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Enduring echoes: early public health nursing in Georgia.

The regional and historical factors influencing how public health nursing developed during the first half of the 20th century in Georgia is the subject of this column. The prevailing view of U.S. public health nursing is that it developed in the 1890s in response to industrialization and immigration. A distinct set of historical circumstances and ideologies within the South, however; determined a uniquely sectional response to the development of public health in Georgia. Among these reasons were rurality, postCivil War poverty, severely limited resources for social services, northern philanthropy for southern disease eradication, race and class issues, the construction of gender, white upper- and middleclass attitudes toward blacks and "poor whites" as inferior and unworthy, a high value placed on home care for the sick by family, friends or servants, a reluctance for institution building, especially for poor and blacks; and states' rights political philosophies that opposed Federal government intrusion.

Public health services grudgingly given and slowly developed may have also been linked to the viewpoint that assumed that, "Black people were savage and bound for dissolution," and therefore did not need health care. Competing with this attitude was an underlying fear that if left unchecked their diseases might spread to the "better" classes (Hewitt 1982, Williamson 1984). In a fictional account of social services for the poor in an Atlanta slum, the persistent negative and ambivalent attitudes of the white power structure toward free health services for the poor were explored (Dern 1959).

The State Board of Health in Georgia was established in 1875 and almost immediately dissolved in 1876, then again revived in 1903 by vote of the General Assembly (Abercrombie 1953). Since tuberculosis was a major public health problem in Georgia at the turn of the century, the General Assembly in 1904 also created the State Commission on Tuberculosis. This organization along with the Georgia Tuberculosis Association focused energy on controlling this fear-provoking transmittable disease. Because general hospitals would not admit patients with tuberculosis, services were offered through clinics and home visiting. In 1908 the fledgling Georgia State Nurses Association pledged money to support district nursing for tuberculosis patients through the Visiting Nurses Association. From 1909 to 1916, the Association investigated conditions in state almshouses, and suggested that trained nurses would be crucial in stemming the tide of tuberculosis within these institutions. One example of a nurse being hired in this capacity occurred in Savannah in 1904. She was hired by the Margaret Bottome Circle of King's Daughters to work with tubercular patients (Parsons 1985, Schissel 1979).

In 1909, funding from the Rockefeller Foundation's Sanitary Commission assisted in the effort to inspect, identify, treat and control hookworm. Ninety-nine counties out of 159 in Georgia contributed money to fight hookworm, but when the Rockefeller Foundation withdrew their financial support, the programs essentially died. The Public Health Service joined in the fight against pellagra in 1909, but it wasn't until 1937 that the cause of the disease, a lack of nicotinic acid (niacin), was identified (Etheridge 1972).

Two major deterrents to early 20th century public health work in Georgia were the absence of a program to collect vital statistics by which to track births, deaths and disease; and a lack of funds to develop county health work. A vital statistics law and creation of a county health department network were enacted in 1914, but it wasn't until 1928 that Georgia was able to get all counties to consistently record both births and deaths. In addition county health work lagged due to budgetary problems, and too few doctors trained in public health work (Schissel 1979).

Nurses working in public health in Georgia during the first three decades of the 20th century were sparsely scattered in visiting nurse organizations, fledgling city departments and assorted philanthropic organizations. Federal programs such as the Children's Bureau formed in 1912, and the enactment of the Sheppard-Towner Act signed in 1921, brought additional attention to the need for public health services. In 1920, the Georgia General Assembly created the Maternal and Child Division in the State Health Department to address Georgia's high infant and maternal mortality rates, increasing the demand for public health nurses to work in the area of maternal and child services (Schissel 1979).

The earliest well-organized effort in public health nursing in Georgia began in Savannah when the Savannah Health Center was organized in 1920 and incorporated in 1931. This Center served a large biracial population with urban and coastal health problems, and employed both black and white nurses. As early as 1904, blacks in Savannah outnumbered whites 36,000 to 31,000, but hospital care for blacks was limited to only two small hospitals, the Georgia Infirmary and Charity Hospital (Hewitt 1982). This lack of medical care forced the African-American population to rely more heavily on public health and home visiting services. The Mary Maclean Milk Depot and Visiting Nurses Association, established in Savannah in 1905, hired a nurse to make house calls to indigent patients. Mary Maclean was later incorporated in the Savannah Health Center, and both merged with the Health Department in 1925 (McCarty 1984).

By 1928, there were only 106 public health nurses spread across 159 counties in Georgia working under the following categories: 34 were connected to health departments, 19 worked as industrial nurses, two were in schools, 15 were in tuberculosis work, and the remainder worked for the Red Cross, the Metropolitan Insurance Company and other organizations (Schissel 1979).

The hardships of the Great Depression facilitated the establishment of permanent health services in most of Georgia's counties with appropriations from Social Security, the U.S. Public Health Service and the Children's Bureau (Abercrombie 1953). New Deal programs created by the Roosevelt administration brought opportunities for nurses to work in many public programs. Caroline Tillinghast (1937) Chairman of the Works Progress Administration (WPA) Committee for the Georgia State Nurses Association reported that:
 When Social Security funds became available
 to the State Department of Health on April 15,
 1936, new opportunities were opened to nurses
 for permanent employment in the public health
 field in this State. Of the 180 nurses who served
 at various times on the Statewide FERA and
 WPA projects, 62 now hold permanent positions
 as public health nurses. Forty-three of these
 nurses were given special training before being
 appointed (49).

At first, 90 counties were served by just 20 nurses. Each nurse had from four to six counties, each with about 50,000 people under her care. Duties included organizing tuberculosis clinics, supervising active cases of tuberculosis, and selecting and supervising additional county nurses. By 1939, Social Security funds were available to send nurses for post-graduate public health training in approved university programs (Carter 1939).

In 1940, Georgia had 19 cities with populations greater than 10,000, and an overall population of over three million. During 1939-1942, 62 counties employed public health nurses, and by the end of 1942, 121 counties had some type of full-time public health service, leaving 38 counties without fulltime services. Diseases controlled by immunizations rapidly declined with these programs in place, but problems that required medical facilities such as tuberculosis, maternal and infant problems and syphilis, were not as easily remedied. By the end of 1947, a total of 408 public health nurses were active in Georgia.

Nurse professional organizations played a large part in the personal development of practicing public health nurses, as did the additional education sought by many of these nurses. These two issues will be discussed in this column in the next issue of Georgia Nursing.

[This information is excerpted from Cannon, R.B. (1995) "Georgia's Twentieth Century Public Health Nurses: A Social History of Racial Relations," Emory University, Atlanta, GA. Unpublished dissertation.]


Abercrombie, T.F. (1953). History of Public Health in Georgia, 1733-1950. Atlanta: Georgia Department of Public Health.

Carter, C.B. (1939). "A personnel study of Georgia's Department of Public Health and Department of Agriculture," M.A. thesis, Emory University, Atlanta, GA.

Dern, P.G. (1959). Settlement Nurse, New York: Prestige Books.

Etheridge, E.W. (1972). The Butterfly Caste: A Social History of Pellagra in the South. Westport, Conn: Greenwood Press.

Hewitt, Mrs. G. (1982). "Black Savannah: Struggle for Social Progress, 1890-1960." Unpublished manuscript. Photocopied.

McCarty, M.J. (1984). "'Visiting Nurse' Name Revived." Savannah-Morning News. 26 July. In personal papers of Geraldine Beasley.

Parsons, M.K. (1985). "White Plague and Double-barred Cross in Atlanta." Ph.D. dissertation, Emory University, Atlanta, GA

Schissel, C. (1979). "The State Nurses' Association in a Georgia Context, 1907-1946." Ph.D. dissertation, Emory University, Atlanta, GA.

Williamson, J. (1984). The Crucible of Race: Black-White Relations in the American South since Emancipation. New York: Oxford University Press.
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Title Annotation:History
Author:Cannon, Rose B.
Publication:Georgia Nursing
Date:Nov 1, 2013
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