew early on that she was called to a life not of privilege, but of serious work (Lannon, 2006). The same leadership attributes of taking risks and challenging rules would later characterize her approach to health care and societal reform. Ultimately, these leadership attributes would compel her to create the organizations that continue to carry on that tradition today—the Henry Street Settlement and the Visiting Nurse Service of New York (VNSNY).

Leaving Rochester in 1889, Wald enrolled in the New York Hospital School of Nursing. One year after graduation, following a discouraging stretch working as a nurse in a juvenile asylum in upper Manhattan, she enrolled at the Women’s Medical College. While studying there, Wald was assigned to the Lower East Side of Manhattan—a defining event that would change her life course. “The lack of public health care for the growing immigrant population of the neighborhood prompted Wald and fellow student, Mary Brewster, to abandon medical studies and work full time in the service of New York’s poorest residents” (Lannon, 2006, n.p.). A fundamental commitment to the poor would, in fact, always underscore Wald’s community-based nursing practice.

Wald first dedicated herself to offering home nursing courses on the Lower East Side, with the purpose of improving the circumstances of child-rearing, stemming communicable diseases, and facilitating the assimilation of new immigrants into the community. Wald based her model of intervention on her belief that the nurses “would not carry the entire responsibility but rather were available for guidance concerning measures that might be taken to alleviate problems” (Buhler-Wilkerson, 1993, p. 1780). Through this model, she promoted a sense of client or patient empowerment and engagement—an approach that continues to resound in today’s era of health care reform and health care delivery.

Quite serendipitously, Wald’s role expanded from classroom health educator to that of home visiting nurse. While teaching, she was called to the home of one of her students by the woman’s young child. Wald recounts following the child through “evil smelling streets,” up “slimy steps,” and into the sickroom. What she found there shocked her. “All the maladjustments of our social and economic relations seemed epitomized in this brief journey and what was found at the end of it,” she later wrote. “The husband was a cripple … the family of seven shared their rooms with boarders … and the sick woman lay in a wretched, unclean bed soiled with hemorrhage two days old” (Wald in Buhler-Wilkerson, 1993, p. 1779). That single walk crystallized the vision, values, and framework for the field of nursing that would eventually constitute home- and community-based care and public health nursing. Catalyzed to action by what she had seen in that neighborhood and in that tenement, Lillian Wald and her nursing colleague, Mary Brewster, moved into the neighborhood, with Wald “rejoicing that her training in the care of the sick gave her an ‘organic relationship’ with the community” (Buhler-Wilkerson, 1993, p. 1779). This concept of grassroots connectivity continues to constitute a fundamental construct of visiting nurse services nationally.

Wald’s bold shift in course evidenced the brand of creativity and imagination that differentiates exemplary leaders. This same quality allowed her to overcome a formidable societal knowledge deficit in pursuing her new direction. Wald had

This empathic competence facilitated her ability to establish the relationships that were critical to achieving health outcomes.

By exhibiting the adaptability, curiosity, and confidence to step from the classroom into the homes of patients, Wald displayed another attribute of exemplary leaders, one that creates a vision that is sufficiently flexible so that it is adaptable in a changing environment. A leader’s vision should identify a common, mutually meaningful purpose and inspire hope, motivate people to become involved, and enable others to act in order to achieve a better future (Kouzes & Posner, 2012). This fundamental adaptability and flexibility continues as a requisite attribute of today’s community-based nursing leaders, as the accelerated rates of change within health systems in transformation call leaders to mobilize staff, patients, and communities to a common, collective vision and goal in circumstances fraught with ambiguity.

Wald’s embrace of this approach is reflected in her insistence on a model of patient and community empowerment, drawing on that attribute of exemplary leaders, which is exquisitely relationship oriented and which affirms the wisdom of actively involving others and investing in partnerships, trustworthy cooperative relationships, and team building (Kouzes & Posner, 2012). Wald nurtured personal strength and self-confidence in others and encouraged others in taking the initiative and having a sense of responsibility, thereby creating an atmosphere of trust, dignity, and empowerment (Kouzes & Posner, 2012). In all that she accomplished, she worked through people—philanthropists who sponsored her settlement house, immigrants who participated in developing the priorities for the Henry Street Settlement, and elected officials who endorsed public policy that promoted the public health.

BUILDING ON THE PUBLIC HEALTH AND SETTLEMENT MOVEMENTS

From the beginning, Wald was determined that her work would address the health of both the individual and of the public. Just as she was influenced by the Progressive Movement and the increasing role of women in achieving social justice, Wald was also significantly impacted by the public health movement. Initiated in the mid-1700s in Rhode Island with the enactment of legislation mandating that pub owners collect data on customers’ infectious diseases, the movement expanded into nationwide, large-scale public health surveillance activities in the 1850s when “mortality statistics based on death registration and the decennial census were first published by the federal government for the entire country” (Thacker, Qualters, & Lee, 2012, p. 3). Systematic reporting of disease in the United States was introduced in the 1870s and, by 1893, all states were required to report infectious disease statistics to the federal government. The year 1893 is also when Lillian Wald and Mary Brewster moved into their tenement house on the Lower East Side of New York City in order to live among the people whom they would serve as public health nurses.

This relocation marked the beginning of Wald’s work at the Henry Street Settlement. The fact that it occurred at this point in the evolution of public health surveillance and public health nursing is more than a coincidence. The timing was ideal for Wald’s new endeavor: Public health nursing evolved in the late 19th century in the United States specifically to treat infectious disease in the home. The crowded, dirty, and densely populated tenements that arose in large urban areas during that period made for easy transmission of infectious organisms. Public concern from all levels of society drove historic change; community organizations mobilized and began sending nurses out into peoples’ homes to care for the sick. With these efforts, nurses were “protecting the public from the spread of infectious disease” (Buhler-Wilkerson, 1993, p. 1779). Lillian Wald developed a nursing model during her tenure as a visiting nurse that “owed much to the Progressive Reform and Public Health movements” (Buhler-Wilkerson, 1993, p. 1778). But she took the practice of public health one step further, believing “that public health nurses must treat social and economic problems, not simply take care of sick people” (Fee & Bu, 2010, p. 1206). Wald addressed social problems, such as social isolation and boredom, by creating recreational programs in the settlement house, and she worked to optimize employment conditions through her sponsorship of labor unions, particularly to address the workplace issues of women.

Wald’s decision to move to the Lower East Side was influenced by the settlement movement as well. This movement, which began in England in the mid-1800s and migrated to the United States shortly thereafter, encouraged educated and middle- to upper-class individuals to move into poor communities and live and work among those they served. Though the original intent was that the poor and uneducated would learn from their settlement benefactors, those managing the settlement houses also learned from those whom they served (Hansan, 2012). The movement became a mechanism for those who had never been introduced to the evils of poverty and the ramifications of its reach to see, firsthand, the horrible conditions in which the impoverished worked and lived. This understanding of a previously unknown, unacknowledged, or hidden reality spurred many settlement house owners to become advocates and activists for social change. Through this process, their immersion—once conceived of as a means of observing those in need, assisting them with health care services, and securing food and shelter for them—became a vehicle for long-lasting, sustained change and transformation, and a way to reach out to an entire population of people previously neglected or left behind.

It is also important to note that the settlement movement offered Wald and other women of her time a leadership opportunity and a chance to promote social change that was largely unavailable through other routes.

In 1895, Lillian Wald and Mary Brewster moved out of their own tenement house into a nearby house donated by financier and philanthropist Jacob Schiff, who had become very interested in the goals of the settlement venture and the mission of the work in which Wald and Brewster were involved. His decision to fund the purchase of the house at 265 Henry Street “provided Wald with the means to more effectively help immigrants and slum dwellers of every race and religion, whose care she made her life’s mission” (Ruel, 2014, p. 2). In this new, larger space, the Henry Street Visiting Nurse Service continued to evolve into what would eventually be called the Henry Street Nurses Settlement.

As the following passage from Wald biographer Robert Duffus indicates, the organization’s activities soon became well known enough to merit comment in one of the city’s leading newspapers.

In 1898, The New York Times reported in an article titled, “A Modest Institution that Does Good in Many Ways on the East Side”:

Over the next decade and a half, the Henry Street Settlement continued to grow steadily. By 1901, it had 15 nurses attending to 3,000 patients. Five years later, in 1906, the settlement was employing 22 full-time nurses who attended to 5,500 patients, making 53,000 professional calls that year (Reznick, 1973) and operating out of 18 district centers (Feld, 2009). By 1910, the staff had grown to 54 nurses who ran convalescent centers, three country homes, a number of first aid stations, and a maternal–child health service. That same year, the staff made 143,589 home visits and administered 18,934 first aid treatments (VNSNY, 2014).

The Henry Street Settlement’s development was rooted in Lillian Wald’s personal philosophy that the nurse’s “organic relationship with the environment should constitute the starting point for a universal service to the region” (Feld, 2009, n.p.). Wald saw this relationship between visiting nurses and their patients as key to helping society understand and empathize with the reality of how this entire population of people suffered, struggled, and tried to survive, as she described in her book, The House on Henry Street (Wald, 1915, p. 2):

At the same time, Wald actively encouraged the city’s public sector to assist in expanding her efforts. “In 1902, she arranged to have a Henry Street nurse provide full-time care to children in public schools. This program led the New York City Board of Health to organize the first public school nursing system” (Lannon, 2006, n.p.). Over the years, her advocacy came to have an impact on a national level as well: “As the Henry Street Nurses’ Service drew national attention, it became the model for similar programs in cities throughout the United States. Public health nursing emerged as a profession as a direct result of Wald’s work and ideas” (Lannon, 2006, n.p.).

EMPOWERING COMMUNITIES TO HELP THEMSELVES

As an exemplary nurse leader, Wald’s approach was aspirational, broad, and visionary. She defined health in its broadest conceptualization. She embraced a philosophy that considered physical, emotional, social, spiritual, and environmental variables in the well-being of individuals and communities. A pioneer in the provision of holistic health care, Wald’s methods encompassed what we now know as the biopsychosocial model of health care. This model recognizes that the psychosocial dimensions (psychological, socioeconomic, and cultural), along with the biologic aspects, contribute to an individual’s functioning in the circumstances of disease or illness.

Although nursing services were a predominant focus of her settlement house, its scope also included housing, education, and social services. Within the Henry Street Settlement, Wald established boys’ and girls’ clubs, social events, classes in English, drama courses, and arts and crafts activities (Feld, 2009). In 1913, Wald described the settlement as having evolved into

This building of “community” was critically important to an immigrant population that was in many ways disconnected from the broader society.

Wald’s broad view of health included standing up for social fairness. She “made sure that her Settlement Houses not only provided services, but also employment, for members of all racial and ethnic groups” (Jewish Women’s Archive, n.d., n.p.). In 1909, her concerns over racial injustice led Wald to host “the National Negro Conference, a gathering held at Henry Street … [that] became the founding meeting of the National Association for the Advancement of Colored People [NAACP]” (Jewish Women’s Archive, n.d., n.p.).

In 1944, VNSNY and the Henry Street Settlement separated into two distinct corporations. Today’s Henry Street Settlement serves a new generation, primarily those of Asian, African American, and Latino backgrounds. With an annual budget of $35 million, the Henry Street Settlement now serves 50,000 individuals annually, supporting a range of programs that are reminiscent of those Wald founded. In the 2013 Henry Street Settlement annual report, which is posted on their website, a client’s words are quoted that poignantly affirm Wald’s continuing impact: “Henry Street changed my life for the better; all I had to do was walk in” (Henry Street Settlement, 2013, p. 7). This concept of neighborhood-based access continues to constitute a significant differentiator of effective community-based organizations.

In taking this broad approach, Wald’s goal was to empower communities and individuals by giving them the skills and infrastructure to improve their own situation—thereby demonstrating the attribute of exemplary leadership that “enables people to do for themselves.” To this end, Wald’s model of care was distinctly focused on patient and community. Cognizant that the health of individuals and groups is significantly impacted by active participation, she mobilized the strengths and the assets of the community. When faced with the ponderous architectural and environmental hazards of the neighborhood landscape, she effected change by mobilizing people to “do for themselves.”

Abraham Davis, who became acquainted with Wald as a small boy, recalled many years later at her memorial service: “She drew us into active cooperation with her and made us participants in her endeavors and thus fashioned our ideals, created our inspirations and stirred our ambitions” (Davis, 1940, as cited in Lannon, 2006, n.p.). When Davis first met Wald, he was attending the neighborhood boys’ club. At her memorial service, he shared his memories of the discussions being held at that time about the widening of Delancey Street—recalling how, through Lillian Wald’s lens, they began to view the possibility of a world no longer confined by narrow streets and congested pathways but instead filled with the advantages of broad thoroughfares, parks, and playgrounds:

This concept of helping patients do for themselves grew out of Wald’s initial step into community-based care, when she instructed young mothers in a classroom-like setting. In reflecting on the legacy of Lillian Wald, journalist Jean Hardin Farleigh recounted that while her work grew out of the needs of the people, “they have furthered it themselves. She prefers to be known as an educator” (Farleigh in Lannon, 2006, n.p.).

It is worth noting that Wald’s vision of health education as the foundation of community-based nursing practice is increasingly emphasized in today’s era of health care reform. Since her time, many factors have combined to largely deemphasize the educational role of visiting nurses and nursing in general—most notably, a public and private payer reimbursement system that has emphasized the technical over the teaching aspects of the nursing role. The result has been the long-standing perpetuation of a volume-based fee-for-service reimbursement system that has, in many ways, fostered client dependency. The current shift toward encouraging patient self-management of chronic conditions, however, is putting a renewed premium on the education and empowerment of patients and their families—a role that visiting nurses are ideally positioned to implement. This tradition of client and community empowerment has also remained a part of the fabric of VNSNY, the community-based health system that Wald founded with Mary Brewster more than 120 years ago. A prime example of this can be seen in VNSNY’s community-based emergency response to “Superstorm Sandy” in 2012, which is described later in this chapter.

Wald’s leadership style, a blend of the visionary and the practical, empowered those working alongside her as well. One of the most remarkable stories of the far-reaching effects of Wald’s leadership by example is that of her protégée, Margaret Sanger, one of America’s great pioneers in the fight to give women access to effective birth control. Kathryn Cullen-DuPont describes in her introduction to Sanger’s autobiography how Margaret found her life’s calling while working for the Henry Street Settlement:

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