1920-1929: Beginnings and Focus of Public Health Nursing in Mississippi
Public health nurses were initially employed in Mississippi by both the American Red Cross and National Tuberculosis Association between 1915 and 1917. The Report of the Mississippi State Board of Health 1897-1923 gives the first indication of public health nurses in the state. Hinds, Washington, and Adams counties supported public health nurses between 1916 and 1917. By 1919, public health nurses were employed in Lee, Bolivar, and Coahoma counties as well. These first public health nurses were employed by the American Red Cross and by the National Tuberculosis Association, two voluntary health associations that influenced the evolution of public health nursing both nationally and within the state.
Funding was apparently a joint effort between the American Red Cross or the Tuberculosis Association and local city or county funds. With the close of World War I, the American Red Cross had taken a national leadership role in establishing public health nursing standards, services, and uniform record and reporting systems. This leadership was significant and influential in Mississippi.
On February 27, 1920, the Mississippi Board of Health was approached by the American Red Cross with the request that "the American Red Cross desired to form a cooperative relation with the Board and place a state nurse in the Office of the Board of Health who would head up public health nursing activities. She would be under the direction of the State Board of Health." According to the Public Health and Medical Licensure in Mississippi 1798-1937, the Board accepted the proposal and Miss Nannie J. Lackland, R.N., was appointed to the position.
About the same time, the United States Public Health Service detailed Chief Nurse Laurie Jean Reid, R.N., to Mississippi to conduct a survey of maternal and infant health care which included the practice of lay midwives. Mississippi had the highest maternal death rate and the highest infant mortality rate of the entire United States.
The survey, completed in 1921, revealed approximately 5,000 women, both white and black, practicing midwifery in Mississippi. Few hospitals existed, and most deliveries, even by physicians, occurred in the home. At the conclusion of the survey, about 4,000 of the midwives wished to embark on an educational program with the State Board of Health, under the supervision of public health nurses.
Lackland resigned in late 1920, and in April 1921 Miss Mary D. Osborne was appointed Director of Public Health Nursing. The American Red Cross continued to fund this position until July 1, 1924 when the State Board of Health assumed full responsibility. Osborne lost no time in developing plans to recruit and train public health nurses. She recognized the major public health problems in the state were in the area of maternal and child care, tuberculosis, and communicable disease.
In 1921, the United States Congress enacted the Maternity and Infant Act, popularly called Sheppard-Towner Act, which set a precedent for federal grant in-aid programs to states for child and maternal care and education of personnel. Mississippi was one of only twenty-eight states that qualified for grants from this funding. Osborne quickly seized that funding source to provide training for nurses in maternal care, child care, and communicable disease. Even though registered in Mississippi, nurses often lacked instruction and experience in these essential areas.
Osborne's endeavors to establish the focus of public health nursing are noted as being extraordinary. Within the first two years, she accomplished the following: 1) queried private physicians as how best to proceed with midwife supervision with physicians' responses being both skeptical and less than enthusiastic; 2) formulated policies for midwives participation in midwife programs; 3) developed a Manual for Midwives; and 4) received reluctant approval from the State Board of Health for permits to be issued to midwives who met the requirements set forth by the State Board of Health.
The Manual for Midwives, produced in 1922 and used as a teaching guide and reference for the midwife, gained national and international recognition. Public Health and Medical Licensure in Mississippi 1798-1937 states that "the Mississippi midwife program attracted attention of workers in other states and countries, and more requests have come from foreign countries for the midwife manual than all other health bulletins combined."
Osborne became the Supervisor of Public Health Nurses and Supervisor of Midwives in 1922, a position she held until her resignation in 1946. Under her supervision, public health nurses began to fan out over the state where needs were greatest and, sometimes, where communities were receptive of these new concepts of nursing. Often women within local communities, such as Mrs. Phifer with the Tuberculosis Association, were the best advocates for establishing public health nursing throughout the state.
The nurses would spend a minimum of two months in a county. Armed with the new Manual for Midwives, the nurse would conduct classes for small groups of midwives; hold prenatal and well baby conferences; and hold immunization clinics. Home visits and school visits were the primary vehicles for delivery of these services. The nurse conducted classes for community groups using the American Red Cross Textbook Home Hygiene and Care of the Sick. Public health nurses also provided care to the sick in their homes who were under the care of a physician. In the Biennial Report of the State Board of Health, 1922-1923, Osborne is clear in stating that the public health instructor is not a charity worker caring for chronically sick and worn out people, but is a "teacher of health" with a duty to prevent sickness. Demonstrations in handwashing, safe disposal of waste, and even helping develop isolation techniques where tuberculosis was involved were nursing interventions utilized to prevent sickness. Nutrition education was an integral component of nursing care as pellagra was a leading cause of morbidity and mortality in the state and malnutrition in general affected an individual's ability to recuperate from illness or to stay healthy.
A second survey went to physicians in 1923, after the distribution of the Manual for Midwives and the demonstrations of public health nursing in the communities. The most frequent response by the physicians was "keep the nurse in the community." This response by the medical community reflected an overall acceptance of the public health nursing initiatives. By this time, not only were physicians impressed by the public health nurse but the citizens of Mississippi realized the value of the public health nurse and recognized that it is just as logical for a nurse to serve the public in the prevention of disease as in the cure.
From May 5 to June 5, 1922, the inundated section of the Yazoo River basin, including parts of Yazoo and Sharkey counties, was under the American Red Cross Mississippi Central Flood Control Committee. A director of nurses and four public health nurses were assigned to this relief effort. The nurses assisted in the care of acute cases of illness, special emphasis on administration of typhoid vaccine, treatment of malaria, and in as far as possible pellagra and feeding people, with special stress on sanitation and waste disposal.
Infectious disease such as smallpox, tuberculosis, malaria, cholera, and typhoid were also priorities for public health nurses. The public health nurse often initially detected an infectious disease, then referred to the physicians for treatment, provided follow-up to cases when indicated, and tried through education and demonstrations to family and caretakers to prevent the spread of disease.
A three month orientation and observation process was established in the early 1920's for nurses new to the concepts and policies of public health nursing. The philosophy was simple: public health nursing was about prevention of disease, the promotion of health, care of the sick and rehabilitation to productive life.
By the mid twenties, the public health nursing force consisted of one full-time supervising nurse, five district nurses, seven half-time county nurses, one part-time dietitian, and one full-time and one part-time stenographer. Nurses were located in the following counties: Hancock, Harrison, Jackson, Rankin, Pike, Yazoo, Humphreys, Sharkey, Washington, and Lafayette.
Disaster struck Mississippi on April 21, 1927 when the levee broke on the Mississippi River near Mounds Landing, near Scott, and about eighteen miles north of Greenville. The devastation of the 1927 flood covered a great portion of the Delta. In terms of destruction of property and danger to public health, the flood was described by President Hoover as "the greatest peace-time calamity in the United States History" according to Public Health and Licensure in Mississippi, 1798-1937. Resources within the state and from the federal government were mobilized for relief. A great portion of this work was administered by the American Red Cross. The coordinated emergency program of the American Red Cross and the State Board of Health embraced the medical, nursing and sanitation services. The efforts put forth included the administration of quinine for malaria prophylaxis, spray oil for mosquito control, and the use of large quantities of lime for disinfection purposes. The effectiveness of these efforts is reflected in the fact there were no epidemics and the incidence of disease was less than expected.
From April 24, to June 30, 1927, seventy Red Cross nurses were dispatched to Mississippi. At the end of the biennial, fourteen Red Cross nurses were still on duty. Thirteen public health nurses affiliated with the State Board of Health from the delta area and other areas of the state were enrolled in the Red Cross program and participated in the mobilization efforts.
Later in 1927, the Rockefeller Foundation provided private funding for a training station for health workers in conjunction with the Sunflower County Health Department following the Mississippi Delta flood, according to Public Health and Medical Licensure in Mississippi 1798-1937. Nurses, physicians, and sanitarians from Mississippi as well as other states and many foreign countries received public health orientation and training through this initiative before it was discontinued in 1932. Some 233 public health nurses had experiences here and many of these nurses remained in Mississippi. Sunflower County Health Department, however, continued as a major orientation site for public health nurses for many years. Pike, Lauderdale, and Washington County Health Departments also later became central orientation centers for public health nurses.
The Rockefeller Foundation in 1929 provided grants through the Rosenwald Fund designated for programs to improve the health and lower the death rates of the black population in the South. These funds, utilized to establish permanent public health nursing positions for black nurses in the state, targeted children where nursing and sanitation would make a profound impact on health and health practices.
Eliza Farish Pillars, R.N., often referred to as the first black public health nurse and hired on February 1, 1926, has been recognized for her admirable work in the area of maternal and child health nursing. Other distinguished black public health nurses are and have been employed by the Mississippi Board of Health. Other advantages of these private grant dollars were educational scholarships for approximately seventy-five nurses into the 1930's.
By the late 1920's, Mississippi reported approximately thirty public health nurses. They contributed three dollars each to start a loan library for public health nurses. This loan library was later merged with the Medical and Public Health Library organized in 1936 by the State Board of Health. (The Medical and Public Health Library was transferred to the University of Mississippi Schools of Medicine and Nursing in 1982.)
The public health nurse was recognized in her community by a blue chambray uniform with white collar and cuffs, the professional dress code implemented in 1927. Expanding public health nursing activities was difficult because of the scarcity of qualified public health nurses in Mississippi. By the late 1920's, minimum qualifications for employment had been established: good physical condition, graduation from high school with a diploma, graduation from an accredited training program, proper professional regard toward organized nursing, registration in the state, and membership in the State Nurses' Association. Osborne cited in the Report of the Mississippi Board of Health 1919-1921 qualities she deemed essential that "nurses chosen for public health needed vision, a great desire to do community work, the ability to work up resources at hand, the adaptability to meet situations as they arose, and most of all infinite patience with people they serve." These qualities are as essential today in public health nursing as they were seventy years ago.
National and international recognition was bestowed on Osborne at the International Council of Nursing in Montreal in 1929. The Conference recognized Osborne for her work in forging a strong network of public health nurses and their accomplishments in lowering maternal and infant mortality through improved midwife practices.
As the decade of the 1920's drew to a close, this stalwart cadre of approximately thirty public health nurses had assessed the health needs of Mississippi communities and had prioritized nursing activities to address health needs in maternal and child health and in communicable disease. This small force of pioneering nurses had developed a plan and strategies to meet the health needs and to lower morbidity and mortality rates and to improve the quality of life for all residents. They had begun implementing their plans and were ready to vigorously pursue their objectives into the next decade.
1930-1939: Expansion of Public Health Nursing in Mississippi
By 1930, Mississippi claimed twenty-five full-time county health departments, according to the Report of the Activities and Accomplishments of the Field Unit of the Mississippi Board of Health, 1931-1945. This report states that, by 1932, thirty-five full-time nursing positions were budgeted. Public health and public health nursing were expanding rapidly in the state. The 1930's decade dawned, however, with difficult economic times as the effects of the Great Depression were being felt within Mississippi and nationally. Several counties were forced to discontinue their organized public health systems.
Public health nursing was undaunted. Shepherd-Towner Act funds for nursing education, midwife supervision, and maternal and child care had been discontinued in 1929; so the Commonwealth Fund was approached by the State Board of Health requesting funds to continue to address public health nursing priorities. In January 1931, Mississippi was one of three states chosen by the Commonwealth Fund for cooperation in a public health program to include medical and nursing education and nursing services. Scholarships for public health nursing education continued throughout the decade and into the 1940's.
The following excerpt from Fever, Floods, and Faith: A History of Sunflower County Mississippi 1844-1976 gives an oral account as told by Mattie Mae Everitt, R.N., and written by Marie Hemphill that describes public health nursing through the depression era:
"Mrs. Everitt described a routine that was strenuous, uncomfortable, and sometimes dangerous. In addition to malaria, the Delta scourge, pellagra was raging in almost epidemic proportions. This malady was caused by malnutrition, mainly a meat, meal, and molasses diet. She recalled the educational campaign the nurses waged in diet preparation, sanitation and screening.
"Transportation around the county was in itself a problem. Mrs. Everitt's duties took her to isolated cabins in the fields, reached by roads that had never been exposed to gravel. Consequently she traveled in a cloud of dust in summer or was frequently pulled out of mud holes in winter by an accommodating farmer with a mule team or tractor. Sometimes reaching her destination might require walking weary distances, riding a mule, crossing a stream in a boat, or walking a shaky log. Her work day began early, and her lunch "hour" usually meant a brief stop--just long enough to eat the cold lunch she had brought along as she sat in her small car which was equipped with side curtains and a rumble seat.
"Mrs. Everitt and her fellow-nurses carried their own coal and wood and built their own fires in the one-room schoolhouses, churches, or vacant store building that had to be utilized in the early days. Quite often in the summer, tables were set up in the shade of the trees on a plantation where the nurses held their clinics and gave immunization shots."
To increase the efficiency and effectiveness of public health nursing service delivery, the county was divided into districts, even though it may have been a one nurse county. Outlying clinics were organized at schools, rural churches, the country store, or under a shade tree. Efforts were made to stress the importance of good health habits, and of having a cow, a garden, screened homes and baby beds, and sanitary privies. Immunizations for typhoid, smallpox, and diphtheria were administered. The public health nurse planned for select home visits within the vicinity of the outlying clinic.
The big brown Field Bag, introduced in the 1920's in conjunction with the midwifery supervision program, became standard equipment when mass immunizations were given. The brown bag contained everything needed to set up conferences including sterno stove, matches, covered pans for boiling needles and syringes, oil cloth sheets to cover a table, patient records, tongue blades, sterile swabs in glass tubes for cultures, glass slides, and tins for hookworm specimens. In addition to the brown bag, the nurse carried a portable table which folded in the middle as part of her standard equipment to set up area clinics and to use at the annual county midwife meetings.
The brown bag was bulky, heavy, and not well suited for use in home visits. The Black Stanley Nursing Bag was introduced for home visiting and became the hallmark identity as public health nursing advanced.
The black nursing bag contained soap and towels for handwashing, alcohol, tape measure, blood pressure apparatus and stethoscope, thermometers, bags and folded newspaper, an apron, hand scales, thumb forceps, kelly clamps, a small enamel pan, tongue blades, cotton swabs and cotton balls. The black bag was lighter than the brown bag and served well as a teaching tool.
Despite the economic difficulties and other obstacles of the times, the Mississippi State Board of Health remained alert to the public health needs in the state and opportunities to address those needs. The Commonwealth Fund continued to be a great benefactor to Mississippi and its public health programs. In 1930, the Commonwealth Fund entered into an agreement with the State Board of Health to establish model health departments in Pike and Lauderdale counties. This agreement included funding for medical and nursing education in public health and the establishment of a Field Unit Division at the state level to serve as a catalyst in public health expansion, establishment of policies, and communication between programs and county health department staff.
Osborne also remained alert to the needs of public health nursing during this time. Osborne had been an active member of the Mississippi Nurses Association since her arrival in Mississippi in the early 1920's. In 1932, she was elected President of the Mississippi Nurses Association. Having established membership to the state association as a requirement for nurses entering public health, she helped establish a special interest group (SIG) for public health nursing within the association. The Public Health Nursing special interest group was the second special interest group to be formed within the association.
In 1933, President Roosevelt initiated the New Deal to relieve the economic hardship of the country. The Social Security Act in 1935 (Public Law 99-271) provided funding to increase public health programs, particularly to extend services and improve health care for mothers and children in rural areas suffering from economic stress. The State Board of Health secured funds in 1934 through the Children's Bureau of the U.S. Department of Labor, providing funding for one state supervisory nurse, four district supervisory nurses, and eighty-two county nurses. The goal of this special project was to place at least one public health nursing position in each county. The efforts to reach this goal were remarkable, but qualified public health nurses were not secured in every county.
Elise Smith, R.N., presented a report titled "Mississippi Special Public Health Nursing Project Made Possible by Federal Funds," at the 1934 Mississippi Nurses Association meeting. She outlined the public health nursing role in this initiative "to teach home, personal and community hygiene and demonstrate care of the physician's patients to members of the family." Home visits, an integral part of this initiative, were made to prenatal cases and infants, preschool and school children, and individuals with tuberculosis and other communicable diseases. Bedside care and demonstrations were given in the homes for the purpose of teaching. Smith's report concluded that by the end of the first week of recruitment sixty-five nurses had been hired. This initiative also included an immunization project against smallpox, diphtheria, and typhoid. Nurses, visiting the schools, would have direct access to administer immunizations to the school-age population. Public health nursing received this project as a means of demonstrating to counties a better understanding of the scope of public health nursing and a need to support and maintain nursing positions. Generalized public health nursing services were aborning!
Another provision of the Social Security Act of 1935 was the establishment of Crippled Children's Services. Elise Smith became one of the Field Advisory Nurses who traveled the state visiting crippled children in their homes, holding conferences with parents, and assisting in the ten field clinics held periodically throughout the state. These nurses, employed by Crippled Children's Services, functioned as advisory orthopedic nurses in counties having organized health departments. The county public health nurse shared in the supervision of the whole child, a truly family-centered service.
About this same time, the family folder was introduced to public health nursing practice in Mississippi by nurses who had benefitted by Commonwealth Fund scholarships through Vanderbilt University, Teachers College, Columbia University in New York, or Western Reserve. The family folder enabled the nurse to consider the family as a whole. Individuals had records within the family folder, but the teaching and demonstrations were interrelated.
The public health nurse might have had a prenatal patient as her primary case, but she assessed other children in the family or possibly the grandmother with tuberculosis or a crippled child all in one visit. It was not "only prenatal today" and "tuberculosis another day."
In addition, the family folder accommodated space for recording environmental observations such as source of water supply, waste disposal, and availability of window and door screens. A blue denim, three compartment, envelope-type carrying case was designed for taking selected records for home visiting. Another compartment contained teaching materials such as directions for making screened baby beds and administration of daily cod liver oil. One compartment held the patient records and the third compartment contained a copy of the rules and regulations for reporting communicable diseases.
Syphilis had been recognized as a major source of morbidity and mortality for many years. In 1938, the U.S.P.H.S. and the State Board of Health cooperated in a major project, with emphasis in Washington County and the surrounding Delta area, to attempt to conquer the disease through case finding, treatment and contact follow-up, and education. Public health nursing was the vanguard of this effort.
A high incidence of disease was identified through this and other screening projects in the state. Consequently, Osborne arranged in May 1938 for Donna Pierce, R.N., with the U.S.P.H.S. to conduct five regional two-day educational conferences so that all public health nurses would have an opportunity to attend. Screening prenatal patients for syphilis was being introduced as a standard nursing intervention at this time.
Paul T. Erickson, M.D., U.S.P.H.S., served as venereal disease medical officer and consultant in Mississippi in the late 1930's. He spoke at the 1940 Mississippi Nurses Association annual meeting about public health nurses and their relationship in this syphilis control project. Erickson cited the public health nurse as the chief means in finding syphilis cases, assuring medical care for case treatment, education, contact finding, and follow-up of lapsed cases. Erickson said that "all along the way, the public health nurse is the chief instrument in clinic operation and in the performance of a long string of necessary intangible roles. If anyone is indispensable to our syphilis control program, no one is more so than the public health nurse."
Mississippi was gradually beginning to recover from the Depression, and economic progress was accelerating. Farm production had broadened through diversification. Industry introduced into the state during this era expanded the economy. Between 1933-1935, Mississippi was surpassed by only one other state in the average increase in number of manufacturing plants, according to History of Mississippi, Volume II by Richard McClemore.
Mississippi was one of the first southern states to recognize the importance of nursing service in industrial hygiene programs. The Division of Industrial Hygiene asked for a public health nurse to visit plants and help institute nursing services. The prevention of disease, improvement of hazardous work conditions, promotion of health practices including nutrition, and first aid were determined to be the interventions to be provided through industrial nursing.
In April 1938, Pearl Walden, R.N., was appointed to the Division of Industrial Hygiene as a specialized industrial nursing consultant, according to Public Health and Medical Licensure in Mississippi, 1938-1947. Walden, along with advisory nurses of the Division of County Health Work, made health promotion, injury prevention, and awareness of county health department services the primary focus for industrial nursing in Mississippi; she encouraged plant management to employ industrial nurses. As these nurses were employed, she arranged for short term educational and direct experience opportunities outside the state as this practice area of nursing was being introduced into Mississippi.
Public health nursing activities previously established were integrated with the new initiatives. Communicable diseases, perinatal and infant care along with midwifery supervision, and tuberculosis control continued to be primary focuses of nursing care.
Dr. Felix J. Underwood, M.D., F.A.C.P., secretary and executive director of the Board of Health since 1924, was quoted in a column titled "Your Health" in the Indianola Enterprise on December 3, 1936, citing the reduction of disease in Mississippi from 1926 to 1936. Typhoid fever was reduced by 84 percent, diphtheria by 24 percent, pulmonary tuberculosis by 40 percent, pellagra by 60 percent, and puerperal septicemia and eclampsia by 37 percent.
Dr. Underwood, who often gave much credit to Osborne and public health nursing, acknowledged that "the public health nursing service in Mississippi, as elsewhere, has been extended, its quality vastly improved. It has come to be recognized as a vital part of an efficient public health administration."
The 1930's decade had begun with the state in a severe economic depression, and some county health departments with full-time public health nursing services were closed. Continued funding from the Commonwealth Fund helped provide for expansion of health departments and public health nursing. By mid 1930, federal project funds became available to assist unemployed nurses and to increase public health nursing services. These projects allowed expansion of public health nursing into areas not previously served.
Public health nursing, enriched through advanced nursing study and well established orientation, became a central service to other State Board of Health departments. All public health nurses received education in the areas of tuberculosis, crippled children services, and syphilis, enhancing their abilities to provide generalized public health nursing in their communities.
Emphasis on all aspects of maternal and child care, including midwife supervision, continued. A noticeable effect of reduced maternal and infant morbidity and mortality began to occur. In 1930, the maternal mortality rate was 9.6 per 1,000 live births, and the infant mortality rate was 68 per 1,000 live births. By 1935, the maternal mortality rate had reduced to 6.7 per 1,000 live births and the infant mortality rate to 54 per 1,000 live births.
Tuberculosis remained one of the most dreaded of diseases and was still one of the leading causes of death in the state. The Sanatorium, established in 1916, continued to serve as a referral source for public health nurses who cared for tuberculosis patients. Often, the Sanatorium could not accommodate new patients. Public health nurses initiated isolation techniques in the home and demonstrated general health promotion activities such as boiling of dishes and hanging laundry in the sun. Assessment of the children in the home of tuberculosis patients was a priority for public health nurses as well. Collaborative efforts in the state had established Preventorium facilities for the purpose of i