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"The best job in the world"

Life could be very bleak back in rural 1930s Wisconsin, where impoverished mothers often had no access to the health-care system. Dedicated public health nurses provided that crucial connection.

By Rima D. Apple

"The baby in a box of rags; a rusty barrel for a stove; no windows; rain leaking through the roof; two rooms and eight children; and the chickens picking at the bread which is rising on the table": scenes that were etched in Nathalie Voge's mind as she evaluated her life as the County Demonstration Nurse of rural Marinette County, Wisconsin, in the 1930s. Recalling these scenes in 1942, she also remembered the roller-coaster ride of her emotions from despair to elation during her tenure in northeastern Wisconsin: "There were many a day when I would return home wondering, 'Will I ever be able to teach that family anything?' And then there were days when I thought a public health nurse had the best job in the world."

Ultimately she was sad to leave the work because "Each day as a county nurse brings joy, sorrow, and always something new and unexpected, but all in all the joy greatly outweighs the sorrows." Voge was not alone in her assessment of the joys and sorrows of the rural nursing.

With commitment and creativity, public health nurses, sent from the state's Bureau of Maternal and Child Health, conscientiously brought the message of good health and well-baby care to residents of rural Wisconsin who were in need of adequate medical care. Often these Wisconsin residents lacked the money to pay health-care providers, or the time or means to travel to medical offices. Some were unaware of the potential benefits of modern medicine; others preferred to trust their health and the health of their children to more traditional methods. The "County Demonstration Nurses," as they were called, sought to serve all of these people in a state-funded program designed to demonstrate the effectiveness of public health nursing.

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The nurses located and counseled Wisconsin families in a variety of places. Sometimes they met their clients at temporary health centers, which were run by the physicians of the bureau with the assistance of local social and charitable organizations.

But these centers were held only infrequently in any given locality. Most often County Demonstration Nurses would attend their clients in their homes, where they could observe domestic conditions that could limit successful application of medical advice. When they returned to their offices, they would write up their visits in monthly reports submitted to the bureau office in Madison. These reports provide a revealing lens for viewing rural life and health care concerns in this period.

When she first arrived in the community, the nurse would need to identify potential clients: pregnant women, new mothers, and preschool children. One source of clients was the intermittent health centers. The nurse would make follow-up visits to mothers who had attended one of the state-run health centers if one had been held recently. If another nurse had preceded her in the county, she could start with the records of previous patients. Elizabeth Murrisy in Marathon County was gratified that her predecessor "had built up the prenatal case load. Wherever I went, it seemed noticeable that maternal work is so much easier to do." Local physicians could and did make referrals as well. A nurse new to a community would attempt to visit all the local physicians individually, discussing the program and consulting with them.

Because of the medical profession's insistence on the separation of "public health" and "private medicine," a national as well as local controversy, the nurses as employees of the state's public health system were particularly careful to reinforce and not challenge the physician's message with referred patients. For instance, physicians were given the choice of either endorsing the nurse's Standing Orders, or modifying them as necessary for their practices. (Typically, "Standing Orders" reflected intensive middle-class standards of the day, emphasizing, for example, the significance of cod-liver oil and orange for young infants, the need to begin bowel training at three months, and the importance of bathing and cleanliness.) Despite the efforts of nurses to placate doctors, some physicians continued to worry that the program was drawing patients away from them. One concerned Tomah physician demanded that the nurse come to his office to describe the routines used to refer patients to private physicians. He was pleased to learn that "the decision was left to the patient." In interactions such as these, the nurses sought to reassure medical practitioners that they were there to support, not detract from, the practice of the private physician.

But health centers, predecessor reports, and medical referrals were of only limited use in identifying clients. Nurses also combed through newly registered birth and death certificates to locate infants and mothers. In some cases, nurses learned of women in need from acquaintances. That is how Grace M. Connors met one of her clients. "Mrs. L. reported by neighbor --- twin boys, 1 mo. old, makes 4 children and the oldest will not be 3 until Christmas Day. . . . Much   [p. 31]   instruction needed here, but I'll have to go easy, give a little at a time." Hazel Nordley, who worked in northern Wisconsin in 1940, also found neighbors crucial in developing her case load. Moreover, Nordley recognized that the early days following birth are critical "teaching moments," or, as she explained, "The mothers have so many questions to ask about the new babies and it always seems as if there is so much information to be given at this time." Therefore, she devised a unique system for reaching new mothers promptly: she distributed to each pregnant woman she saw a mimeographed postcard, asking her to complete and mail the card immediately after birthing. Mothers appreciated her consideration and within months of beginning the program, Nordley reported that many of the cards were being returned quickly. Nurses were also often called upon to lecture at local Homemakers Council, Girl Scout troop, or high school classes. They used these opportunities to identify other potential patients in the community.

In addition to these specific actions designed to locate pregnant women, new mothers, and young children, there was also serendipity. In October 1936 in Pulaski, Mildred Cook found Mrs. J. B. while looking for another address. The woman was due in March, yet she had not seen her doctor; Cook urged her to do so. The next day the nurse was gratified to learn that the woman had followed her advice and had visited the physician. Moreover, "Doctor was very pleased with this work." Thus, through her counsel, Cook had accomplished two important goals of the State Health Department. She had convinced a client of the importance of prenatal medical examinations and she had cemented a particularly positive relationship with the local physician.

Nearly all the nurses related anecdotes about finding patients while simply driving about the countryside, and their stories provide critical descriptions of the Depression rural life. Connors wrote with particular delight in October 1936:

Mrs H: Saw baby washing on the line. Peeked at mail box for name, and went in, and lo and behold she was expecting me, as she had heard that I called on all new babies. Was I glad ever that I had taken the name from the mail box, so that I could call her by name. She had two preschoolers also, and had a number of questions saved up to ask. I find quite a few families by watching for washings on lines on my way to and from some place.

Mrs. H. was typical of patients described in the nurses' reports. For one thing, she had several young children. Nurse after nurse described such mothers: nineteen years old and third pregnancy; sixteen and pregnant; twenty-one years old, fourth pregnancy; seven months pregnant, with three children already, the oldest one four years old.

Mrs. H. was also typical in that she wanted, and according to the nurses she needed, instruction on child-care. The nurses were always pleased to note when mothers asked for their advice. Connors recounted a few weeks later that Mrs. H. "took instructions graciously and I believe will follow them." In the case of Mrs. J., a mother with an infant and three preschoolers, Connors reported: "Very poor family. Mother very responsive. Food charts that I gave her before, she keeps on the kitchen wall   [p. 32]   where she can refer to them frequently, and follows them as closely as possible."

But for each patient who "took instructions graciously," there were others who were not compliant. Nurses encountered patients who either would not or could not cope with the advice given them. Wisconsin farmers were hard-hit during the Depression and families utilized the labor of all able-bodied, and perhaps less than able-bodied members. Most commonly mothers' inability to act on the nurse's instructions resulted from economic and social conditions beyond their control. In September 1937, Sadie Engesether movingly described one family she frequently visited: "Called at the J. S. house; guess conditions will never improve. Mrs. S. was out in the hay field and baby being cared for by 12-year-old girl. House filthy. Did not give her advice re. the poor puny baby as she looked too worn-out to care what happened."

Nurses often reported that mothers needed to leave their children in order to find food or to work for wages. During a visit to a Black River Falls family in western Wisconsin, the nurse found a five-month-old baby in the care of a blind grandmother and the mother out picking blueberries. The baby slept in a large bed with a bottle propped beside her. There were flies everywhere. "Explained to grandmother that flies were disease carriers, and every effort should be made to keep the flies away from the baby," the nurse wrote later. "Grandmother said this was very difficult as there are no screen doors and the screens on the windows are very poor." In this case, the mother had won $5 in a community drawing and planned to purchase a baby carriage with some of the winnings. The nurse advised them to buy the carriage and also netting to cover the baby to protect her from flies.

Not all residents of rural Wisconsin were as hard-pressed economically. Nurses sometimes encountered better-off and better-educated women. In Taylor, a town in western Wisconsin, in 1938, the nurse was pleased to report about her visit with Mrs. H. O. Mr. O. was principal of the school in Taylor and the family had a two-and-a-half-month-old daughter. Significantly, Mrs. 0. had been reading and carefully following the instruction in Infant Care, the popular baby-care manual distributed by the U.S. Children's Bureau. Her baby was breast-fed on a regular schedule and given cod-liver oil and orange juice daily. Both regularity of feeding and the administration of cod-liver oil and orange juice were keynotes of the advice of state nurses, reflective of the advice found in much of the popular and medical literature of the day. Not surprisingly, the nurse had a very high opinion of this case: "Baby is apparently on an ideal schedule and appears to be in excellent condition."

But more often, the reports were filled with sad stories of lack of resources, lack of knowledge, lack of emotion and energy. In the homes of Polish and Irish immigrants and native-born residents, nurses would find women who were to deliver shortly but lacked the most rudimentary elements of layette and supplies for home birth. There were families who stretched two quarts of milk per day for a family of four, five, or more, and there were ramshackle houses without such basic utilities as running water and indoor plumbing.

Connors cogently explained why many women were not getting prenatal care: "Cannot pay M.D. any more than $15.00 and that is on time. Relief pays only $15.00 for delivery. M.D. can'st [sic] have anywhere from 8 to 16 prenatal visits, delivery, driving anywhere from 5 to 40 miles, post-natal visits, and postnatal examinations for $15.00 a case and not lost [sic] money. These mothers can't have proper food, cod liver oil, and calcium."

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Lack of economic resources in many cases made it difficult for these rural women and their children to heed the well-meaning advice of the public health nurses who visited them.

Frequently, nurses described the trials and tribulations of simply reaching potential patients. Nurse Louise Steffens recognized that her ignorance of rural conditions made her task more arduous. Concerned that many families lived on country roads which made them difficult to reach, she astutely remarked, "The conditions of the roads is nothing new to the residents of the country, but is very new to me." Catherine McLetchie colorfully recounted making a call on a family living deep in the woods:

It was necessary to leave the car at a neighbor's, and walk through several fields, in one of which a bull was tethered. He seemed only mildly interested in the nurse, who luckily was wearing blue, not red! After walking through woods, up and down hills, and crawling under two fences, in twenty minutes or so the house was reached. Then the whole process was repeated on the return journey. It was a very hot, tired, and perspiring nurse that finally reached the car and relaxed somewhat behind the wheel.

Though written from the perspective of nurses who understood that travelling conditions impeded their ability to deliver optimal health care, such reports are indicative of the problems faced by rural families as well. If dedicated public health nurses had difficulties getting to these women and their children, how likely was it that a private physician would make frequent calls? That food and other supplies could be delivered regularly and easily? That families could maintain easy contact with the larger world?

But despite these geographic and economic obstacles, or perhaps because of them, many women were as eager as Mrs. H. to hear about the latest medical advice and be reassured by medical professionals that their children were healthy and normal.

Particularly popular with nurses and mothers were bath demonstrations. Ruth Exner, working in Grant County in 1940, made special efforts to speak to mothers in the early postpartum period because she realized that "young mothers are anxious to learn simpler ways of taking care of their new babies. One thing in particular is the baby's bath tray, which has appealed to so many." Hazel Nordley found that among young mothers "this service is appreciated a great deal" and even "mothers who have children have asked for the bath demonstration." The "appropriate" infant bath was modeled on middle-class standards and required extensive material resources, including sterile cotton, separate washcloth and basin, and special "mild baby soap." Moreover, it was a complex and time-consuming procedure, beginning with the mother scrubbing her hands and arms up to the elbows, then washing the infant's eyes and ears with dampened sterile cotton, then weighing the baby, then washing the infant's face with a washcloth, then soaping the baby on a changing table, then placing the baby in a basin and rinsing her, then drying the baby, and then oiling her, before dressing her in a light shirt and diaper.

It is doubtful that many of the poor, exhausted mothers could continue similar routines daily. Yet whether they could follow through on the nurse's instructions or merely wanted to have another pair of hands helping in the family, mothers' interest in infant bathing indicates the value they placed on the assistance of health-care experts.

Consequently, many nurses apparently used the demonstration of a bath as an opening wedge to initiate discussion of other aspects of child care. Thelma Burke understood that a mother could use this practical instruction to learn more. "I've given one infant demonstration bath where the mother 'fired' questions at me," she reported from north central Wisconsin in 1939. "If I can get over the road, I'll return next week to see how much they have been able to follow." Despite the eagerness of this young mother to hear about modern concepts, Burke despaired of her practicing them because "Since Grandma, who came from Poland, lives there, too, it might be very difficult for the mother to do what she really wants."

The County Demonstration Nurse Project was not a permanent function of the State Health Department, spanning primarily from the 1930s to the early years of World War II. Yet despite of, or perhaps because of, the transient nature of their work in the community and their inherently middle-class, professional outlook, the nurses sent reports back to the Bureau of Maternal and Child Health that detail a unique and revealing picture of rural health. The County Demonstration Nurses knew that they came into their counties as strangers. They knew they needed to quickly and efficiently identify women and children who required their services and expertise and to bring them into the health-care system. The nurses were typically idealistic, sometimes naive, often rigid in their faith in modern medicine, but always determined. They were convinced that they could be, and should be, of service. Their efforts to bring modern health care to the struggling mothers and children of the rural counties of Wisconsin provide a critical perspective on rural life in Wisconsin before World War II.