PUBLIC HEALTH NURSING AND TUBERCULOSIS

OTTO R. EICHEL, M.D.

Secretary, State Department of Health

The rapid development in recent years of modern sanitary activities has brought the public health nurse to the front as a very important agency. In the control and prevention of tuberculosis she may be regarded as the most important single agency with the exception of the hospital itself. This is true even though the disease presents so large a problem that almost every private and public organization concerned with the physical welfare of the people is either directly or indirectly a cooperating agency in its control.

A valuable advance in the campaign against the disease is the employment of county nurses. Section 47 of the New York State County Law gives the boards of managers of county tuberculosis hospitals "authority to employ a county nurse or nurses for the discovery of tuberculosis cases and for the visitation of such cases and of patients discharged from the hospital and for such other duties as may seem appropriate; and may cause to be examined by the superintendent or one of his medical staff suspected cases of tuberculosis reported to it by the county nurse or nurses or by physicians, teachers, employers, heads of families, or others; and to take such other steps for the care, treatment and prevention of tuberculosis as it may from time to time deem wise." Although several counties have availed themselves of this opportunity by appointing nurses, eventually every county should have one or more nurses thus employed. Obviously, these workers have before them a task of large dimensions, with opportunities for the accomplishment of definite and constructive results, worthy of the application of the highest degree of training, intelligence and skill.

The work should be conducted with the following specific objects constantly in view:

Examination and diagnosis

I To secure as soon as possible the examination by competent physicians of all persons suspected of having tuberculosis.

2 To secure the examination of the sputum of persons who have had a cough for a month or more.

3 To secure the examination by competent physicians of all persons who have been exposed to a known infectious case of tuberculosis (in the examination of children a diagnosis of tuberculosis should be made preferably in accordance with the method approved by the National Association for the Study and Prevention of Tuberculosis).

Isolation and treatment

To secure sanatorium or hospital treatment for all cases of tuberculosis:

I Early cases to receive treatment for cure and education.

2 Advanced cases to have adequate supervision and proper care. (Both types of cases to be under supervision in sanatoriums and hospitals or by nurses, health officers, or physicians so long as they are discharging tubercle bacilli.)

The well-qualified nurse should begin with at least a general knowledge of the nature of the disease, its modes of invading the human body, the usual means by which it is spread, and the measures regarded as essential in its treatment and control.

The nurse should not overlook the fundamental purpose for which she is appointed, even if from time to time she must temporarily devote herself to other public health work. The danger of permitting her activities to become routine will be ever present. Forms and procedures are necessary in the technique of almost any work,- they are part of the machinery with which results are accomplished,- but they must not be confused with results themselves. It is necessary and excellent to have a complete record of all diagnosed cases, including those under medical observation, and of all patients returned from hospitals and sanatoriums, but it is equally essential to secure the entrance to the hospital of all accepted patients, to keep suspected cases under observation until they are discharged as no cases and to continue supervision of proven cases either by personal visitations or in cooperation with health officers and physicians.

Further, the general social service work incidental to the searching out and supervision of tuberculous patients, although it should be developed, must be kept subsidiary to the main object of achievement. For example, adequate material relief without effective isolation or oversight of the patient is essentially inefficient.

As a first step subsequent to her employment, the county nurse or welfare agent may prepare a program which should be understood and approved by those who will have general direction of her work. This program will naturally be based upon the definite requirement of the Law which states that her duties shall be to discover and visit tuberculosis cases and patients discharged from the hospital, and take such other steps for the care, treatment and prevention of the disease as may be wise.

The preliminary work should if possible consist of a survey or study of the special factors which relate to the disease in the community,— including a tabulation of the actual number of reported cases, the

number of deaths, indication of the numerical ratio between the reported cases and deaths, institutional and other facilities, the attitude of the physicians and cooperating public health agencies, any systematic work already undertaken or proposed, the enforcement by local health officers of the Tuberculosis Law, and any special conditions which may affect the entire local situation.

This survey will provide exact information for use as a basis for her subsequent operations.

It may be found that the number of deaths equals or exceeds the number of reported cases, or the number of reported cases and deaths may be exceptionally small as compared with the size and character of the community. As it is well known that there are at least five active cases of tuberculosis for each death from the disease — it should be at once apparent that there must necessarily be a large number of concealed or unreported cases present.

The nurse's next step would be visitation of reported cases to ascertain their general status and the presence of unreported cases in the same families, and to bring about so far as possible the admittance to hospitals of the known cases. This should be undertaken, so far as practicable in cooperation with the physicians and health officers. One clue will lead to another, and eventually systematic efforts will result in the discovery of the major part of the active cases of the disease.

Naturally, successful work along these lines presupposes on the part of the nurse tact, diligence, patience, and skill. She must repeatedly overcome the human elements of ignorance, prejudice, and opposition, both from patients and others who may misunderstand her purpose. The persevering nurse who aggressively labors to unearth and provide for all the cases of tuberculosis in the community, will inevitably find the hospital facilities for their care inadequate. Tuberculosis is largely a disease of poverty, and where poverty is found, there also are the complicated economic problems which are underlying causes of the disease itself.

Therefore very often her success with any given patient or his family will depend more upon good social management than anything else. This may present the only difficult problem in the home. Although the nurse may teach sanitation to the family, under such circumstances she may find it necessary also to enlist the advice or assistance of some responsible charitable agency. The agency may be the county superintendent of the poor, overseer of the poor, county agent for dependent children, local branch or committee of the State Charities Aid Association, philanthropic citizens, charity organization society, local or State health authorities, a free dispensary, or some other institution.

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In a community with very limited institutional facilities, and authorities.

either uninformed or indifferent as to their tuberculosis problem, the nurse becomes also a publicity agent and constructive builder. She must assist in awakening public opinion and in stimulating such opinion to concrete action, especially adequate hospital provision. This especially may be the legitimate direction for her activities if she is employed by the board of supervisors of a county which has no tuberculosis hospital. In a county which has a hospital, her chief line of activity will be the finding of concealed or unsupervised cases, the promotion of their registration, the maintenance of sanitary oversight of them, and the visitation of discharged patients. The nurse will then be attached to the hospital, which should become the center of the tuberculosis campaign. of the county.

In no instance, should the county nurse act as an office worker or a member of the hospital's indoor staff. Nor is she justified in devoting considerable attention to general public health work except in time of crisis or emergency. She is unqualifiedly an outside worker whose field of best endeavor is among the people themselves; and without question it is her legal obligation, and that of those who direct her work, to confine it to persistent and constructive efforts for the care, treatment and prevention of tuberculosis.

THE PUBLIC HEALTH NURSE AND THE PROMOTION OF CHILD HYGIENE

HENRY L. K. SHAW, M.D.

Director, Division of Child Hygiene

From the standpoint of a public health nurse, child hygiene includes prenatal instruction to expectant mothers, the proper feeding and care of infants, supervision and protection during the preschool period and assistance in school medical inspection. Work of this character is being carried on in nearly all of the larger cities in the State although practically nothing is being attempted along these lines in the smaller towns and villages. One-half the population of the State, outside of the city of New York, is rural and the State Department of Health aims to assist and aid any community in securing the services of a public health nurse, whose work naturally would embrace child welfare activities.

The death rate among infants is excessive and largely unnecessary, and in many rural districts it is higher than that in cities. After the first year comes the dreaded second summer in which the diet of the child has to be carefully watched, for the majority of mothers do not know how and what to feed their children. The period of early childhood,

from two to seven years of age, is one in which the susceptibility to communicable diseases is very great. The child is obliged to leave the home and enter school after the seventh year and is subject to the educational laws of the State until he is sixteen years of age. During this period he comes under the supervision of the school medical inspector, and the school nurse.

It seems feasible and practicable to establish in the small rural communities a Health Center which is the headquarters for the public health nurse's activities. Here the nurse should keep a record of all the families whose social and economic conditions are such that instruction and supervision is desirable, and these should receive her friendly oversight until the children reach the school period. The nurse should be able to give prenatal advice and care; see that proper obstetrical facilities are available; emphasize the importance of breast-feeding; and, when this is not possible for the mother, demonstrate correct methods of artificial feeding; outline the diet after the first year; urge the necessity of caring for the teeth; see that young children are kept away from infectious diseases; and, when necessary, summon a physician to safeguard the public health. Another duty which comes properly within her province, is to arrange for class instruction of mothers at the Health Center.

The public health nurse having official connection with the health officer, with whom she works in closest cooperation, has access to the birth certificates and reports of communicable diseases. She should visit the home whenever a birth is reported, note existing conditions and, if it seems advisable, offer her services in any capacity in which she may be needed. In cases of infectious diseases she should visit the homes regularly and see that proper precautions are taken to observe the sanitary regulations and that the isolation and quarantine features are maintained. It is advisable for the nurse to make such visits toward the end of the day, and at these times wear different apparel than she does at other places.

A very important duty of the public health nurse is the supervision of midwives; to see that they have the proper license to practice their calling and that they do not fail to report the births at which they assist. She should ascertain if nitrate of silver solution has been placed in the eyes of every new-born infant.

The opportunities for child welfare work by the public health nurse are many and her sphere of usefulness is wide. In order, however, to accomplish the greatest amount of good her work should be systematized and correlated under a general plan which when necessary can be modified to meet changing conditions.