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Public health nursing in early 20th century Canada/Les services infirmiers de sante publique au debut du 20e siecle au Canada.

Community-based nurses had been at work in some Canadian cities for at least three decades by the time the Canadian Public Health Association was founded in 1910. (1) Journals such as the American Journal of Nursing, the Visiting Nursing Quarterly, and the Canadian Nurse provided the profession with compelling accounts of nurses working in a variety of roles to prevent illness and promote the health of vulnerable populations such as: immigrants; the urban poor; infants and children; and isolated families living in rural and northern Canada. The terms "visiting nurse" and "district nurse" were used interchangeably in the journals and textbooks of the time, and in all cases, these nurses were defined as public health nurses (PHNs). Lillian Wald, a registered nurse and social reformer who founded the Henry Street Settlement in New York City in 1895, coined the term PHN in 1893 to describe the nurses who worked in poor and middle-class communities rather than in hospitals or in the homes of wealthy employers. (2)

Little is known about the earliest Canadian PHNs, but most were likely employed singly or in pairs by charitable or religious organizations who established small community-based outreach programs in many parts of Canada. For example, it is known that a diet dispensary in Montreal employed a district nurse as early as 1885. (1) Toronto's Nursing-at-Home Mission was established in 1889 to support two nurses who worked with poor families living near the Children's Hospital. (1) In 1897, the Victorian Order of Nurses (VON), a national district nursing association modelled on the British Institute of Queen's Nurses in Britain, was founded in Ottawa. (3) In many communities, the VON contracted with local governments or charities to provide PHN programs, and they have continued to do so throughout their history. As well, many voluntary PHN programs were founded by local organizations during this era, including the Margaret Scott Nursing Mission (Winnipeg, 1905), (4) the Lethbridge Nursing Mission (1909), (5) and the St. Elizabeth Visiting Nurses' Association (c.1910). (6)

School health programs, sponsored by local school boards, emerged early in the 20th century. In 1907, the Montreal school board inaugurated the first medical inspection program in Canada. (7) Mandated to identify and seek treatment for school-aged children with preventable health problems or communicable conditions, school boards initially hired physicians to work in the schools. However, they soon discovered that the effectiveness of school health programs was significantly enhanced when nurses made home visits to the families of children identified in the school setting as being ill or at risk of developing illness. In 1909, school boards in Winnipeg and Hamilton employed nurses to work with school-aged children and their families. (7,8) In addition to the physical inspection of children, school-based PHNs also provided health education programs to children and their families. (7-9)

In response to the high mortality rates associated with tuberculosis (TB) and preventable childhood illness, early PHNs also worked in communicable disease control and child health programs. However, unlike school nurses, their first employers were voluntary organizations. Between 1901 and 1910, milk depots and child health programs organized by local charities were established in Toronto, Montreal, and Winnipeg. (3,6,8) In 1905, a private donor enabled the Toronto General Hospital to employ a nurse, Christina Mitchell, to work with TB patients in their homes. (6) However, the magnitude of the public health problems associated with poverty, communicable disease and lack of knowledge about prevention of illness overwhelmed the fiscal and organizational resources of charitable organizations. By the early 20th century, most were seeking public funding to maintain their programs. So, for example, in 1910, Winnipeg's civic health department provided annual grants to the local district nursing association and the milk depot to support their child health programs. (10) In the long term, however, transfer of voluntary PHN programs to civic governments became the solution of choice. TB control programs were often the first to be integrated into the public sector. TB control PHNs were transferred to health departments in Ottawa in 1905, and in Toronto in 1907. (6,10) In 1914, both the Toronto and Winnipeg health departments took over voluntary child health programs and created Child Hygiene Departments to continue this work. (6,8) In most jurisdictions, PHNs worked in specific programs within health departments. The early exception was Toronto, where the health department amalgamated its communicable disease control and child hygiene programs in 1914. (6) This decision, according to Eunice Dyke, Superintendent of Toronto's PHNs, reflected the department's desire to "specialize in homes rather than diseases." (11) The scope of their practice was enlarged in 1917 when the board of education's nurses were transferred to the health department and their responsibilities were integrated into the practice of the department's generalist PHNs. (6)

In rural areas, development of PHN services proceeded at a much slower pace. Hampered by sparse populations and the general belief that the costs associated with PHN services should be paid by municipal (county) authorities, funding to employ PHNs was difficult to sustain. In some instances, local women's groups such as the Women's Institute or the United Farm Women employed physicians or nurses to conduct child health clinics or school inspections because no other organization was willing to provide the service. (7,12) In 1916, after years of lobbying from farm women's groups and social reformers, Manitoba became the first province in Canada to establish a provincially funded PHN service. Drawing on the experience of the Toronto Health Department, these PHNs worked as generalists in rural districts where the local government was willing to pay a portion of the costs associated with the service. (12)

Early PHNs were justifiably proud of their achievements. They were identified as elite members of the nursing profession because of the higher educational standards required for public health work and the complexity of their practice. (7,13,14) The physical and psychological demands were significant. Urban PHNs walked many miles as they traversed their districts, enduring harsh weather conditions, perilous footing and unsanitary conditions. Rural PHNs travelled by horseback, train, dog sled, motor vehicle, airplane and on foot to cover the many miles between home visits. (12) Learning to drive became a rite of passage, and the many photographs of PHNs posing beside a car attest to the affection that they held for their mechanical travelling companions. In both rural and urban settings, PHNs often worked alone, making difficult--even life and death--decisions with only their own knowledge, skill and courage to guide them.

Because public health programs were under provincial jurisdiction and remained outside Canada's national health insurance programs, the chronological development of PHN programs varied from one province or territory to the next. However, some generalizations are possible. In the mid-20th century, PHNs incorporated the prevention of chronic diseases into their practice. Communicable disease control remained a cornerstone of the profession. Early PHNs battled cholera, smallpox, typhoid fever, and a multitude of other infections that are almost unknown today. Contemporary PHNs, working in a global context, continue to deal with the challenges of tuberculosis prevention and control and work on the frontlines to prevent the introduction and spread of pandemic infections such as SARS and Influenza A virus subtype H1N1. They continue to promote the health of mothers and children. Environmental health also remains an integral part of their practice as PHNs develop and implement community-based interventions to mitigate the impact of global climate change, local disease vectors, occupational hazards, local sanitary conditions, and food safety on human health. Finally, PHNs advocate for and work with the communities in which they practice, focussing--as they always have--on the social determinants of health and creation of communities committed to the just and equitable distribution of material resources and political power.

The third in a series of five historical articles to commemorate 100 years of CJPH Guest Editor: Maureen Malowany, PhD

REFERENCES

(1.) McLeod C. District nursing in Canada. AJN 1902;2(7):503-7.

(2.) Buhler-Wilkerson K. Public health then and now. AJPH 1993;83(12):1778-86.

(3.) Penney S. A Century of Caring: The History of the Victorian Order of Nurses for Canada. Ottawa, ON: VON Canada, 1996.

(4.) Jones E. Influenza 1918: Disease, Death, and Struggle in Winnipeg. Toronto, ON: University of Toronto Press, 2007.

(5.) Richardson S. Women's Enterprise: Establishing the Lethbridge Nursing Mission, 1909-1919. NHR 1997;5:105-30.

(6.) MacDougall H. Activists and Advocates: Toronto's Health Department 1883-1983. Toronto: Dundurn Press, 1990.

(7.) Duncan S, Leipert B, Mill J. "Nurses as health evangelists"?: The evolution of public health nursing in Canada, 1918-1939. Adv Nurs Sci 1999;22(1):40-51.

(8.) McKay M. Region, faith, and health: The development of Winnipeg's Visiting Nursing Agencies, 1897-1926. In: Elliott J, Stuart M, Toman C (Eds.), Place and Practice in Canadian Nursing History. Vancouver, BC: UBC Press, 2008;70-90.

(9.) Gleason M. Race, class and health: School medical inspection and "healthy" children in British Columbia, 1918-1939. CBMH 2002;19(1):95-112.

(10.) McKay M. Public health nursing. In: Bates C, Dodd D, Rousseau N (Eds.), On All Frontiers: Four Centuries of Canadian Nursing. Ottawa: University of Ottawa Press, 2005;107-24.

(11.) Royce M. Eunice Dyke, Health Care Pioneer: From Pioneer Public Health Nurse to Advocate for the Aged. Toronto: Dundurn Press, 1983;49.

(12.) McKay M. "We need at this time as never before healers and binders, and that is particularly women's work": Public Health Nursing in Manitoba, 1904-1922. Unpublished paper given at the Agnes Dillon Randolph International Nursing History Conference, March 20-21, 2009, Charlottesville, VA.

(13.) McPherson K. Bedside Matters: The Transformation of Canadian Nursing, 1900-1990. Toronto: Oxford University Press, 1996.

(14.) McKay M. The origins of community health nursing in Canada. In: Stamler L, Yiu L (Eds.), Community Health Nursing: A Canadian Perspective, 2nd ed. Toronto: Pearson Educational, 2008;1-19.

Marion McKay, RN, PhD [1]

Author Affiliation

[1.] Associate Dean, Faculty of Nursing, University of Manitoba, Winnipeg, MB, E-mail: marion_mckay@umanitoba.ca.

Avant que l'Association canadienne de sante publique soit fondee en 1910, on comptait deja des infirmieres communautaires dans certaines villes canadiennes depuis au moins trois decennies1. Les periodiques scientifiques, comme l'American Journal of Nursing, le Visiting Nursing Quarterly et le Canadian Nurse, offraient a la profession des recits convaincants d'infirmieres qui jouaient divers roles dans la prevention des maladies et dans la promotion de la sante des populations a risque comme: les immigrants, les gens pauvres des regions urbaines, les nourrissons et les enfants ainsi que les familles isolees vivant dans les regions rurales et nordiques du Canada. Les termes << infirmiere visiteuse >> et << infirmiere de quartier >> etaient utilises de maniere interchangeable dans les periodiques scientifiques et les manuels de l'epoque et, dans tous les cas, on designait ces infirmieres comme etant des infirmieres de sante publique (ISP). Lillian Wald, infirmiere autorisee et reformatrice de la societe, qui a fonde le Henry Street Settlement a New York en 1895, a invente le terme ISP en 1893 pour decrire les infirmieres qui travaillaient au sein de collectivites pauvres et de classe moyenne plutot que dans des hopitaux ou dans les residences de riches employeurs (2).

On en sait peu au sujet des premieres ISP, mais la plupart etaient probablement embauchees seules ou en equipes de deux par des organismes caritatifs ou religieux ayant mis sur pied de petits programmes communautaires d'approche a de nombreux endroits au Canada. Par exemple, on sait qu'un dispensaire dietetique a Montreal embauchait deja une infirmiere de quartier en 1885 (1). La NursingatHome Mission de Toronto a ete mise sur pied en 1889 pour soutenir deux infirmieres qui travaillaient avec les familles pauvres vivant pres du Children's Hospital1. En 1897, on a fonde a Ottawa les Infirmieres de l'Ordre de Victoria du Canada (VON Canada), une association nationale d'infirmieres de quartier creee a l'image du British Institute of Queen's Nurses en Grande-Bretagne (3). Dans de nombreux pays, VON Canada a conclu des ententes avec les gouvernements locaux et les organismes caritatifs pour offrir des programmes de soins infirmiers de sante publique, et continue de le faire. En outre, au cours de cette periode, de nombreuses initiatives benevoles de soins infirmiers de sante publique ont ete mises en oeuvre par des organismes locaux, y compris la Margaret Scott Nursing Mission (Winnipeg, 1905) (4), la Lethbridge Nursing Mission (1909)5, et la St. Elizabeth Visiting Nurses' Association (v.1910) (6).

Les programmes de sante scolaire, parraines par les commissions et les conseils scolaires locaux, ont emerge au debut du 20e siecle. En 1907, la commission scolaire de Montreal a inaugure le premier programme de controle medical au Canada (7). Mandates pour cerner et traiter les enfants d'age scolaire atteints de problemes de sante evitables et de maladies transmissibles, les commissions et les conseils scolaires ont d'abord dote les ecoles de medecins. Cependant, ils ont rapidement constate que l'efficacite des programmes de sante scolaire etait grandement amelioree lorsque les infirmieres faisaient des visites a domicile chez les familles d'enfants identifies en milieu scolaire comme etant malades ou a risque de developper une maladie. En 1909, les conseils scolaires de Winnipeg et de Hamilton ont embauche des infirmieres pour travailler avec les enfants d'age scolaire et leurs familles (7,8). En plus de l'examen physique des enfants, les ISP en milieu scolaire offraient egalement des programmes d'education sur la sante aux enfants et a leur famille (7-9).

En reponse aux taux de mortalite eleves associes a la tuberculose (TB) et aux maladies infantiles evitables, les premieres ISP ont egalement travaille a la lutte contre les maladies transmissibles et aux programmes de sante de l'enfant. Toutefois, contrairement aux infirmieres en milieu scolaire, leurs premiers employeurs etaient les organismes benevoles. Entre 1901 et 1910, des centres de distribution du lait et des programmes de sante de l'enfant, organises par des organismes caritatifs locaux, ont ete mis sur pied a Toronto, a Montreal et a Winnipeg (3,6,8). En 1905, un donateur prive a permis au Toronto General Hospital d'embaucher une infirmiere, Christina Mitchell, pour travailler a domicile avec les patients atteints de TB (6). Cependant, l'ampleur des problemes de sante publique associes a la pauvrete, aux maladies transmissibles et au manque de connaissances sur la prevention des maladies a aneanti les ressources financieres et organisationnelles dont disposaient les organismes caritatifs. Des le debut du 20e siecle, la plupart de ces organismes etaient a la recherche de fonds publics pour maintenir leurs programmes en place. Ainsi, par exemple, le service de sante civique (civic health department) de Winnipeg a commence a verser en 1910 des subventions annuelles a l'association locale d'infirmieres de quartier et au centre de distribution du lait pour appuyer leurs programmes de sante de l'enfant (10). A long terme, le transfert des initiatives benevoles de soins infirmiers de sante publique aux gouvernements civiques est par consequent devenu la solution de choix. Les programmes de lutte contre la tuberculose etaient souvent les premiers a etre integres au secteur public. Les ISP qui oeuvraient dans la lutte contre la tuberculose ont ete transferees aux services de sante a Ottawa en 1905, et a Toronto en 1907 (6,10). En 1914, les services de sante de Toronto et de Winnipeg ont pris en charge les initiatives benevoles de sante de l'enfant et cree les services d'hygiene pour enfants (Child Hygiene Departments) afin de poursuivre ce travail (6,8). Dans la plupart des territoires, les ISP travaillaient dans le cadre de programmes particuliers au sein des services de sante. La premiere exception fut Toronto, ou le service de sante a regroupe ses programmes de lutte contre les maladies trans missibles et de services d'hygiene pour enfants en 1914 (6). Selon Eunice Dyke, surintendante des ISP de Toronto, cette decision refletait le desir du service de << se concentrer sur les residences plutot que sur les maladies >> (11). La portee de leur pratique a ete elargie en 1917 lorsque les infirmieres du conseil scolaire ont ete transferees au service de sante et leurs responsabilites ont ete integrees a la pratique des ISP generalistes du service de sante (6).

Dans les regions rurales, le developpement des services de soins infirmiers de sante publique s'est fait beaucoup plus lentement. Gene par la nature eparse des populations et la conviction generale selon laquelle les couts associes aux services prodigues par les ISP doivent etre defrayes par les autorites municipales (comtes), le financement de l'embauche d'ISP etait difficile a maintenir. Dans certains cas, des groupes locaux de femmes, comme le Women's Institute ou le United Farm Women, embauchaient des medecins ou des infirmieres pour diriger les cliniques de sante pour enfants ou les controles dans les ecoles parce qu'aucun autre organisme n'etait pret a offrir ce genre de services (7,12). En 1916, apres des annees de lobbying de la part des groupes d'agricultrices et de reformatrices de la societe, le Manitoba est devenu la premiere province au Canada a mettre en place un service de soins infirmiers de sante publique finance a l'echelle provinciale. S'appuyant sur l'experience du service de sante de Toronto, ces ISP travaillaient comme generalistes dans les districts ruraux ou le gouvernement local etait pret a defrayer une portion des couts associes au service (12).

Les premieres ISP etaient, avec raison, fieres de leurs realisations. Elles ont ete designees comme des membres de l'elite de la profession d'infirmiere, en raison des normes educatives plus elevees exigees concernant le travail en sante publique et la complexite de leur pratique (7,13,14). Les demandes physiques et psychologiques etaient considerables. Les ISP en region urbaine parcouraient de nombreux kilometres dans leur district respectif, malgre les conditions meteorologiques parfois defavorables, les surfaces dangereuses et les conditions non hygieniques. Les ISP en region rurale voyageaient a cheval, en train, en traineau a chiens, en voiture, en avion ou a pied afin de parcourir les nombreux kilometres qui separaient les residences visitees (12). Au fil du temps, elles ont du apprendre a conduire pour exercer leur profession et les nombreuses photographies d'ISP a cote de leur voiture viennent confirmer l'affection qu'elles portaient a leur compagnon de voyage mecanique. Dans les milieux ruraux et urbains, les ISP travaillaient souvent seules, prenant des decisions difficiles--parfois concernant des questions de vie ou de mort--guidees seulement par leurs connaissances, leurs competences et leur courage.

Comme les programmes de sante publique relevaient de la competence provinciale et ne s'inscrivaient pas dans les programmes nationaux d'assurance-maladie du Canada, le developpement chronologique des programmes de soins infirmiers de sante publique variait d'une province a l'autre ou d'un territoire a l'autre. Cependant, il est possible de faire des analogies. Au debut du 20e siecle, les ISP ont integre la prevention des maladies chroniques dans leur pratique. La lutte contre les maladies transmissibles demeure la pierre angulaire de la profession. Les premieres ISP ont lutte contre le cholera, la variole, la fievre typhoide et une multitude d'autres infections que l'on ne voit presque plus aujourd'hui. Les ISP d'aujourd'hui travaillent dans un contexte mondial et continuent a relever les defis que representent la prevention et la lutte contre la tuberculose et a travailler sur les premieres lignes afin de prevenir l'introduction et la propagation d'infections pandemiques comme le SRAS et le virus de la grippe A (H1N1). Elles continuent de promouvoir la sante des meres et des enfants. La sante de l'environnement demeure egalement une partie integrante de leur pratique alors que les ISP elaborent et mettent en place des interventions communautaires afin d'attenuer les repercussions des changements climatiques a l'echelle mondiale, des vecteurs de maladie locaux, des risques professionnels, des conditions sanitaires locales ainsi que de l'insecurite alimentaire sur la sante humaine. Enfin, les ISP defendent les collectivites et travaillent pour ces dernieres au sein desquelles elles oeuvrent, se concentrant, comme elles l'ont toujours fait, sur les determinants sociaux de la sante et la creation de collectivites engagees dans la repartition juste et equitable des ressources materielles et du pouvoir politique.

Troisieme d'une serie de cinq articles historiques commemorant le centenaire de la RCSP. Directrice scientifique invitee: Maureen Malowany, Ph.D.

References

(1.) McLeod C. District nursing in Canada. AJN 1902;2(7):503-7.

(2.) Buhler-Wilkerson K. Public health then and now. AJPH 1993;83(12):1778-86.

(3.) Penney S. A Century of Caring: The History of the Victorian Order of Nurses for Canada. Ottawa, ON: VON Canada, 1996.

(4.) Jones E. Influenza 1918: Disease, Death, and Struggle in Winnipeg. Toronto, ON: University of Toronto Press, 2007.

(5.) Richardson S. Women's Enterprise: Establishing the Lethbridge Nursing Mission, 1909-1919. NHR 1997;5:105-30.

(6.) MacDougall H. Activists and Advocates: Toronto's Health Department 1883-1983. Toronto: Dundurn Press, 1990.

(7.) Duncan S, Leipert B, Mill J. << Nurses as health evangelists >>?: The evolution of public health nursing in Canada, 1918-1939. Adv Nurs Sci 1999;22(1):40-51.

(8.) McKay M. Region, faith, and health: The development of Winnipeg's Visiting Nursing Agencies, 1897-1926. In: Elliott J, Stuart M, Toman C (Eds.), Place and Practice in Canadian Nursing History. Vancouver, BC: UBC Press, 2008;70-90.

(9.) Gleason M. Race, class and health: School medical inspection and << healthy >> children in British Columbia, 1918-1939. CBMH 2002;19(1):95-112.

(10.) McKay M. Public health nursing. Dans: Bates C, Dodd D, Rousseau N (Eds.), On All Frontiers: Four Centuries of Canadian Nursing. Ottawa: University of Ottawa Press, 2005;107-24.

(11.) Royce M. Eunice Dyke, Health Care Pioneer: From Pioneer Public Health Nurse to Advocate for the Aged. Toronto: Dundurn Press, 1983;49.

(12.) McKay M. <<We need at this time as never before healers and binders, and that is particularly women's work >>: Public Health Nursing in Manitoba, 1904-1922. Article non publie presente lors de la Agnes Dillon Randolph International Nursing History Conference, mars 20-21, 2009, Charlottesville, VA.

(13.) McPherson K. Bedside Matters: The Transformation of Canadian Nursing, 1900-1990. Toronto: Oxford University Press, 1996.

(14.) McKay M. The origins of community health nursing in Canada. Dans: Stamler L, Yiu L (Eds.), Community Health Nursing: A Canadian Perspective, 2nd ed. Toronto: Pearson Educational, 2008;1-19.

Marion McKay, IA, Ph.D. [1]

Affiliation de l'auteure

[1.] Doyenne associee, Faculte de soins infirmiers, Universite du Manitoba, Winnipeg, Manitoba, Courriel: marion_mckay@umanitoba.ca.
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Author:McKay, Marion
Publication:Canadian Journal of Public Health
Geographic Code:1CANA
Date:Jul 1, 2009
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