Nursing History Review, Volume 22: Official Journal of the American Association for the History of Nursing [28 ed.] 9780826144546, 9780826122957

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NURSING HISTORY ­R EVIEW OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR THE HISTORY OF NURSING

ISSN 1062-8061 ISBN 978-0-8261-2295-7

2014—Volume 22

CONTENTS

E d i t o r ’s N o t e

10

The Future of Health Care’s Past Patricia D’Antonio

S h a r e: N u r s i n g H i s t o r y R e v i e w

Articles

13 Nurses Across Borders: Displaced Russian and Soviet Nurses after World War I and World War II Susan Grant 37 “Coming to Grips with the Nursing Question”: The Politics of Nursing Education Reform in 1960s America Dominique Tobbell 61 “It’s Been a Long Road to Acceptance”: Midwives in Rhode Island, 1970–2000 Simone M. Caron

New York

T h e F u t u r e o f H e a l t h C a r e ’ s P a s t : A Symposium in Honor of Joan E. Lynaugh, PhD, RN, FAAN 95

Setting the Stage Julie A. Fairman



 anel 1: Thinking Beyond Professional P Boundaries and International Borders Boundary Crossings in the History of Health Care John Harley Warner

102

107

Tiptoeing Towards a History of Nursing in Europe Anne Marie Rafferty

Panel 2: Challenging Conventions 114 International Nursing History: The International Council of Nurses History Collective and Beyond Geertje Boschma 119

History and Nursing History at Penn in the 1980s Naomi Rogers

126

Inspiration and Guidance Arlene Keeling

132

Panel 3: A New Generation of Scholars A Graduate’s Gratitude Keith C. Mages

137

Joan Lynaugh Winifred C. Connerton

140

Reflections on a Legacy of Mentorship Margo Brooks Carthon



Notes and Documents

144 Edward L. Bernays and Nursing’s Code of Ethics: An Unexplored History Guy Philbin and David M. Keepnews 159

The Future of Health Care’s Past in Closing A Colleague’s Salute to Joan Lynaugh Barbara Brodie

The Future of Health Care’s Past in

Summation 163

Transnational Feminist Practices and the History of Nursing Susan Reverby



In Memoriam

166 A Salute to Rosemary Theresa McCarthy, RN, PhD, FAAN, Colonel U.S. Army (Retired) Barbara Brodie and Eleanor Bjoring 171 Eleanor Krohn Herrmann, February 1, 1935–July 31, 2012: Excerpts from a Eulogy by Lawrence Herrmann



Media Reviews

179

The Recipes Project: Food, Magic, Science and Medicine Reviewer: Susan Hanket Brandt

181 Binding Wounds, Pushing Boundaries: African Americans in Civil War Medicine Exhibit Reviewer: Barbara Maling 183

Controlling Heredity: The American Eugenics Crusade 1870–1940 Reviewer: Bonnie Pope

185

Nursing in America: A History of Social Reform Reviewer: Jennifer Casavant Telford



Book Reviews

188 Racial Innocence: Performing American Childhood from Slavery to Civil Rights by Robin Bernstein Reviewer: Briana Ralston 190

Gender and the Making of Modern Medicine in Colonial Egypt by Hibba Abugideiri Reviewer: Janna L. Dieckmann

193 Florence Nightingale on Wars and the War Office: Collected Works of Florence Nightingale, Volume 15 edited by Lynn McDonald Reviewer: Jean C. Whelan 195 Australia’s Controversial Matron: Gwen Burbidge and Nursing Reform by Judith Godden Reviewer: Gerard M. Fealy 198 Das Tagebuch der jüdischen Kriegskrankenschwester Rosa Bendit, 1914 bis 1917. Herausgegeben und kommentiert von Susanne Rueb und Astrid Stölzle [The Diary of a Jewish War Nurse Rosa Bendit, 1914 until 1917] by Susanne Rueb and Astrid Stölzle Reviewer: Geertje Boschma 200 Come from Away: Nurses Who Immigrated to Newfoundland and Labrador by Jeanette Walsh and Marilyn Beston Reviewer: Susan A. LaRocco 201

Downs: The History of a Disability by David Wright Reviewer: Beth Linker

204 Body and Soul: The Black Panther Party and The Fight Against Medical Discrimination by Alondra Nelson Reviewer: Linda Maldonado

206 North Carolina and the Problem of AIDS: Advocacy, Politics & Race in the South by Stephen J. Inrig Reviewer: LaShanda Brown 208 Pills, Power, and Policy: The Struggle for Drug Reform in Cold War America and Its Consequences by Dominique A. Tobbell Reviewer: Cynthia Connolly 210 The Nursing Profession: Development, Challenges, and Opportunities edited by Diana J. Mason, Stephen L. Isaacs, and David C. Colby Reviewer: Lisa M. Zerull 213

New Dissertations

Cover Photo: Class of 1918, Chestnut Hill Hospital School of Nursing, ­Philadelphia, PA 19118. Reprinted with the permission of the Barbara Bates Center for the Study of the History of Nursing, School of Nursing, University of Pennsylvania. Nursing History Review is published annually for the American Association for the History of Nursing, Inc., by Springer Publishing Company, LLC, New York. Business Office: All business correspondence, including subscriptions, renewals, advertising, and address changes, should be sent to Springer Publishing Company, LLC, 11 West 42nd Street, New York, NY 10036. Editorial Office: Submissions and editorial correspondence should be directed to ­Patricia D’Antonio, Editor, Nursing History Review, University of Pennsylvania, 420 ­Guardian Drive, Room 307, Philadelphia, PA 19104-6096. See Guidelines for contributors on page 7 for further details. Members of the American Association for the History of Nursing, Inc. (AAHN) receive Nursing History Review on payment of annual membership dues. Applications and other correspondence relating to AAHN membership should be directed to: David L. Stumph, IOM, CAE, Executive Director, American Association for the History of Nursing, Inc., 10200 W. 44th Avenue #304, Wheat Ridge, CO 80033. Phone: 303 422.2685. E-mail: [email protected] Subscription Rates (per Year): For institutions: $95. For ­individuals: $95. Outside the United States—for institutions: $95. For individuals: $95. Payment must be made in advance by check (in U.S. dollars drawn on a U.S. bank) or international money order, payable to Springer Publishing Company, LLC, or by MasterCard, Visa, or American Express. Indexes/abstracts of articles appear in: CINAHL® print index & database, Current ­Contents /Social & Behavioral Science, Social Sciences Citation Index, Research Alert, RNdex, Index Medicus/MEDLINE, History Abstracts, America; History and Life. Permission: All rights are reserved. No part of this volume may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying (with the exception listed below), recording, or by any information storage and retrieval system, without permission in writing from the publisher. Permission is granted by the copyright owner for libraries and others registered with the Copyright Clearance Center (CCC) to photocopy any article herein for $5.00 per copy of the article. Payments should be sent directly to Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA. This permission holds for copying done for personal or internal reference use only: it does not extend to other kinds of copying, such as copying for general distribution, advertising or promotional ­purposes, creating new collective works, or for resale. Requests for these permissions or further information should be addressed to Springer Publishing Company, LLC. Postmaster: Send address change to Springer Publishing Company, LLC, 11 West 42nd Street, New York, NY 10036. Copyright © 2014 by Springer Publishing Company, LLC, New York, for the American Association for the History of Nursing, Inc. ISSN 1062-8061 ISBN 978-0-8261-2295-7

GUIDELINES FOR CONTRIBUTORS

The Nursing History Review, the official publication of the American Association for the History of Nursing, is a peer-reviewed journal, published annually for subscribers and members of the Association. Original research manuscripts are welcomed in broad areas related to the history of nursing, health care, health policy, and society. The Review prefers manuscripts of approximately 40 pages, inclusive of endnotes. Submitted manuscripts must be prepared using the guidelines specified in the Chicago Manual of Style, 16th edition. Manuscripts must have a title page that contains the full title of the manuscript; the author(s) name(s) and credentials as they are meant to appear in print, institutional affiliations, preferred mailing addresses for all authors, and relevant contact information for the corresponding author. The title page must be followed with an abstract of approximately 150–200 words. Manuscripts must be double-spaced and of letter-quality print. They must also use a type size of at least 12 characters per inch or 12 points. Please leave generous margins of at least 1 inch. All pages—including text, notes, and reference pages—must be numbered consecutively. All notes must be double-spaced and placed at the end of the manuscript as endnotes rather than footnotes. Authors are responsible for securing permissions for all materials submitted. If more than 500 words of text are quoted from a book, or more than 250 words from an article, or if a table or figure has been previously published, the manuscript must be accompanied by written permission from the copyright owner. Initial submissions of manuscripts may be sent by e-mail to nhr@nursing. upenn.edu. All submissions will be acknowledged when received. Final versions of manuscripts accepted for publication should be prepared in MS Word. The final packet must be submitted via e-mail to [email protected]. Photographs or other figures accompanying the final manuscript must be attached as TIF files with resolutions of at least 600 dpi. All appropriate permissions and copyright releases must accompany the final submission. All correspondence regarding manuscripts should be sent to: Patricia D’Antonio, PhD, RN, FAAN, Editor, Nursing History Review, University of Pennsylvania School of Nursing, 407 Claire M. Fagin Hall, 418 Curie ­Boulevard, Philadelphia, PA 19104-6096. Phone: 215/746.4188. Fax: 215/573-2168. E-mail: [email protected] or [email protected].

AMERICAN ASSOCIATION FOR THE HISTORY OF NURSING, INC. Jean C. Whelan President Mary Tarbox First Vice President and Chair, Strategic Planning Committee Mary Gibson Second Vice President and Chair, Program Committee Susan LaRocco Secretary Jennifer Telford Treasurer Barbara Gaines Director and Chair, Publications Committee Joan E. Lynaugh Director and Chair, Awards Committee

Annemarie McAllister Director and Chair, By-Laws Committee Ewing “Rusty” Lusk Director and Member, Finance Committee Gerard Fealy Director and Member, Strategic Planning Sylvia Rinker and Melissa Sherrod Chair, Nominating Committee Cynthia A. Connolly Director and Member, Research Award Committee Gertrude Hutchinson Archivist

NURSING HISTORY REVIEW Patricia D’Antonio, Editor Cynthia Connolly, Associate Editor Lynne Dunphy, Book Review Editor Winifred Connerton, Media Editor Tiffany Collier, Assistant Editor Editorial Review Board Ellen D. Baer Florida

Wanda C. Hiestand New York

Nettie Birnbach Florida

Arlene Keeling Virginia

Eleanor Crowder Bjoring Texas

Joan Lynaugh Pennsylvania

Barbara Brodie Virginia

Lois Monteiro Rhode Island

Olga Maranjian Church Connecticut

Sioban Nelson Toronto, Canada

Julie Fairman Pennsylvania

Paulo Joaquim Pina Queirós Coimbra, Portugal

Marilyn Flood California

Anne-Marie Rafferty London, England

Karen Flynn Illinois

Susan Reverby Massachusetts

Janet Golden New Jersey

Naomi Rogers Connecticut

Christine Hallett Manchester, England

Meryn Stuart Ottawa, Canada

Diane Hamilton Michigan

Nancy Tomes New York

Carol Helmstadter Ontario, Canada

EDITOR’S NOTE

The Future of Health Care’s Past On April 14, 2012, the Barbara Bates Center for the Study of the ­History of Nursing held a symposium on the “Future of Healthcare’s Past” both as a ­festschrift to honor Joan E. Lynaugh and as a celebration of the 25th ­anniversary of the Bates Center that she, with Ellen Baer and Karen Buhler-Wilkerson, created in 1985. I am delighted to have the opportunity to publish some papers from this festschrift and birthday celebration in this volume of the ­Nursing History Review. These papers speak to the very personal effects Joan has had on so many professional careers; and to the very profound effect she has had on transforming what Sioban Nelson has called the “­professional agenda” of nursing history—internalist narratives that spoke to the concerns of the discipline—to one that used the history of nursing as a lens to see how the experiences of nurses answered broader questions about women’s (and some men) roles, opportunities, labor, and place in health care practices.1 But this festschrift and symposium allowed me to think more deeply about Joan’s role as the founding editor of the Nursing History Review. Joan, in consultation with colleagues such as Vernon Bullough and Barbara ­Brodie, brought together an interdisciplinary editorial board that consisted of such scholars as Nettie Birnbach, Olga Church, Donna Diers, Marilyn Flood, Diane Hamilton, Darlene Clark Hine, Beatrice Kalish, Susan Reverby, and Nancy Tomes. Together the Board and Joan made the critical decisions that immediately set the standards that made the Review the preeminent journal in our field. These standards still guide the Review some 21 years later. First, the ­Review patterns itself after other historical journals: rather than clinical journals that expect authors to make their case in less than 16 pages, the Review allows authors some 30 or so manuscript pages to make nuanced arguments about topics that uses nurses and nursing to engage with important historiographical debates. Second, Joan remained committed to an absolute ­insistence on the highest quality of scholarship—even if that meant publishing few ­articles in each volume. She insisted on an interdisciplinarity and global focus long ­before Nursing History Review 22 (2014): 10–12. A Publication of the American Association for the History of Nursing. Copyright © 2014 Springer Publishing Company. http://dx.doi.org/10.1891/1062-8061.22.10



Editor’s Note

11

these were popular. Joan also created the template for an active ­editorship: she never waited for papers to come to her but rather ­actively sought out those within and outside our discipline mining the insights that the history of ­nursing might create. And she gave so generously of her time to young scholars and to those working without the support of formal ­centers. The result: the Review, published annually, has a small and specialized ­audience of historians and nurses, but its global prestige and impact as the leading journal in its field belie its size. In 2003, the Review was selected as one of the first of only 27 nursing journals chosen to calculate impact factors by the ISI Web of Knowledge; and in 2004, our quantitative ­colleagues recognized its place as an influential journal with a strong international ­presence.2 I have certainly stood on the shoulders of a giant—a giant who not only mentored me in this role when I first assumed editorship in 2002 but who also knew when to step back and let me chart a new direction for the Review as it made its way into the 21st century. And looking out on these shoulders, I am very excited about the future of health care’s past. The field of the history of nursing, to paraphrase Ellen Lageman is once again in ferment and its ­scholars, to paraphrase Celia Davis, see themselves working on the cutting edge of history, policy, and practice. Recently, a new generation of ­scholars with ­different backgrounds and experiences are turning to the history of nursing with new paradigms and methodological tools. As importantly, these scholars have moved the history of nursing beyond the traditional nation-state analysis that structured Lageman and Davis’ seminal collected essays some 30 years ago. They have begun an exciting process of using the historical experiences of nurses to track the global flow of ideas and practices. And they have begun to use these experiences to problematize and reconceptualize notions of citizenship, state, nation, and empire. Why is this important? This new literature points to the exploration of ways in which nurses historically maintained and participated in multiple ideological networks and exchanges that transcended conventional narratives of the mission of institutions, shaping of events, and place of particular ­actors. It allows us to explore, as do the authors of articles in this volume, how the nurses and their initiatives existed at the fulcrum of very real policies and politics, and identities and practices. Some may be situated within traditional nation-state boundaries, but they all ask us to reconsider any direct relationship between formal authority and policy implementation. Rather they invite us, instead, to consider the ways those in practice—and with the closest relationship to those served—negotiated, in some cases supported, and in other cases subverted, but in all cases influenced the agendas of those who would see particular agendas come to fruition. They place their historical nurses “in the

12

Editor’s Note

middle”—in liminal states that reveal something about power, place, and particular moments in time. It may be that the Nursing History Review is in its own liminal state. On April 14, 2012, the Barbara Bates Center for the Study of the History of Nursing hosted an international symposium that brought together an international group of leading interdisciplinary scholars to reflect on the past and the future direction of the history of health care. But this symposium was also a festschrift that paid tribute to Joan by reflecting backward on her influence on the field of the history of nursing; that celebrated the 25th Anniversary of the Center that she and like-minded colleagues, Ellen Baer and Karen BuhlerWilkerson, created; and that looked to the future that talented students and scholars both within and outside the discipline might create. As I opened this note I turned to Joan’s role—one she has always described as a “labor of love”—as the founding editor of the Nursing History Review. In closing, I am especially delighted that the Review might repay its debt to her by publishing many of the papers presented at her festschrift. And in this volume, we bid good-bye to Barbra Mann Wall and Jean C. Whelan who have so ably and steadfastly served as the Review’s Book Review and Media Review editors for so many years. I thank you for your dedication to the Review and, through it, to the association. But I also have the pleasure of welcoming Lynne Dunphy as our new Book Review Editor and Winifred Connerton as our new Media Review Editor. Welcome! And we look forward to your helping the Review stand even higher and see even further.

Notes 1. Sioban Nelson, “The Fork in the Road: Nursing History Versus the History of Nursing?” Nursing History Review 10 (2002): 175–188. 2. Molly Dougherty, et al., “International Content of High Ranking Nursing ­Journals in the Year 2000.” Journal of Nursing Scholarship 36, no. 2 (2004): 173–179.

Patricia D’Antonio, PhD, RN, FAAN University of Pennsylvania School of Nursing 407 Claire M. Fagin Hall 418 Curie Boulevard Philadelphia, PA 19104-6096

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ARTICLES

Nurses Across Borders: Displaced Russian and Soviet Nurses after World War I and World War II Susan Grant University of Toronto and University College Dublin Alice Fisher Fellow, Barbara Bates Center for the History of Pennsylvania

Abstract. Russian and Soviet nurse refugees faced myriad challenges attempting to become registered nurses in North America and elsewhere after the World War II. By drawing primarily on International Council of Nurses refugee files, a picture can be pieced together of the fate that befell many of those women who left Russia and later the Soviet Union because of revolution and war in the years after 1917. The history of first (after World War I) and second (after World War II) wave émigré nurses, integrated into the broader historical narrative, reveals that professional identity was just as important to these women as national identity. This became especially so after World War II, when Russian and Soviet refugee nurses resettled in the West. Individual accounts become interwoven on an international canvas that brings together a wide range of personal experiences from women based in Russia, the Soviet Union, China, Yugoslavia, Canada, the United States, and elsewhere. The commonality of experience among Russian nurses as they attempted to establish their professional identities highlights, through the prism of Russia, the importance of the history of the displaced nurse experience in the wider context of international migration history.

Many readers, whether historians of Soviet Russia or not, are familiar with the first great wave of Russian emigration during the Russian Civil War (1917–1922). The conditions of war and revolution led to a flood of ­émigrés

Nursing History Review 22 (2014): 13–36. A Publication of the American Association for the History of Nursing. Copyright © 2014 Springer Publishing Company. http://dx.doi.org/10.1891/1062-8061.22.13

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to many parts of Europe, China, North America, and beyond. With the establishment of the Soviet Union in 1922, many of these émigrés became “stateless”—a status many retained throughout their lives or until they finally received citizenship in another country after World War II.1 This ­article focuses on Russian and Soviet nurses because their experience opens a window into what could be described as a unique chapter in migration history. The peculiar Russian and Soviet historical experience highlights a range of problems that arose once these displaced persons sought employment as nurses. Rather than focus exclusively on World War II, however, this article also provides a retrospective historical analysis of Russian nurse migration and transmigration that spans the period from just before the outbreak of World War I in 1914 to the resettlement of displaced persons during the 1950s and 1960s. The full context of the processes of war and revolution, as well as broader international political, social, and cultural developments—especially those pertaining to the nursing profession—facilitates a greater understanding of the conditions in which ordinary Russian and Soviet citizens who were nurses coped with the immense changes in the first half of the 20th century. It also highlights important issues such as statelessness, professional status, transnational migration, and their impact on the lives of ordinary citizens. The first years of the 20th century in Russia were turbulent ones. The 1905 revolution, World War I, abdication of Tsar Nicholas II, February Revolution (February 1917), and Bolshevik Revolution (October 1917), followed by the civil war (1917–1922), created conditions of extreme political, social, and economic instability and dislocation. The Bolsheviks, led by Vladimir I. Lenin, were in power and rallying the worker and peasant masses against their ideological enemies—the “bourgeois” classes. Nurses, who had until then been closely associated with religion and aristocratic patrons—and in fact were called “Sisters of Mercy” (sestry miloserdiya)—were in a vulnerable position once the socialist state was declared. During the Russian Civil War, “Red” Bolshevik forces fought against “White” forces (an assortment of generally anti-Bolshevik groups including former Tsarist military officers and “foreign interventionists”). Nurses fought on both sides, whether as Sisters of Mercy or Bolshevik “red sisters.” The first wave of emigration occurred during and after the civil war, owing, among other things, to the defeat of the White armies, political instability, and worsening economic and social conditions. The émigrés from this “first wave” established Russian cultural centers and communities wherever they migrated (including Paris, Prague, Berlin, and Harbin) forming what is known as “Russia Abroad.” These communities attempted to continue their



Displaced Nurses after World War I and World War II

15

cultural and linguistic traditions, ready to return to Russia in anticipation of a time when communist power would be removed.2 Russian schools, societies, hospitals, and other institutions were established in the countries where the émigrés settled.3 Although some efforts were made to integrate into their new countries (especially in Europe), emphasis was largely on preservation of the Russian way of life. Because of further political instability in the late 1930s, many émigrés who had settled in Manchuria and China migrated to the United States, especially San Francisco. This second wave occurred during and after the World War II. At this point, the United Nations (UN) Relief and Rehabilitation Administration (UNRRA), set up in 1943,4 assumed responsibility for displaced persons, including Soviet citizens in the Allied zones of Occupied Germany (the UNRRA was not invited to work in the Soviet zone). The International Refugee Organization (IRO) took over this responsibility in 1946–1951, and from 1950 the UN High Commissioner for Refugees (UNHCR) undertook responsibility for displaced persons. Most of the material drawn on here emanates from the International Council of Nurses5 (ICN) Refugee files in the Barbara Bates Center for the History of Nursing in Philadelphia. These documents offer invaluable information to historians of Soviet Russia and nursing alike.6 They confirm the overall pattern of Russian emigration during the 20-year period between about 1919 and 1941, when Russia Abroad was especially active. As Marc Raeff has noted, although many of the personalities involved in Russia Abroad survived World War II, its “institutions and communicative framework were not recreated.” The Russian émigré cultural center “shifted to the United States,” but its “sense of identity and cohesiveness” was never revived.7 The accounts of émigré nurses found in the ICN files reflect this general trend and to an extent unite the two “waves” of emigration.8 It becomes clear from many accounts that for several of these women (the nurses in these files were mostly female9), their sense of self by this stage depended not on their national identity but on their sense of professional identity. As a recent study of population displacement after World War I has asserted, forms of identity such as gender, religion, or occupation are just as important categories of analysis as national or ethnospatial identity.10 Taking the occupation of nursing as such a category, the idea of the preeminence of professional identity will be explored. The files examined here relate to both émigré Russian nurses and Soviettrained nurses and citizens who were in the IRO camps set up in Western Germany and the Philippines after World War II to deal with repatriation of refugees and displaced persons who had ended up on foreign soil.11 The task of determining professional status, as the ICN files attempt to do, was not an

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easy one, given the fragmented personal histories of Russian and Soviet citizens and the widespread loss or destruction of personal and professional documentation. The approximately 100 files I examined in detail were those of women ranging in age from 20 (this seems exceptionally young because nearly all the women were older than 30) to late 50s. These were women with some prior nurse training and work experience and consequently were unlikely to favor a new form of employment or reeducation in countries where they resettled. In examining these case files, the focus of this article is initially on the fate of the wave of nurses from the earlier, post-1919 period, particularly those who managed to preserve their identity as nurses throughout their period of exile.12 It then moves to the second wave (post-1945) of Soviet refugees to assess the professional and personal conditions in which they found themselves after migrating to North America, Australia, and elsewhere.

The First Departure: Between Borders The flight of Russian nurses after the civil war has not really been explored to any great extent in the academic scholarship. It is generally known that about 1,500 formally trained Russian nurses emigrated from Russia after the White army left the Crimea in 1920.13 These refugees were “retrained by National Red Cross Societies in Turkey, Serbia, Bulgaria, and Belgium,” but many “were unable to find nursing work and instead went into factory, office, bank, and domestic service.”14 In Paris, the cause of the Russian nurses was taken up by chief matron of the Russian Red Cross (in exile), Madame ­Alexandra Romanoff, who approached many international organizations, such as the ICN and the American Friends Service Committee, seeking financial aid and assistance for Russian émigré nurses.15 Based in Paris, Romanoff traveled to the United States on fundraising missions and published articles to raise support and awareness of the conditions of Russian nurses.16 She was also involved with fundraising for the Paris Union of Russian Nurses, whose Central Committee she chaired. Given the spate of international appeals for Russian refugee children, war victims, and famine victims, it is not clear how great a response Romanoff received for Russian nurses.17 Some further support was forthcoming, as she acknowledged the help of the Committee for Assistance to Nurses at the Headquarters of the Russian Red Cross, but she nevertheless regretted that a lack of resources limited support to a few extreme cases.18 As for the many nurses who remained in Russia after the revolution and civil war, it has generally been perceived that numbers of them died, were



Displaced Nurses after World War I and World War II

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­ urdered, or joined the Bolsheviks. Romanoff herself claimed her organizam tion possessed a “long list of tortured, violated and executed nurses,” with ­others “languishing in prisons and concentration camps.”19 Although there was no doubt that there was a great deal of suffering and death among ­Russian nurses, as there was among vast swaths of the war- and hunger-ravaged population overall, there are no definitive statistics for the number of nurses who perished during the civil war. The aristocratic and religious association of the prerevolutionary Russian nurse (officially “Sister of Mercy” until 1926) no doubt placed nurses (especially those opposed to the Bolsheviks) in danger, but it should be noted that nurses trained in short-term courses by the ­Bolsheviks or who took the Bolshevik side also fell prey to violence and murder.20 The actions and political positions of Russian nurses varied considerably during this period. There were of course nurses in Russia who decided to support the communist cause. The American Quaker and nurse Anna Haines came across one such nurse who worked in Dr. Vera Lebedeva’s Clinic for Motherhood and Infancy. This nurse was working as an instructor in several Moscow institutions “to try to standardize the work of all the old and the new student nurses.”21 Haines noted that she was “an intelligent woman, trained in the old days here, understanding a little English, speaking French well. She is not a Communist, but sympathizes entirely with their work and says they have gone far beyond the old regime in their health activities.” The nurses who fled Russia at the end of the civil war and then fled Europe after World War II formed part of both the first and second waves of emigration. Some of their experiences are recorded in the ICN correspondence, letters, and questionnaires sent to those intending to apply for a nursing license in North America. The “double wave” nurses found in the ICN files came primarily from China and Yugoslavia and included many Russian women born and educated in these countries. Those who began their training before or during World War I tended to spend the war working in military hospitals, hospital trains, or sometimes hospital ships and later, during the civil war, moved east toward Vladivostok, Manchuria, and China or west toward Europe and Yugoslavia, again forming part of Russia Abroad.22 Although physically severed from their homeland, like their European counterparts they often maintained their cultural heritage throughout the period of their “exile.” Many of the questionnaires showed that those who settled in Shanghai or Tientsin never learned to speak Chinese.23 This was also the case with those later born in China. Russian was their first language, with English or French usually counted as their second. In the training schools and hospitals these Russians worked alongside other Russians, Europeans, Americans, and some Chinese.

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The ICN files show that the nurses who served with White forces during the Russian Civil War and retreated toward Vladivostok and then Manchuria or China experienced mixed fortunes, as did their families. For those growing up and entering education, the choice of educational institution played a decisive role when they later arrived in North America after World War II. Some of the nurses applying for state registration were denied an all-important ­Certificate of Professional Status—necessary to become a registered nurse (RN)—because they had attended “private” training colleges in Shanghai, Tientsin, or Harbin (a White stronghold after the October Revolution) or found that, once they had left China without any paperwork, it was very difficult to obtain any information after the war.24 The problem with the private training schools was that they were not—it was claimed by the ICN—recognized by the government of China or the ICN itself. One of the few schools attended by Russians that was recognized by the Chinese government and the ICN was the École Professsionnelle Française (General School of Nursing) in Shanghai. The École was a large hospital “staffed mostly by French sisters who were in charge of the various departments.”25 Because the Nurses’ Association of China had been a full member of the ICN from 1922 until World War II, and because the École appeared on the list of state accredited schools of nursing in China, Russians who trained there and could provide authentic documentation were virtually guaranteed professional certificates in North America. Much of the information Alice Sher—ICN assistant executive secretary responsible for dealing with displaced persons—received on the Chinese situation came from the testimony of a British nurse who had spent a considerable period working in China before returning to Britain.26 This nurse seemed to have had several nursing contacts in China and to be reasonably well informed on developments there. She noted that the Nurses’ Association of China had “no dealings” with Russia in Harbin, although “the Mission Hospitals of ­Manchuria had their schools registered with us and the Nurses there took our N.A.C. exams.”27 The nurse’s connection stopped once the Japanese entered Manchuria in 1931. She added that it was generally the mission hospitals with an American or British matron in charge that were registered with the Nurses’ Association.28 The Association was abolished when China became a Communist republic in 1949. In her correspondence with Sher, this British nurse conveyed that, as far as she understood, the École was of good standard, run by a French Roman Catholic order, and that it was a general hospital with about 750 beds.29 Another school on the state-accredited list in China and recognized by the Nurses’ Association of China was the Country Hospital School of ­Nursing in Shanghai. The school was reputedly of a high standard, with the floor sisters



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mostly Europeans and the matron a British State Registered Nurse.30 ­Several other mission hospitals were recognized, with nurses with documentation from these assured a Certificate of Professional Status. Russian nurses who had trained and qualified in Russia before moving East also had a mixed fate as immigrants or refugees when they arrived in North America. One Russian nurse, born in Samara in 1900, entered a ­private nursing school in Kiev in 1916 where she was only able to train for 1 year (8  months theoretical and 4 months practical) as a result of the war. Her diploma was lost during the October Revolution. She was a military nurse during the civil war period in 1918–1923 and then moved east, working in private nursing in Girin, Harbin, and Tientsin. Her lack of a complete formal education with an established school meant that, despite her many years (1923–1946) working in private nursing, she fell below the accepted standards of professional nursing and could not obtain the Certificate allowing her to work in North America.31 Another stateless Russian, from Vladikavkas, born in 1893, managed to pass the U.S. registration exam and become an RN in New Jersey. She had attended a Red Cross School of Nursing at the First City Hospital in Moscow in 1912–1914 and had worked as a nurse in military hospitals, city hospitals, and clinics in Russia, Bulgaria, France, and Germany before migrating to the United States in 1950.32 The fact that each case was thoroughly assessed meant that most individuals, wherever their countries of emigration or immigration, were judged solely on the educational and professional documentation they provided. ­Immigrant and refugee nurses who had trained under the Tsarist system were generally looked on favorably because the state-approved Schools of Nursing of the Russian Red Cross then “were of high repute,” and those who had their original diplomas were able to have their professional status acknowledged by the ICN.33 The by and large fair and equal nature of this process allowed immigrants and refugees with nurse training to integrate into the countries where they had migrated if they wanted to do so. Based on their occupational qualification, refugee and immigrant nurses could (in theory at least) enjoy the same rights and opportunities as other citizens of the countries to which they had migrated. The other group of nurses who formed this double wave of emigration were those who went to Yugoslavia. Once again, as part of Russia Abroad, Russian communities established cultural and educational centers here in an effort to maintain their national identity as it had been prior to the ­Bolshevik Revolution. This state of semi-merger into their new country created the same kinds of problems as those that afflicted migrant nurses in China. Some of the nursing schools were not state accredited and registration applicants

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were consequently not eligible for Certificates of Professional Status. One ­Toronto-based nurse who claimed to be a State Registered Nurse in ­Yugoslavia was informed that the courses she attended in Belgrade did not entitle her to such a qualification because these were just 12 months in duration and were “run by Russian doctors, who never intended to replace nursing training as received at state accredited schools of nursing, where the official length of training since 1930 was 3 years.”34 Again it was apparent that attendance at a state-accredited School of Nursing was the only form of training that would be recognized internationally. Those who had only attended smaller, White Russian community hospitals and training schools were left having to retrain or pass an examination. No matter how difficult an individual case history, no exceptions were made by the ICN. For many nurses, their case files spanned several years, depending on the length of time it took to gather, prepare, and process all necessary documentation. This could be an arduous and trying affair. Most of these refugees were once again faced with a host of challenges, such as having to settle into another new country and culture, raise children, take care of older relatives or spouses, or in some cases learn a new language. Seeking employment under such circumstances was no easy task. Moreover, the cost of living, educational fees, medical fees, and in many cases absence of a surviving kinship network meant these women had to rely on any skills and training they had received to earn a living. As a result of their recent war experience, nursing was one such skill. Whether fully or partly trained nurses or feldshers35 or trained as auxiliary medical personnel during war, many identified themselves professionally as nurses. Those applying to become an RN had, in many instances, already been working in hospitals or clinics after immigration but were eager to advance professionally for various reasons.36 This could not be done without the proper qualifications, even where the quality of their work was satisfactory. Indeed, the RN administrators writing for information on the official professional status of their Russian and Soviet employees frequently testified to their good work and professionalism. Irrespective of this, refugee nurses could not advance in the profession in qualification and salary unless they qualified as an RN in their new states. Refugees who wanted to attain such status had to be both patient and persistent in their efforts and, most important, be in possession of the requisite documentation or manage to acquire it through their former training schools (many now behind the Iron Curtain). Most of these refugees were persistent. One woman who trained in St. George’s Convent, Petrograd (St. Petersburg) and received a diploma in 1917 but could not produce any original document authenticating this fact had managed to procure a certificate from the National Association of



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the Red Cross in Paris that certified she had received her nursing training in St. ­Petersburg. According to this nurse, the “Russian Red Cross in Exile was officially recognized in Yugoslavia as an independent organization, and the Russian nurses were not registered in the Yugoslav Red Cross,” although they had “equal rights with the Yugoslav nurses.”37 She had been informed by an official representative of the Russian Red Cross in Exile that the “Russian Red Cross was never registered with the Yugoslav Red Cross but directly with the Russian Red Cross in Exile in Paris.” She had spent most of her time in ­Yugoslavia working for the Russian émigré Red Cross in Belgrade, and after the war migrated to California. She even enlisted the help of friends and relatives in the United States and England to testify on her behalf that she was indeed a nurse of the Russian Red Cross. She was evidently prepared to use all possible measures to prove her professional status. Curiously, whereas most nurses examined in these ICN files had an IRO camp as their final address before emigration after World War II, this nurse wrote that her address prior to emigration had been in St. Petersburg. In doing this, she clearly merged the first and second waves of emigration, denoting her entire existence prior to 1949 as a continued state of exile. The only emigration she recognized was the second one to the United States.

On New Shores: Soviet Feldsher Nurses in North America After World War II, Soviet citizens in the Allied zones of occupation in ­Germany frequently ended up in UN and IRO refugee centers there. Those claiming to be nurses or to have had some nurse training were to attend an interview with the International Nurses Screening Board,38 where professional nurses from a wide range of countries interviewed all refugees in their native language and determined whether these individuals could be classified as professional nurses in their own country. Those deemed to have attained such status could be issued with Certificates of Professional Status. When these citizens later arrived in their country of resettlement, the interviews would be taken into account when it came to establishing their qualifications against international standards (as evidenced earlier). The Certificate of Professional Status was one of the key documents required by employers in the West. Another crucial determinant in the granting of a nurse licence was a country’s membership in the ICN, which set accepted international standards for professional nursing. Russia had never been a member, and the Soviet Union, unsurprisingly, also never became one.

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This—as the material examined here shows—raised innumerable difficulties for displaced persons who claimed to have received their qualifications in ­either Tsarist or Soviet Russia. Nurses who had trained in the state accredited Schools of Nursing in China during the period when China was a member of the ICN were in a better position than those trained in schools not recognized by the national nurses’ association. Even if they were not fully recognized as nurses (but rather as feldshers or midwives), they were at least able to receive a Certificate of Professional Status and could move on to the next stage in ­attaining registration. In most cases, nurses from Russia and the Soviet Union were not classified as “nurses” but as feldshers or midwives (akusherki), as a “State Registered Feldsher and Midwife” of those countries. One Soviet nurse who trained in Ukraine between 1939 and 1941 was told, you are entitled to “work as a Midwife” because based on the original Russian statement, “you are a midwife and not a nurse.”39 Others were not even eligible for this title. One Ukrainian woman who studied at the Red Nursing School for Sanitary and Prophylactic Care ­between 1926 and 1929, and who worked as a nurse and a laboratory assistant until 1934, was only officially recognized as an “assistant to the sanitary doctor.”40 Even though she began training as a doctor in 1934 and worked as a doctor during the war, she had no diploma to prove this. Furthermore, she was informed that even if she did have such documentation, “medical training and nursing training are not identical,” so she would still not qualify as a nurse in the Western sense. Still, others were even less lucky in gaining some kind of recognition—one applicant from Gomel’, Belarus (then living in Quebec) had her case rejected entirely because she had no documentary evidence of her 3 years training in the Gomel’ Medical Assistant School (she had translated this from the Russian “Gomel’ Feldsher School”—Gomel’skaya Fel’dsherskaya Shkola), graduating with the title “Medical Assistant” (or feldsher).41 The matter was perhaps further complicated because nursing courses also existed in the Soviet Union, but feldsher courses seemed to be more popular if one is to gather anything from the ICN files alone. This preference for feldsher courses was noted too by Swiss historian of medicine Henry E. Sigerist, who commented that a girl “may prefer to become a feldsheritsa [female feldsher] or a physician rather than a nurse.”42 With a definitive lack of knowledge and understanding about what these courses and their curricula entailed, proving one’s nursing credentials would be a challenge. One nurse from Lviv, Ukraine, was one of the few (in the ICN files at least) in a position to provide an authentic diploma stating that she was a nurse and midwife of the Ukraine, and thus received her IRO Certificate without much difficulty.43



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As the ICN files indicate, women arriving in North America wanting to work as RNs but without adequate training or proper documentation had to take an exam and in some cases retrain. For those who had already undergone training in their own countries, worked in hospitals, and considered themselves qualified nurses, this created a sense of frustration and disillusionment. One refugee working in a New York hospital, who claimed to have been in the nursing profession since 1932, complained that she did the work of an RN but was recognized only as a nurse’s aide because she did not have an American license.44 The sense of injustice at not being granted equal pay and status for performing what they perceived to be the same work as their registered colleagues was palpable. In the view of many of these refugees, the title feldsher or midwife was equal to, if not better than, that of a nurse. One Soviet woman wrote to Sher explaining that after graduating from a medical feldsher school, she received the title feldsher, “which is the Russian designation for nurse.”45 In spite of feelings of confusion or annoyance, these refugees were still dependent on the ICN, and consequently Sher had to assume the role of both intermediary and appeaser. When it came to the classification of their status, some refugees were more willing to recognize distinctions but ultimately came to the same conclusions. The woman from Gomel’, living in Quebec, who had had her case rejected personally wrote to Sher to put forward her understanding of the difference between a nurse and a feldsher. She agreed with Sher’s differentiation in regard to the training, and that she “above anyone” understood this “huge difference.”46 In her opinion, Canadians had “fewer classes,” and she considered herself just as able and qualified as her colleagues in Montreal. In concluding she stated that in Russia, a feldsher worked as a nurse and in many cases as a senior nurse.47 Another nurse (also living in Quebec) stated that she chose the feldsher-midwife course in preference to a nursing course hoping to get better training because “the years of study were longer and the program was much higher.”48 When she arrived in Canada, she compared the program she had attended at home with those in her newly adopted country and found them “very much alike.” Both these Quebec-based women displayed a clear eagerness to compare, interpret, and even validate their training and profession. Their awareness of the differences between two systems of the same profession perplexed them, but at the same time both seemed finally to understand and accept these differences, acknowledging that there was merit in both. In reality, in the Soviet Union a feldsher was not considered a nurse and there was a demarcation ­between nursing, feldsher, and midwife courses, with different emphasis in the course curricula as well as salary after qualification. But it is also true that

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in practice, as suggested by the earlier testimonies, some feldshers could very well have ended up working as nurses and senior nurses. For international medical personnel, meanwhile, determining the quality and quantity of training could be quite difficult, and this was often exacerbated as a result of the fractured nature of the training undergone by refugee and émigré nurses, whether in the Soviet Union, China, or Yugoslavia. One IRO nursing consultant who had dealt with Russian refugees from China in the Samar refugee camp, Philippines, noted: Many nurses, who have been in this camp, will write regarding their status and it is realized, that many are not eligible, although they consider that they are qualified nurses. Frequently they have had no instructions and have merely worked in a ­Doctor’s office in China.49

There were evidently vast differences in the skills and experiences of those Russian and Soviet refugees arriving in North America, Australia, and elsewhere. At the same time, it has been asserted that the ICN postwar discourse implicitly “assumed superiority of Anglo-American political institutions and social reforms.”50 Officials in hospitals in North America and other countries wrote to the ICN wanting some form of clarification about Soviet nursing qualifications. One New Jersey RN knew that “feldshers” were not professional nurses in the Western sense, but nonetheless wanted to “determine what deficiencies a person would have to make up to qualify as either a professional nurse or a practical nurse” in the United States.51 The fact that women were arriving in North America in the 1950s referring to themselves as feldshers evidently caused considerable confusion among American medical personnel, who were unsure whether this meant they were nurses or doctor’s assistants. Indeed, similar problems had arisen in the Soviet Union in the 1930s, with the disparities in the training and experience of nurses the subject of growing criticism in the medical press. Even in Russian history, the standards, qualifications, and general reputation of the feldsher (as well as the nurse) have been the subject of much debate, and their status frequently subject to revision by the authorities. In the ICN files, the title feldsher seemed to be divided into prerevolutionary and Soviet categories, the latter generally regarded as lower quality. In one file, it was noted that the “training as now followed in the USSR in no way compares favourably with the high standard of Feldsher training in Tsarist Russia.”52 This would appear to flatter the prerevolutionary feldsher, who did not hold a particularly well-respected position in prerevolutionary Russia or the 1920s. So low was the general opinion of feldshers in Russia at this time that Samuel Ramer has noted that there was a marked



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e­ ffort to curtail and eventually eliminate this type of feldsher under communist rule, and by 1924 “virtually all exclusively feldsher schools had ceased to exist, though a few schools for feldsher-midwives remained.”53 In the revolutionary fervor of the 1920s, the feldsher had been marked for elimination, but in reality many schools remained in existence because of the urgent need for medical personnel. The Commissariat for Education established polytechnical institutes that would train different types of nurses, but circumstances meant that feldshers remained into the 1930s (particularly in rural areas); gradually, feldsher training became subsumed to the polytechnical training institutes, with these institutes replaced by feldsher schools in 1936.54 When Russian and Soviet refugees thus arrived in North America with documentation asserting that they were feldshers, it was in many cases left to the ICN’s Alice Sher to explain the exact position. Sher, who had been president of the International Nurses Screening Board and worked for both the IRO and UNRRA in West Germany, was the point of call for Western medical officials requiring clarification regarding the professional status of Russian and Soviet nurses seeking employment as RNs.55 As she often indicated in her communications with these officials, there were several generally similar classifications of feldshers and their duties. The International Nurses Screening Board, Sher explained to one misinformed and confused official, “classified all qualified Feldschers [sic] in their own category, and they have usually been employed as practical nurses,” but they were not nurses or midwives unless they had undergone additional training. Sher herself again wrote, the “training of Feldsher is not the equivalent of a nursing training, nor of the training of midwives, although a Feldsher can, and usually does have quite an extensive training, gaining much professional knowledge of these two categories.”56 Henry Sigerist had a more positive definition, claiming that the feldsher could “best be compared to the American public health nurse working in the country, with the difference that the feldsher is also trained in minor surgery and ­obstetrics,” but by the 1950s it was likely that such differences had become more pronounced.57 Given the difficulties in directly translating the term feldsher, its historically negative reputation, and the general lack of popular knowledge surrounding medical training and professional status in the Soviet Union, it is no wonder Sher found herself constantly explaining the term “feldsher” to RN administrators across North America and beyond. Another main point of concern emerging from the ICN files was the age at which Russians and Soviets began their medical training. Many of those wanting to become nurses or feldshers did not have a complete high school education and entered training courses when they were as young as 15 years. Sher commented in a letter to an Australian official in 1956 that

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“nursing training there [in the Soviet Union] is not comparable with nursing training in the western world” and that “in the USSR . . . they admit to their schools of nursing girls from the age of fifteen.”58 To those in the West, the idea of very young girls with incomplete secondary education was anathema to their standard of higher education and professionalism among nurse graduates. In spite of this, official attitudes toward Russian nurses were not uniform in the West. In France, for instance, a 1946 law stated that only State Registered Nurses were allowed to practice, but that anyone who had completed a short nursing course and “had been practicing until they had been obliged to pass a special examination” was permitted to continue practicing as a professional nurse.59 The special term “Authorized to Practice” was used for nurses who did not obtain their registration in France but were regular trained nurses granted the same rights as State Registered Nurses and “considered to be on the same level.” A disadvantage attached to this status was that they could not become members of the French Trained Nurses’ Association, but their professional identity cards did mean they could obtain registration in other countries (France was a member of the ICN). This law meant that Russian refugee nurses trained under the Tsarist system working as nurses in France were now entitled to the same professional status as French nurses.60 The position for refugees with this status had not been so clear-cut in the immediate aftermath of the war, and for a considerable period there was confusion about the exact rights and status of the women who had volunteered for short-term training courses and considered themselves nurses thereafter. This story is similar to that of the British Voluntary Aid Detachments (VADs), as Anne Summers and Christine Hallett have highlighted.61 The horrors and strain of war forced many volunteers to learn a great deal in a short space of time, but once the war was over, some of them returned to their regular occupations. Others had been attracted to nursing and some considered themselves suitably qualified nurses, although the ICN classified them as practical nurses or nurse aides. In reply to an RN on the Board of Examiners in ­Sacramento, California, Sher had to explain that references to courses in ­Russia or ­Germany during the war meant short-term courses that did not grant any form of registration, as some refugees had claimed. During World War II, Sher elucidated, the “UNRRA used to run short nursing courses, varying from six weeks to three months—occasionally 6 months—for nursing personnel employed in the various sick bays and hospitals for Displaced Persons.”62 These courses, however, did not confer any type of professional registration, for the “­purpose of this course was to enable practical nurses to acquire more theoretical knowledge and practical experience.” With most ICN refugees having served ­during the war in a nursing capacity (no matter



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what their prior professional qualifications or experience), questions relating to such short-term courses frequently recurred. In the context of these refugee nurses migrating to another country, it must be borne in mind that, by applying for licensure, they were set to join the ranks of a profession that already had its own history and traditions. ­Nursing was still relatively new as an accepted profession. Nurses in many different countries had long been striving for adequate national recognition and ­support. By the time refugee nurses started arriving after the war, great strides had been made toward these goals, so it was important that these ­“newcomers” also recognize the position of their colleagues and the struggles many of them had gone through to achieve their own professional status. As Patricia D’Antonio has shown in relation to the United States, “Registration battles flared across the country in the early twentieth century as small groups of trained nurses in every state sought the same legal protections for their practice of nursing that physicians had for their practice of medicine.”63 Issues such as gender, race, and class were central to the nursing debate that raged in the United States, and so issues of integration, professionalism, and ­status had to be addressed and taken very seriously. Licensure and professional status were highly significant and of utmost importance. By the 1950s, there were three ways of becoming an RN in the United States. The first was through the traditional hospital-based diploma (becoming less popular at this stage), the second was through college programs in schools attached to universities (becoming more popular), and the third was through the newly established community colleges (surging in popularity by the 1970s).64 It was therefore critical that ­Russian and Soviet refugee nurses have an internationally accepted level of training or be willing to acquire it if they wanted to progress and become an RN. A further problem that emerges from the ICN files, although more political than professional, was that some of those who fled Tsarist Russia, but especially the Soviet Union, changed their names to conceal their identity. It often took several letters for this to become evident, no doubt much to the chagrin of vexed administrators. The reasons for the name changes hardly merit explanation, except that in most cases reluctance to divulge a true identity was motivated not by self-protection but for the welfare of family members still living in the Soviet Union. This was particularly so for younger refugees. A 20-yearold nurse living in Michigan had two last names, one (her real name) that she never used “because she escaped from Germany during the war and did not want anything to happen to her family.”65 All her original nurse training documentation was under the name she no longer used. Another nurse, from Ukraine but living in Canada, insisted that the ICN refrain from making any contact with Russia (the Soviet Union) for fear of “damage” to her family.66

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Other problems arising in the files were confusion about dates (important in determining age, length of training, etc.) along with lost or destroyed personal documentation. A 31-year-old Ukrainian-Polish nurse living in ­Minnesota wrote to Sher to apologize for not having any nursing certificate because, she admitted, “I destroyed all my personal papers in Germany, being persecuted by the Soviet Repatriating Agents. I had to do so to avoid forcible repatriation to the S[oviet] U[nion] in accordance with the Yalta Conference.” She continued that “similar actions were being done by the thousands of DPs of all nationalities from the Soviet Union to protect themselves against forcible repatriation which meant arrest, tortures, slavery in the Soviet concentration camps or execution.”67 The latter type of case was a serious problem for those left with virtually no forms of personal identification, not to mention any documents pertaining to professional qualification. Extraneous political circumstances continued to play a dominant role in the lives of Soviet refugees. It is also evident from the earlier comment that these nurse refugees were politically aware of developments during their time of displacement and acted in ways that concealed their national identity to avoid repatriation. These refugees were of course victims, but they were not entirely passive—they took action where possible to help determine their own future. Nevertheless, the destruction of documents, accidental or not, left many refugees in a helpless position. One such case was that of a Russian émigré in China who had married a U.S. Navy officer just when war broke out; both ended up in a Japanese prison camp for 3 years. Once this refugee nurse was released and attempted to recover some of her documentation, she was informed by the British Consul that, according to word from Shanghai, when the ­“communist [sic] occupied China they send [sic] Russian sisters (nuns) back to Russia,” closed the hospital, and “destroyed all papers.”68 Moreover, they “considered Russian sisters as enemies because they escape from Russia to China during [the] Revolution.” It was very likely that this woman would never obtain the documentation to apply for a nursing license in the West. Political and diplomatic factors continued to intervene and dictate the fortunes of many of these refugees, long after the war had ended and they had been repatriated.

Conclusion: Borderless Nurses in a New Society When these refugee nurses finally arrived in their countries of adoption after World War II, they no doubt felt a wide range of emotions—hope, despair, fear, and relief. For many, this was the second time they had gone through



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such an experience. This time, however, any lingering attachment to their home country and its culture was significantly weakened.69 War and the affirmation of Soviet power had seen to that. Families and national allegiance had been more or less broken beyond repair by the devastation during 1939– 1945, and any hopes of returning to Russia seemed lost. Refugees resettling in North America and elsewhere were neither in a position to unite and preserve a Russian culture nor were there opportunities to do this. As Marc Raeff has observed, the “new arrivals—the Displaced Persons—were not eager to reconstitute a Russia Abroad” and sought only peace, security, and a stable livelihood.70 Generational change and a need for personal survival resulted in the prioritization of professional identity over Russian national identity, a change that in some ways had already begun in the 1930s. Using any nurse training they had, these refugees—as the ICN files ­attest—desperately sought to be professionally recognized in their new homeland. Social and economic circumstances ensured that, whatever their former attitude toward Russian identity and politics, the greater need now was securing employment. The objective was not restoration of some sort of Russian independence but rather personal and financial independence. Such an objective was certainly realizable in North America, where there was a great demand for nurses. Those arriving with nursing skills were undoubtedly presented with an opportunity to work as nurses. In a letter to Sher in August 1966, one woman wrote that “there is a great shortage” of nurses in the area and that the hospital was “anxious to employ” her.71 Refugee nurses in North America quickly realized that, through their professional qualifications, they could find a place in the societies they were entering. Many were assisted by the efforts of RN administrators, who were eager to keep on refugee feldshers or midwives who had already proved their worth, even if they did not have qualifications equal to those of their Western colleagues. The ICN Refugee files demonstrate the remarkable postwar commitment to the preservation of individual dignity and identity through professional employment. Local RN administrators, the ICN, and Sher all worked ­together over several years to ensure that these displaced nurses would finally be able to settle down and reestablish their professional identities. Indeed, as one IRO senior officer remarked at a World Health Organization meeting, “the nurses of the world had achieved an objective as yet reached by few other ­professions.”72 Those Russian and Soviet citizens who survived one and in many instances two world wars were presented with an opportunity to rebuild their lives in a new country. This was easier for some than for others, with Russian and Soviet nurses in a more difficult position than those from other countries.

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The political isolation and fragmentation of Soviet and Russian nursing organizations placed myriad challenges before its citizens, challenges that became all too apparent when exposed to the norms and standards of international nursing associations. Founding member of the ICN Lavinia Dock had for years been calling for Russian and later Soviet membership in the ICN, but the failure of first Tsarist and then Communist governments to admit their nurses to the international “sisterhood” of trained nurses served to undermine their status internationally and diminished any hope of establishing professional links between Soviet and Western nurses.73 In spite of the obstacles placed before these refugee nurses, eventually their personal commitment to their profession together with the collaborative support of the ICN witnessed many make the transition from émigré and displaced person to professional nurse in the West. This could then become a stepping stone to acquiring a greater sense of individual and social identity in their new homelands.

Acknowledgments

The research for this article was funded by an Irish Research Council CARA Mobility Postdoctoral Fellowship and the Alice Fisher Society Fellowship, the Barbara Bates Center for the Study of the History of Nursing, University of Pennsylvania. Thanks are due to faculty members at the Barbara Bates Center who helped shape my ideas in formulating this article, to the two Nursing ­History Review anonymous reviewers, and also to Prof. Donald Filtzer, University of East London and Frank Wolff, Institute for ­Migration Research and Intercultural Studies, Osnabrück University, who read and commented on the article.

Notes 1. By December 1922, diplomatic recognition and protection of Russian exiles in Europe and the Far East was withdrawn by the new Soviet state, leading to severe legal problems for the now stateless refugees. Fridtjof Nansen’s introduction of a passport for these refugees helped alleviate the problem somewhat, and by 1923 the right of those holding Nansen passports to cross international borders—provided they did not adopt another nationality—was recognized by 39 countries. See Peter Gatrell, A Whole Empire Walking: Refugees in Russia during World War I (Bloomington: Indiana University Press, 1999), 194; and Claudena M. Skran, Refugees in Interwar Europe: The Emergence of a Regime (Oxford: Clarendon Press, 1999), 102, 109, 32–40. The USSR in 1922 comprised the republics of Russia, Ukraine, Belorussia, Georgia, Azerbaijan, and Armenia. Following World War II



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and the Yalta Conference, Soviet territories expanded to include Eastern Bloc countries such as Latvia, Lithuania, Estonia, Czechoslovakia, Romania, Hungary, and Poland. 2. Marc Raeff, Russia Abroad: A Cultural History of the Russian Emigration 1919– 1939 (New York: Oxford University Press, 1990), 4–5. 3. In the case of nurse training, some of the smaller schools established by Russians were not recognized by the Chinese. In one case, Alice Sher wrote to RN Lily Taylor in Samar that “it has been impossible for me to obtain verification as to whether the Association of Russian Doctors’ School of Nursing in Tientsin, China, was recognized by the Nurses’ Association of China. Apparently, it was a small hospital which just served the White Russian community in Tientsin.” She added that the school had not been functioning for several years. MC#112, ICN Box 15, Folder 1795, 6 February 1951. 4. The establishment of the UNRRA followed the 1942 Declaration by United Nations by 26 nations to continue the war, and the signing in November 10, 1943 of the UNRRA Agreement. The UN Charter itself was not ratified until 24 October 1945. 5. The International Council of Nurses was a federation of national nursing associations founded in 1899 in London by, among others, Ethel Bedford Fenwick, Lavinia Dock, and Agnes Karll, with the aim of establishing and improving international standards of nursing. 6. International Council of Nurses Records, Center for the Study of the History of Nursing, School of Nursing, University of Pennsylvania, MC#112, Series 1, Records 1946– 1970; provenance Constance Holleran, ICN Executive Director, Geneva, Switzerland. Access to these files is restricted and names cannot be cited. After World War II, the ICN provided a means of establishing and verifying credentials for more than 3,000 refugee nurses throughout the world (MC#112 Brief Description). Of the files in this series, some 209 (two boxes) deal with “stateless” Russian nurse refugees. My analysis is based on a selection of almost 100 of the most detailed cases that include correspondence, letters, and so on. 7. Marc Raeff, “Recent Perspectives on the History of the Russian Emigration (1920–40),” Kritika: Explorations in Russian and Eurasian History 6, no. 2 (Spring 2005): 319–34, 319. 8. On the category of “waves” of Russian emigration, see Raeff, “Recent Perspectives,” 333–34. 9. Of the more than 200 case files I looked at, only 4 related to male nurses (two came through a nursing or feldsher course at the Military Medical Academy in St. Petersburg, one trained in China, and one had emigrated to the United States in 1912). 10. Nick Baron and Peter Gatrell, “Population Displacement, State-Building, and Social Identity in the Lands of the Former Russian Empire, 1917–1923,” Kritika: ­Explorations in Russian and Eurasian History 4, no. 1 (2003): 59. 11. In the post–World War II context, a displaced person or refugee was “a person . . . who is outside his country of nationality or former habitual residence, and who, as a result of events subsequent to the outbreak of the Second World War, is unable or unwilling to avail himself of the protection of the government of his country of nationality or former nationality.” Marjoleine Zieck, UNHCR and Voluntary Repatriation of Refugees: A Legal Analysis (The Hague: Martinus Nijhoff, 1997), 52; see Chapter 3 for general discussion of repatriation policy. It should be noted too that Russia, Ukrainian SSR, Belorussian SSR, Poland, and Yugoslavia voted against the IRO Constitution and never joined it, a fact which meant that the IRO (1946–1951) was considered largely “an instrument of and for the countries of refuge” (p. 59).

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12. In terms of “exile,” “refugee,” “deportee,” or “repatriate,” I share the argument of Nick Baron and Peter Gatrell, who maintain that such categories of displacement are contingent on official and personal perceptions and that “all migration involves elements of both choice and coercion,” to different degrees. Baron and Gatrell, “Population Displacement,” 54. 13. Meryn Stuart with Geertje Boschma, “Seeking Stability in the Midst of Change,” in Nurses of All Nations: A History of the International Council of Nurses, 1899–1999, ed. Barbara L. Brush, Joan E. Lynaugh, et al. (Philadelphia: Lippincott, 1999), 76. A figure of “over one thousand Russian trained nurses” in exile was estimated by Count Paul N. Ignatieff, who appealed to American nurses for funding on behalf of Romanoff and the Union of Nurses, “An Appeal for Russian Nurses,” AJN 28, no. 4 (1928): 399. For nursing during World War I, see Laurie Stoff, “The ‘Myth of the War Experience’ and Russian Wartime Nursing during World War I,” Aspasia: International Yearbook of Central, Eastern, and Southeastern European Women’s and Gender History 6 (2012); V. P. Romaniuk, V. A. Lapotnikov, and Ia. A. Nakatis, Istoria sestrinskogo dela v Rossii [The History of Nursing in Russia] (St. Petersburg: SPbGMA, 1998). 14. Stuart with Boschma, “Seeking Stability,” 76. 15. American Friends Service Committee Archives, Philadelphia, AFSC Foreign Service—Russia, Correspondence between Friends, 18 February and 25 March 1924. 16. Madame Romanoff does not appear to have borne any relation to the Romanov dynasty but was apparently the A. V. Romanoff of the Georgievskii sister community, part of a group of Russian nurses sent to Paris in 1915/1916 by the Russian Red Cross to take care of wounded Russian soldiers in France. See, for example, Vestnik Krasnogo Kresta 9 (1916): 3176–77. 17. Correspondence with the AFSC suggests that Madame Romanoff had raised some $300–$500 by 1924, a sum she had requested be distributed through AFSC channels with preference for Old Red Cross nurses from Russia. (When some of these funds were used to help support work in Dr. Lebedeva’s clinic, Romanoff protested and requested they be directed toward nurses outside Russia.) Romanoff had received $459 in 1923 through donations from the American Nurses’ Association, AFSC Foreign Service—Russia, 18 February and 25 March 1924; AFSC Foreign Service—Russia, Letters from Philadelphia to Russia, Wilbur K. Thomas to S. E. Nicholson, 18 February 1924; Agnes G. Deans, “Headquarters American Nurses’ Association,” AJN 23, no. 6 (1923): 507. 18. Alexandra Romanoff, “An Appeal from Russia: An Open Letter to American Nurses,” AJN 2, no. 3 (1922): 226–29. 19. Romanoff, “An Appeal from Russia,” 228. There are also references to incarcerated sisters in the State Archives of the Russian Federation (GARF), f. 3341, op. 1, d. 61 and f. 8419, op.1, d. 292. 20. In 1919 near Petrograd, three nurses captured by the Whites were hanged in bandages from the beams of their field hospital with their Komsomol (Communist Youth League) pins stuck through their tongues. Richard Stites, The Women’s Liberation Movement in Russia: Feminism, Nihilism, and Bolshevism (Princeton, NJ: Princeton University Press, 1978), 318. 21. AFSC, Foreign Service—Russia, Correspondence Philadelphia—Moscow (two folders), no. 244, 27 June 1925, Anna Haines-Wilbur K Thomas. 22. Initially, wealthier citizens sought refuge from the Bolsheviks in the major ­Siberian cities under White control, but as the White movement collapsed, they fled ­farther east, to Vladivostok and beyond. By this stage many had run out of money and resembled “men moving like living dead through the taiga,” J. D. Smele, Civil War in Siberia:



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The Anti-Bolshevik Government of Admiral Kolchak, 1918–1920 (Cambridge: ­Cambridge University Press, 1996), 369–71, 593, cited in Nick Baron and Peter Gatrell, Homelands: War, Population and Statehood in Eastern Europe and Russia 1918–1924 ­(London: ­Wimbledon Anthem Press, 2004), 21. 23. According to Raeff, “the situation in Kharbin was a little different because none of the émigrés could or would attend Chinese secondary schools.” Russian exile children in Harbin attended Russian schools, and later an English language school became popular. Raeff, Russia Abroad, 57. It should be noted that cities such as Shanghai could be considered “international” cities, home to different linguistic communities where Chinese was generally not used, and that schools in Harbin and Tientsin often taught in a wide range of languages (English, Russian, German, Hebrew) to prepare students for further migration (my thanks to Frank Wolff for these points). 24. See, for example, the attempts of a woman in Canada to contact a Harbin hospital where the administration had changed seven times and apparently kept no records. MC#112, ICN Box 16, Folder 1833, 13 October 1955. 25. MC#112, ICN Box 15, Folder 1784, Alice Sher to Louise Alfson, RN, ­Washington (Olympia), 29 November 1951. 26. Alice C. Sher was appointed assistant executive secretary of the ICN in 1948 and the files came under her purview. Sher had previously served as president of the ­International Nurses Screening Board, an experience that, according to Daisy Bridges, had helped bring “the work concerned with refugee nurses within the compass of the ICN; and by being closely involved with the resettlement of these nurses, the ICN had established friendly contacts with nursing registration authorities in various parts of the world.” Moreover, the ICN possessed the names and personal records of more than 4,000 displaced nurses, and Sher’s experience as president had prepared her for establishing the professional status of refugee nurses. Daisy Caroline Bridges, A History of the International Council of Nurses, 1899–1964: The First Sixty Five Years (Philadelphia: J.B. Lippincott, 1967), 126, cited in MC#112, ICN Box 15, Brief Description. 27. MC#112, ICN Box 15, Folder 1794, GS to GB, 15 August 1956. 28. MC#112, ICN Box 16, Folder 1833, GS to Sher, 4 November 1953. These mission hospitals had also been run by Irish and Scottish Presbyterian missions. MC#112, ICN Box 16, Folder 1834, GS to Sher, 6 April 1955. 29. MC#112, ICN Box 16, Folder 1830. Sher quotes Stephenson in a letter to Henrietta Walsh, RN, Colorado, 12 February 1960. For an introduction to the history of nursing in China, see Stuart with Boschma, “Seeking Stability,” 86, 88. 30. MC#112, ICN Box 15, Folder 1758, Alice Sher to Lily Taylor (nursing consultant, IRO, Samar, Philippines). 31. MC#112, ICN Box 15, Folder 1722. Similarly, see MC#112, ICN Box 15, Folder 1798; Box 16, F 1822, F 1835. 32. MC#112, ICN Box 15, Folder 1792, 18 December 1962. 33. MC#112, ICN Box 16, Folder 1738, AS to ED (Toronto), 23 March 1956. ­Regarding the Tsarist system of nursing as of high repute is an unusual statement, given that these schools were still far from professionally organized training centers. Soviet ­accounts (and some contemporary medical accounts) were critical of the Tsarist system. 34. MC#112, ICN Box 16, Folder 1894, 15 May 1952. 35. Feldshers (a Yiddish and German term meaning field barber or company surgeon) were first introduced into Russian armies by Peter the Great in the 17th century, and by the

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19th century could best be described as paramedics who were trained in first aid and could perform certain minor surgeries and administer certain medicines. They were often not very well educated and filled practices in rural areas where physicians were lacking. For a definition of the feldsher, see Mark G. Field, Soviet Socialized Medicine: An Introduction (New York: Free Press, 1967), 127; for more discussion see Samuel C. Ramer, “Feldshers and Rural Health Care in the Early Soviet Period,” in Health and Society in Revolutionary Russia, ed. Susan Gross Solomon and John F. Hutchinson (Bloomington: Indiana University Press, 1990), 121–45. 36. It seemed to be the case that after working in a U.S. medical institution for more than 3 years, refugee nurses could apply for promotion (once they had been professionally certified). MC#112, ICN Box 16, Folder 1837, 22 February 1952. This was the claim made by one Russian nurse who wanted to be certified so she would be eligible for promotion because her husband could no longer work for medical reasons and had not worked long enough to receive a pension. 37. MC#112, ICN Box 15, Folder 1748, 30 May 1955. Unusually, both the Russian Red Cross in Exile and Soviet Red Cross were recognized by the International Committee of the Red Cross (ICRC). See John F. Hutchinson, “‘Custodians of the Sacred Fire’: The ICRC and the Postwar Reorganization of the International Red Cross,” in International Health Organizations and Movements, 1918–1939, ed. Paul Weindling (Cambridge: Cambridge University Press, 1995), 28. 38. The International Nurses Screening Board was “a body set up by UNRRA and later taken over by IRO, composed of refugee nurses of different nationalities who had held leading positions in their own countries.” Bridges, A History of the International Council of Nurses, 148, cited in MC#112, ICN Box 15, Brief Description. 39. MC#112, ICN Box 15, Folder 1725, 6 November 1964. The problematic nature of nursing identity in a Soviet context should be noted because nurses were grouped with midwives, dentists, pharmacists, and so forth in the category “mid-level” medical personnel (srednii meditsinskii personal ). As Elizabeth Murray has argued, such factors “denied Russian nurses a key role in the creation of their own occupation and prevented them from developing a separate professional identity.” Murray, “Russian Nurses: from the ­Tsarist ­Sister of Mercy to the Soviet Comrade Nurse: A Case Study of Absence of Migration of Nursing Knowledge and Skills,” Nursing Inquiry 11, no. 3 (2004): 136. 40. MC#112, ICN Box 15, Folder 1725. 41. MC#112, ICN Box 16, Folder 1808, 6 November 1958. She claimed to have lost her diploma during a German attack on Kharkov in 1941. 42. Sigerist also noted that a student could, after 7 years of schooling, enter a “medical technicum or secondary medical school, from which he or she will be graduated as feldsher, nurse, or midwife after having attended a three year course.” Henry E. Sigerist, Socialized Medicine in the Soviet Union (London: Norton, 1937), 129. He also provided statistics to show that in 1937, there should be 44,770 students enrolled in feldsher schools, 13,300 in midwifery schools, and 95,000 in schools of nursing (medical and nursery) (p. 145), but that “much propaganda will be necessary to mobilize the 95,000 students needed for enrolment in schools of nursing in 1937” (p. 147). This was also conveyed much earlier, in 1920–1921, when students interviewed in Novgorod stated that they dropped out of nursing courses because they were not sure they really wanted the title “sister.” The awful conditions in schools and dormitories did not help uptake levels either; see GARF, f. A-482, op. 14, d. 121, l, 2. 43. MC#112, ICN Box 16, Folder 1825, 21 April 1953, AS to MFW, RN Registrar, Toronto.



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44. MC#112, ICN Box 15, Folder 1751. 45. MC#112, ICN Box 16, Folder 1864, 28 June 1963. 46. MC#112, ICN Box 16, Folder 1808, 16 December 1958. 47. Feldshers had 3 years training as opposed to 2 years for a nurse, and their training was more thorough. Ellen Albin, “Nursing in the USSR,” AJN 46, no. 8 (1946): 526–27. This Russian nurse added that she was in no way criticizing the Canadian system of nursing or attempting to change Sher’s mind, but that she wanted to get her point across. 48. MC#112, ICN Box 16, Folder 1859, 27 October 1964. 49. MC#112, ICN Box 15, Folder 1722, L. E. Taylor to Ms. Daisy Bridges, 1 November 1951. 50. Brush, Lynaugh, et al., Nurses of All Nations, 121. 51. MC#112, ICN Box 16, Folder 1841, EA to AS, 4 January 1956. 52. MC#112, ICN Box 15, Folder 1745. It should be noted that there were two types of feldsher during this time, the usually untrained and criticized rotnye (company) feldshery, and the more educated and favored shkol’nye (school) feldsher. 53. Ramer, “Feldshery and Rural Health Care,” 132. 54. Ibid., 137. 55. Sher and the ICN helped almost 2,000 refugee war nurses between 1950 and 1966. Joan E. Lynaugh noted that the “ICN officially assumed responsibility for the Nurses (Displaced Persons) Professional Register from the IRO in 1950” and that Sher assisted refugees from Eastern Europe, China, Palestine, Cuba, Germany, and so on to establish their professional credentials. This project was so complicated by Cold War politics and dislocation that the files remained open until 1983. See Alice C. Sher, “The Stranger in Our Midst,” International Nursing Review 7 (1960): 11–17; Lynaugh, “From Chaos to Transformation,” in Brush, Lynaugh, et al., Nurses of All Nations, 124. 56. MC#112, ICN Box 15, Folders 1709, 1711. For later American impressions on the development of nurse and feldsher training in the Soviet Union, see Thelma Ingles, “An American Nurse Visits the Soviet Union,” AJN 70, no. 4 (1970): 754–62. 57. Sigerist, Socialized Medicine, 145. 58. MC#112, ICN Box 15, Folder 1719, Sher to Tully, 17 January 1956. See also, for example, MC#11, ICN Box 16, Folder 1913. The official age for nursing applicants was revised several times in the postrevolutionary period but was generally 17 or 18 years. This was admittedly a problem for Soviet medical workers also, with one doctor in 1939 (one of the main doctors in Leningrad’s Botkin Hosptial) complaining that the medical technical colleges received anyone from age 15 years, which meant they were just 17 years when finishing college. This, he noted, was “curious” when nobody younger than 18 years was permitted entry into the infectious diseases departments. GARF, f. 8009, op. 5, d. 61, l.73. He urged a reexamination of the nurse training schools and the age of those entering them. 59. MC#112, ICN Box 16, Folder 1807, Madame d’Amigny (Secretary for Foreign Activities, National Association of State Qualified French Nurses) to Alice Sher, 4 January 1960. 60. One refugee entitled to this status was seeking registration in California but had been working on a hospital ship during the war, then in Odessa, and then in France from 1932 to 1950. She had first trained with the Russian Red Cross in Riga, 1912–1914. MC#112, ICN Box 16, Folder 1807. 61. Anne Summers, Angels and Citizens: British Women as Military Nurses, 1854–1914 (London: Routledge, 1988), 237–79, 289; Christine E. Hallett, Containing Trauma: Nursing Work in the First World War (Manchester: Manchester University Press, 2009), 8–9. There was

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also opposition to volunteer nurses entering the profession after the war in France; see Katrin Schultheiss, Bodies and Souls: Politics and the Professionalization of Nursing in France, 1880– 1922 (Cambridge, MA: Harvard University Press, 2001), 179. In the Russian case Florence Farmborough (a British nurse serving in Russia), although only trained as a volunteer with the Russian Red Cross, nonetheless considered she had gained sufficient theoretical knowledge and practical experience to be called a nurse. Imperial War Museum, London, “British Civilian Red Cross Nurse Served with Russian 10th Field Surgical Otryad on Eastern Front, 1914–1916,” interview between Florence Farmborough and Margaret A. Brooks, recorded 1975, Sound No. 312/17/08. 62. MC#112, ICN Box 15, Folder 1723, 4 January 1961. Similar short-term Red Cross courses were conducted in Russia during World War I. 63. Patricia D’Antonio, American Nursing: A History of Knowledge, Authority, and the Meaning of Work (Baltimore: Johns Hopkins University Press, 2010), 115. 64. Ibid., 170. 65. MC#112, ICN Box 15, Folder 1752, 2 June 1955. 66. MC#112, ICN Box 16, Folder 1876, 28 February 1964. In any case the ICN at all times protected refugee identities in relation to contact with their native countries. This woman did request that the ICN contact the Zaparozh’e Ukrainian Nurses Association for confirmation of her professional status in Ukraine—“her home country.” The ICN refused to do this because it was not aware such an Association even existed. There were several Ukrainian files in the ICN records, some trained in Zaparozh’e or Kharkov in the 1930s. 67. MC#112, ICN Box 15, Folder 1742, 12 April 1954. 68. MC#112, ICN Box 15, Folder 1737, 31 August 1961. 69. By the 1930s, it was becoming increasingly difficult for émigrés to maintain strong cultural links, largely because of problems with secondary education and more complete integration into the educational and professional life of their new countries. See Raeff, Russia Abroad, 57, 59, 71–72. As Raeff commented, World War II delivered the “final blow” to Russia Abroad (6). 70. Ibid., 7. 71. MC#112, ICN Box 15, Folder 1756, 16 August 1966. This is not surprising given that by 1950, the American Hospital Association reported that there were more than 22,000 unfilled nursing positions, and that by 1968, 9,200 hospitals had been built with more than 400,000 beds with patients waiting for nurses. Philip A. Kalish and Beatrice J. Kalish, Advance of American Nursing (Boston: Little, Brown, 1978), 504, 370, cited in D’Antonio, American Nursing, 167–68. 72. Bridges, A History of the International Council of Nurses, 159. 73. Box 1, Folder 2, Correspondence 1944–1949. n.d. Lavinia L. Dock Papers, Manuscript Division, Library of Congress, Washington, DC.

Susan Grant, PhD Irish Research Council CARA Mobility Postdoctoral Fellow University of Toronto and University College Dublin 37 Meadow View, Churchtown Dublin 14, Ireland

“Coming to Grips with the Nursing Question”: The Politics of Nursing Education Reform in 1960s America Dominique A. Tobbell University of Minnesota

Abstract. The 1950s and 1960s were decades of change for the American nursing profession. A new generation of nurse educators sought to create greater professional autonomy for the nurse by introducing new models of education that emphasized science-based learning over technical skills and bedside care, and creating new clinical roles for the nurse, based on advanced graduate education. They confronted resistance from an older generation of nurses who feared becoming “second-class citizens” in increasingly academic nursing schools, and from academic health care institutions all too comfortable with the gendered hierarchy on which the traditional model of nursing education and practice was predicated. Using the University of Minnesota and University of California—Los Angeles (UCLA) as case studies, and based on institutional records and more than 40 oral histories with nursing and medical faculty, this article describes the generational conflicts this new cadre of nurse educators confronted within schools of nursing, and the institutional politics they struggled with as they sought to secure greater institutional status for the schools among the ­universities’ other health science units.

In February 1963, the dean of the University of California—Los Angeles (UCLA) medical school wrote to UCLA’s chancellor: It would be best to abandon a Nursing School at UCLA, except as a ­Hospital ­ iploma School . . . . If a ‘School of Nursing’ is to be retained at UCLA it would D require a great effort to reform it, and the ‘School’ should, in effect, become a ­Department of the School of Medicine.1

Nursing History Review 22 (2014): 37–60. A Publication of the American Association for the History of Nursing. Copyright © 2014 Springer Publishing Company. http://dx.doi.org/10.1891/1062-8061.22.37

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Five years later at the University of Minnesota, 22 members resigned from the School of Nursing, citing their dissatisfaction with the director of the school, Edna Fritz. One resigning faculty member wrote to Fritz that At one time a competent and creative faculty was free to develop a nursing program to which it was committed. When I joined the faculty there was an excitement of dialogue, intellectual initiative, constructive criticism, and the push for inquiry . . . . This is no longer the case. The faculty is now fragmented and non-functioning. The curriculum is deteriorating . . . . Faculty and student morale has been seriously damaged . . . . You have encouraged fragmentation of faculty by supporting obstruction and rewarding non-productivity.2

A few months later, Fritz was fired as director of the School of Nursing. Although separated geographically, these two scenes reflect the contested politics of nursing education reform in the United States during the 1960s. Through the mid-20th century, most American nurses were trained in hospital training schools (or diploma programs) in which training and practice was, as Julie Fairman describes, “rule based, activity oriented, and relied heavily on the repetition of procedures rather than scientific or social theory-based decision making.”3 Across the United States during the 1950s and 1960s, ­however, a new generation of nurse educators sought to create greater professional ­autonomy for the nurse by introducing models of education that emphasized science-based learning over technical skills and bedside care. They also sought to create new clinical roles for the nurse based on advanced graduate education. As these educational reforms were gradually implemented throughout the country, the primary site of nursing education shifted from hospital-based diploma schools to colleges and universities.4 The introduction of education reform at nursing schools did not pass uncontested. Indeed, within a few years of being implemented, curriculum reforms introduced at UCLA School of Nursing in the 1950s and at the University of Minnesota School of Nursing in the early 1960s were causing problems for faculty, students, and administrators alike. The introduction of reform was also not a uniform process. Rather, the character and politics of education reform at an institution depended on the personalities involved and the local culture and politics of the specific institution. Using the University of Minnesota and UCLA as case studies, this article describes the generational conflicts this new cadre of nurse educators confronted within schools of nursing, and the institutional politics they struggled with as they sought to secure greater institutional status for the schools among the universities’ other health science units.5



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This article also situates the politics of nursing education reform within the broader context of state health policymaking and the politics of statesupported academic health institutions in the United States in the decades after World War II. Despite massive infusions of federal funding into health science research and health care, by the 1960s the United States had no mechanism for matching biomedical research and workforce production with the country’s health care needs. In the absence of a comprehensive national health policy, state-supported academic health institutions, like those at UCLA and the University of Minnesota, became sites in which federal and state health policies intersected and were implemented in local settings. Thus, during the past half-century, state governments have relied on schools of medicine, nursing, dentistry, public health, pharmacy, and ­veterinary medicine to respond to the health care needs of state residents. In ­exchange for state funding, academic institutions have been required to ­produce enough of the “right type” of health care professionals willing to work in the state. Even when private academic health institutions have received state support, neither their constitutions nor their priorities have been shaped by the land-grant mission of state institutions. Private institutions have been able to prioritize research and specialty education without the tension of producing sufficient primary care and rural health care workers to meet the state’s health care needs. In contrast, because the UCLA and University of ­Minnesota Schools of Nursing sought to reform nursing education, state legislators called on them to produce more professional nurses able to meet the states’ growing health care needs. As a result, these nursing schools, along with other statesupported schools throughout the country, were sites in which federal, state, institutional, and interprofessional politics intersected in the making of the American nursing workforce and the creation of state health policies.

Nursing Education After World War II Substantial changes took place in American nursing education after World War II.6 These changes were led in part by sociologist Esther Lucille Brown and nurse educators Hildegard Peplau and Virginia Henderson, who ­offered compelling critiques of nursing education based on new, theoretically grounded definitions of nursing practice. In 1948, on behalf of the National Nursing Council and with funding from the Russell Sage Foundation, Brown published Nursing for the Future, a thorough survey of the qualitative and quantitative status of nursing practice and education. Brown’s report called for

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all forms of professional nursing education to be placed within institutions of higher education and for university-based nursing schools to be autonomous with the same status as the university’s other professional schools.7 Henderson and Peplau’s critiques of nursing education were influenced by the Brown report and were also based on their experiences with diploma and baccalaureate degree programs, and their disillusionment with the traditional model of nursing practice. For Henderson, “the regimentalized patient care” that nurses traditionally performed “and the concept of nursing as merely ancillary to medicine” were outdated concepts that should be replaced. Nursing, redefined, would primarily complement “the patient by supplying what he needs in knowledge, will, or strength to perform his daily activities and also to carry out the treatment prescribed for him by the physician.”8 Nursing education should be reformulated to prepare nurses for their new role as an “expert and an independent practitioner.” It was time, Henderson argued, to replace the regimented, procedure-based hands-on training of the diploma model with “a liberalizing education, a grounding in the physical, biological, and social sciences, and the ability to use analytic processes.”8 Peplau, who like Henderson held a theoretically grounded and patientoriented view of nursing practice, advocated advanced graduate nursing education to prepare nurses for expertise in specialist clinical areas such as psychiatric nursing. Beginning in the mid-1950s, Peplau advocated that psychiatric nurses should have expertise as counselors or psychotherapists. By developing “specific interpersonal techniques useful in intervening in specific pathological behavior of patients,” taught at the master’s level, the psychiatric nurse would establish a therapeutic relationship with patients. Although the psychiatric nurse engaged in specialized clinical practice, Peplau maintained, the technical work of nursing should fall to the general duty nurse.10 As the nature of nursing work expanded and patient care assumed greater complexity after the war (which, nurse educators argued, necessitated the curriculum reforms), much of the so-called “traditional” bed and body work of nursing was transferred to less-trained “technical nurses” (or bedside nurses), practical nurses, and nursing assistants. Practical nurses were typically trained in 1-year programs principally located in hospital-based nursing schools or, increasingly, offered by vocational educational systems. Between 1950 and 1963, the number of practical nurse programs in the United States increased from 144 to 737.11 In 1951, Mildred Montag introduced the concept of a new, specialized nursing worker, the technical nurse, whose training would be more than that for a practical nurse but less than that for the diploma or baccalaureate (BS)-prepared professional nurses. Technical nurses were to assume responsibility for the hands-on bodywork of nursing. They would be trained



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in 2-year associate degree programs based at community colleges, receiving general and nursing education and clinical instruction. The first three associate degree programs were established in 1952, and by 1960 there were more than 100 such programs in the United States.12 In this new educational hierarchy, the BS-prepared nurse assumed the status of the “professional nurse” and the responsibilities of the expert and ­independent clinical practitioner. Professional nurses, typically after ­completing advanced graduate education, would go on to serve as clinical supervisors, educators, or administrators. Even by the 1970s, however, the distinction ­between associate-degree and BS-prepared nurses had become blurred in clinical practice.13 The Division of Nursing of the U.S. Public Health Service underwrote the planning and implementation of many of these reforms. As Cynthia ­Connolly and Joan Lynaugh have documented, the division began funding nursing ­research projects in 1955, and in 1962 established the Nurse Scientist Graduate Training program, which supported nurses pursuing research-based graduate degrees in university science departments. Other sources of federal funding came from the Health Amendments Act of 1956, which “allocated money to prepare nurses to become teachers, supervisors, and nursing service administrators.” Following publication of the Surgeon General’s Consultant Group on Nursing’s report Toward Quality in Nursing Education, Congress passed the 1964 Nurse Training Act, Title VII of the Public Health Service Act. The Act provided federal funds for new teaching facilities, “curricular experimentation, faculty development, and an expanded Professional Nurse Traineeship Program.”14 From the 1950s through the 1970s, individual nursing schools around the United States debated the merits of reformulating nursing education, experimenting with new curricula that eliminated dependence on a medical model of practice and emphasized instead nursing theory and patientcentered practice. The efforts of the UCLA and the University of Minnesota Schools of Nursing to revise the undergraduate nursing curriculum reveal the highly contested nature of nursing education reform during these decades.

The Gendered Politics of Health Education at UCLA In 1949, Lulu Wolf Hassenplug was appointed founding dean of UCLA’s School of Nursing. Hassenplug had graduated with a diploma from the Army School of Nursing at Walter Reed Hospital in 1924, and earned a ­baccalaureate

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degree from Columbia University Teachers’ College in 1927, and a Master of Public Health degree from Johns Hopkins University. She came to UCLA already a leader in nursing education, having played an instrumental role ­developing Vanderbilt University’s baccalaureate nursing program.15 At UCLA, ­Hassenplug oversaw the elimination of the hospital-based diploma program and the introduction of a 4-year baccalaureate in nursing in 1950 and a ­Master of Science graduate program in 1951. In the late 1950s, the school began ­planning for a doctoral program in nursing. UCLA’s baccalaureate program was the first in the country to provide nursing students with the same preparation regardless of whether they wished to become clinicians, educators, or administrators. Students who wanted to pursue careers as educators, administrators, or clinical specialists would, after receiving their baccalaureate, enter the graduate program for advanced specialized education. All other nursing baccalaureate programs in this era tracked students into either education, clinical practice, or administration.16 From the late 1950s throughout the 1960s, however, the UCLA School of Nursing was under constant attack from the surgical faculty, medical school dean, and hospital director, all of whom lamented the loss of the traditionally trained bedside nurse. As Hassenplug recalled, “we got complaints” from physicians when the School revised the nursing curriculum because “the physicians thought our students were their own.”17 In February 1957, for example, UCLA neurosurgeon Eugene Stern wrote to the medical school dean lamenting the substandard education being received by UCLA’s nursing students. The nursing students are not learning adequate bedside care . . . . They appear to be more concerned with the psychological aspects of case studies to which they are assigned rather than being concerned with learning the rudiments of nursing care . . . . They likewise are taught minimal, if any, responsibility to the physician.18

For Stern, the decline in the quality of UCLA’s nursing education could be correlated with the elimination of the hospital-based diploma program and the now minimal role of the physician in training nurses.18 Stern joined his colleagues in the Department of Surgery in calling for ­reform of nursing education at UCLA. Specifically, the surgeons wanted nursing students to return to the wards and operating rooms like the ­earlier ­diploma students, and for “nurse training” to be “implemented by a ­curriculum of which and in which the physician shares supervisions, consults, and participates.”19 As chair of UCLA’s department of surgery, William P. ­Longmire ­explained, the surgeons’ hostility to the nursing reforms was because “Many



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of us felt that our school was not graduating the type of nurse who would then become involved in patient care.” Longmire took particular issue with the school’s new philosophy, “that the student nurses were actually to have no ward assignments; they were to come on the wards as observers, to study the patient’s case but not to actively participate in the patient’s care.”20 The surgeons had the support of the medical school dean, who drew up a proposal to reorganize the nursing school and transfer the nursing curriculum to the School of Medicine. In this plan, the nursing faculty would be appointed “to the appropriate department of the Medical School as a division of nursing with such titles as are appropriate—that is, Professor of Nursing (Surgery), Professor of Nursing (Obstetrics), and so forth—as a division of the Department. Each Medical School department could sponsor the appropriate parts of the Nursing curriculum.” A nursing faculty member would be assigned oversight of the curriculum and hold the position of associate dean within the medical school.21 This proposal circulated in the medical school and university administration for several years. But, as Dean Hassenplug recounted, in those years the nursing school had the “honest support” of the university chancellor and provost of health sciences.22 In 1960, however, when physician Franklin D. Murphy was appointed chancellor and the position of provost for the health sciences was eliminated, the institutional politics at UCLA shifted. With the considerable power of his office, Murphy joined the assault on the nursing school. In June 1968—in an attempt to “come to grips with the nursing question”—the chancellor’s office circulated a proposal that called for the termination of existing undergraduate and graduate nursing programs; the transfer of responsibility for undergraduate nursing education to an Office of ­Nursing Education located in the UCLA Hospital; and the discontinuation of the nursing school. The department of surgery, medical school dean, and hospital director fully endorsed Murphy’s proposal.23 Faculty throughout the university, however, including members of the ­departments of medicine, pediatrics, and psychiatry, submitted a position paper “in vigorous opposition” to the proposed closing of the school.24 The  ­university Committee on Educational Policy issued a report that concluded, “The ­administrative unit for the education of nurses at UCLA should be the School of Nursing.”25 Moreover, Dean Hassenplug mobilized a nationwide political campaign in support of the nursing school. On receiving the proposal on a Friday afternoon in late June, Hassenplug alerted “all the deans of university schools of nursing, the national nursing organizations, our friends in the federal government” about what was happening: “Our attack, I might say, was fast and furious, and it was supported at every step.” By Tuesday morning,

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UCLA’s president, chancellor, and regents were being bombarded with phone calls, newspaper coverage, and letters demanding continuation of the nursing school. Soon thereafter, the chancellor and his allies abandoned their efforts to close the school.26

Professional Conflict at the University of Minnesota Although UCLA’s nursing faculty confronted criticism from physicians, the example of the University of Minnesota is emblematic of the resistance the new generation of nurse educators faced from their colleagues within nursing. Since 1919, the School of Nursing at the University of Minnesota had offered a 5-year baccalaureate program that required nursing students to take 2 years of liberal arts education before beginning 3 years of hospital-based clinical education. In 1962, however, the school introduced a new “integrated” 4-year baccalaureate degree that incorporated liberal arts and nursing courses throughout the 4 years, eliminated the 30-hr a week clinical service requirement, and emphasized coursework in the behavioral and psychological aspects of nursing.27 Edna L. Fritz had been appointed director of the nursing school after the retirement of Katherine J. Densford in 1959 and oversaw the introduction of the new curriculum. Fritz had received her baccalaureate nursing degree from Russell Sage College in 1940 and her Master’s in Nursing Education from ­Columbia University Teachers’ College in 1942. When she arrived at ­Minnesota, she was completing a doctorate in education at ­Teachers’ ­College under the supervision of Mildred L. Montag; she received her ­doctorate in 1965.28 Prior to her arrival at Minnesota, Fritz had worked for the ­National League of Nursing (NLN), first serving as director of a demonstration ­project integrating specialized clinical instruction into the ­curriculum and then as assistant director of the NLN department of baccalaureate and higher degree programs.29 Prior to her work with the NLN, Fritz had served as a nursing ­instructor at Cornell University, New York Hospital (now New  ­York-­Presbyterian ­Hospital) and Boston University General Hospital. Fritz thus brought to Minnesota experience with and a commitment to curriculum development but little experience with university administration. When Fritz arrived at Minnesota in 1959, the undergraduate nursing curriculum was already being developed by a small group of the faculty. ­According to retired faculty member Marilyn Sime, the reform group “had a new vision . . . for delivering nursing education.” The older 5-year



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c­ urriculum had been predicated on a “medical model” and the assumption that nursing care, at least within the hospital, would be delegated by the physician. In that curriculum, the emphasis had been on clinical instruction. The new curriculum considered nursing care as something separate from delegated medical care. It taught students to “stud[y] patient behaviors, and arriv[e] at . . . a nursing diagnosis of the patient’s needs and develop[e] a nursing care plan around those concepts rather than around the medical conditions.”30 In this way, the curriculum reforms drew explicitly on the work of Esther Lucille Brown, Hildegard Peplau, and Virginia Henderson, who called for nursing education to be grounded in the physical, biological, psychological, and ­sociological sciences to prepare nurses for independent practice that would be oriented to the individual needs—physical, psychological, and emotional—of patients.31 As Sime recalled, however, the new curriculum “wasn’t loved by all. There were faculty that felt that too much had been lost and not enough gained by this new approach.”32 As Florence Marks (another former faculty member) elaborated, the faculty were no longer “teaching the didactic medical things, what you would do with this medical situation, this clinical situation. All those things were not there” anymore. Instead, the students “were supposed to know enough theory that they could figure these out for each patient. It was not something they learned, you know, as A, B, or C.”33 In 1961, Marie Manthey was completing her baccalaureate degree while the curriculum was in transition. As she described it, “The faculty was divided. I don’t think they really knew how to manage the transition without pretty much destroying each other.” Manthey recounted taking a clinical course taught by three faculty members, two of whom were leading the reforms. The third had been on the faculty since the 1930s and was “an extremely brilliant clinician with a lot of understanding of the medical sciences.” What Manthey “saw as a student was these teachers standing up in front of us, two of them humiliating the third one, and the third one was the only one talking about anything I was interested in, which had to do with dealing with patients who are sick.”34 Manthey went on to earn her Master’s in Nursing Administration from the university and from 1964 to 1971 served as associate director of nursing at Minnesota’s University Hospital. Reflecting on this period of educational reform, Manthey noted that The curriculum swung so far over to a non-clinical side that it was absolutely frightening. People were coming out of the school with an RN, if they passed their boards . . . [they] came out not having ever given an injection, never having seen a delivery.

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As Manthey perceived it, nursing students were being discouraged from doing physical care for the patients. So they were interviewing patients. They would come back and they would write down every single word that was said by the patient . . . analyze and, then, decide whether to admit [the patient] or not. People told me that if they so much as gave a patient a drink of water, they would be marked down by the faculty for engaging in nursing care activity.35

In essence, the nursing curriculum reforms reflected a growing tension among nurse educators about the fundamental principles of nursing and the appropriate balance between theory and practice in undergraduate nursing education. The difficulty of integrating theoretical and practical knowledge into the curriculum reflected an explicit tension built into the structure of nursing education. Whereas in medical schools, the teaching faculty held both faculty positions in the medical school and clinical positions in the teaching hospital, in nursing schools during this period, including the University of Minnesota’s, they rarely held clinical positions in the teaching hospital’s nursing service. Thus, faculty clinical practice was not integrated into the structure of academic nursing. At Minnesota, this led to conflict and divisions between the nursing faculty and members of the University Hospital nursing service. During those years, the faculty would hear from the nursing service, “‘You’ll never make a good nurse. You don’t get enough experience. Some things, you have to learn just by practice.’” In response, the faculty would say, “‘You get the foundational theory. Eventually, you get the practice.’”36 Minnesota’s nurse educators also faced resistance to the educational ­reforms from university administrators and regents. As part of the reforms, the nursing school eliminated its Practical Nursing Program in 1967. This program, launched 20 years earlier, had provided 1 year of technical training to prepare practical nurses for licensure (these were the class of nurses who now assumed responsibility for the lower skill bed and body work of the traditional diploma-trained nurse). When the school began the practical nursing program in 1947, it was only one of four such programs in the state. By the mid-1960s, however, there were 25 practical nursing programs in ­Minnesota.37 When the school revised the baccalaureate curriculum, it eliminated the practical nursing program so as to better utilize the faculty’s resources, and delegated the preparation of practical nurses to the state’s junior colleges. School Director Edna Fritz wrote to the university vice president for academic affairs in April 1966, With the resources available to us, the greatest contribution the University can make to the nurse supply of the state and region is through efforts to expand enrollments in Masters programs that prepare faculty to serve the many schools that exist, thus permitting expanded enrollments in them.38



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Indeed, in 1966, 85 nursing schools in the upper Midwest reported 109 faculty vacancies and a need for 41 additional faculty positions.39 As Fritz saw it, the university nursing school’s priority was to train advanced degree nurse educators who could fill these positions. The closing of the practical nursing program, however, provoked “some very grave resistance by a few people,” not least the university regents. Powerful regent Charles Mayo (of Mayo Clinic fame) was particularly upset because he viewed the university’s practical nursing program “as the one sound program” the nursing school had. Mayo was a physician wedded to the traditional diploma-school model of nursing education.40 The directors of the university hospital and its nursing service also worried that without the guaranteed supply of practical nurses graduating from the nursing school, the university hospital would be forced to compete with other local hospitals and clinics for the practical nurses trained by other, perhaps lower quality programs.41 The educational reformers at Minnesota, however, clashed most significantly with school Director Edna Fritz. In 1967, the reformers wrote to ­Robert Howard, dean of the College of Medical Sciences (which had authority over the nursing school), demanding action to rectify “what we perceive to be the major problem in the school, namely administrative interference with faculty functioning . . . . We feel that the relationship between the faculty and the director of the School of Nursing must be examined objectively.”42 Howard disagreed with their assessment and put his full support behind Fritz, which ultimately led many of the faculty to resign from the school. Unfortunately, little archival or oral history evidence is available to support this group’s contentions about Fritz’s leadership style (sadly, they have all since passed away). The tension seems to have centered on a fundamental disagreement about the degree of clinical instruction in the new curriculum. Although Fritz supported curriculum reform in general, she wanted the faculty to be more ­engaged with clinical teaching. This approach followed from Fritz’s earlier work on an NLN-funded demonstration project, which had integrated concepts ­associated with specialized clinical areas into the basic nursing curriculum at Cornell University-New York Hospital School of Nursing.43 Fritz questioned the reformers’ decision to replace “clinical laboratory practice” hours in the curriculum with “classroom laboratory” hours, noting “It is this practice that has so minimized the opportunities of students to apply their learnings in ­reality situations.”44 Fritz also advocated a faculty practice model, championed by Dorothy Smith at the University of Florida, in which responsibility for clinical education would be shared by the faculty and nursing service. This diverged significantly from the practice during Katherine Densford’s tenure as director, when the hospital

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nursing service had primary responsibility for clinical instruction. By pushing the faculty “to doll up in a uniform and a white cap and go back into the clinical areas,” Fritz ostracized some of the school’s most senior faculty who had not worked on the wards since their training in the 1920s and 1930s. In doing so, Fritz contributed to a generational and philosophical divide that already existed among the faculty and between the faculty and nursing service.45 This divide foreshadowed the conflict that emerged during the creation of nurse practitioner programs in the 1960s and 1970s. As Julie Fairman has described, although an older generation of nurse educators often saw nurse practitioners as physician wannabes, a younger generation—grounded in second-wave feminism—saw a unique role for nurse practitioners thoroughly distinct from that of physicians.46

Building the State’s Nursing Workforce The efforts to reform nursing education at Minnesota and UCLA coincided with growing regional and national concerns among health care leaders and policymakers about impending shortages of health care workers, including nurses. Several studies of the nursing shortage conducted in the early 1950s predicted that between 50,000 and 75,000 new graduate nurses were needed each year.47 In 1963, the Surgeon General’s Consultant Group on Nursing (on which Hassenplug served) declared that the “Nation’s supply of nurses today has great inadequacies, both in numbers and in educational preparation.” By 1970, the group concluded, the country would need 850,000 professional nurses, with 200,000 of them having at least a baccalaureate degree, and another 100,000 having graduate preparation to meet the critical need for nurses prepared for teaching and leadership positions. This translated into schools needing to graduate 53,000 new nurses each year by 1970.48 The degree of nursing shortage varied across states and regions.47 In ­January 1957, for example, the University of California issued a report that projected that unless enrollment in the UCLA and University of ­California— San ­Francisco (UCSF) Schools of Nursing expanded, by 1965 the Western United States would face a shortage of more than 18,000 nurses. Within that ­shortage, the committees predicted deficits of 8,000 baccalaureate-trained nurses and 5,980 nurses with master’s degrees or higher.50 In Minnesota, nursing shortages were less severe. In 1966, the Upper Midwest Nursing Study reported that Minnesota’s rate of nurse graduates from all nursing programs was nearly twice that of the country and, moreover, the upper Midwest region served as “an important source for nursing personnel.”51



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As a result of California’s shortages, the authors of the University of ­ alifornia report proposed a statewide plan for nursing education in which C the UCLA and UCSF Schools of Nursing would retain their undergraduate curricula but would also “put special emphasis on graduate education, particularly the preparation of nursing educators.” Furthermore, “no other collegiate programs should be established on other campuses of the ­University of ­California.” Because only UCLA and UCSF had adequate facilities in medical education, the report’s authors contended that only these schools were equipped to provide nursing students “the quality of general and professional education now required for competence in the expanding fields of nursing.” Following the recommendations of the Ginzberg report of 1948 and the Bridgman report of 1953, the University of California report called for the abandonment of hospital schools of nursing and for 2-year curricula (leading to an associate degree) to be established at the state’s junior colleges, and 4-year curricula (leading to baccalaureates) at the state’s other 4-year institutions.52 Graduate nursing education should remain the province of UCLA and UCSF. The expectation, of course, was that many of these advanced graduate nurses would join the faculty at the junior and state colleges to boost their undergraduate curricula. Ultimately then, the report proposed a statewide ­division of educational labor in the university, state college, and junior college system.53 In response to these concerns, nurse educators framed their calls for educational reform as necessary for resolving the impending crisis in nursing supply and fulfilling the university’s obligation to the state. Since the late 1940s, state legislators had looked increasingly to academic health institutions receiving state funds to expand educational opportunities and better coordinate the production and distribution of the state’s health workforce. In March 1949, for example, at a meeting of the Finance Committee of the California Senate, Senator Bradford S. Crittenden offered his support for the budget of the University of California but warned that he and other members of the committee and the Senate would be influenced in their enthusiasm by the present attitude and future planning of the University toward the problem of training enough professional people concerned with health and related problems to meet the needs of the State.

Crittenden felt the committee’s support was contingent, in particular, on the university addressing why the state had a shortage of doctors, dentists, nurses, pharmacists, and veterinarians.54 The nursing education reforms of the 1950s and 1960s were thus situated squarely within the politics of state health education and workforce policies.

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To this end, the nursing faculty at UCLA warned administrators who wanted to shut down the school and reestablish nursing education as either a hospitalbased program or a department within the medical school, that they would violate the mandates set by the California Master Plan for Higher Education. In 1959, the California state legislature had asked the University of California and the California Board of Education to investigate the problems raised by exploding student population growth and mounting financial competition between the state’s public universities and colleges, and develop a plan that would allow the state to continue to support higher education within its limited fiscal resources. The resulting Master Plan for Higher Education, codified in the Donahoe Higher Education Act of 1960, described a functional division of educational labor (consistent with the one already proposed for nursing education) between the University of California, the California state colleges, and the junior colleges.55 In April 1962, UCLA’s ad hoc committee on nursing, which had been appointed by Chancellor Murphy to review the organization of the nursing school in light of the medical school’s complaints, concluded, “Clearly the University has an obligation . . . to continue a program in Nursing directed at alleviating” the shortages of nurses, nurse administrators, researchers, and educators, “at least until such a time as the State Colleges may take over some . . . of these functions.” As such, the committee was thoroughly opposed to merging nursing into the medical school: the prime function of nursing education at UCLA should not, in the long run, be an attempt to contribute significantly to the direct production of practicing nurses, but rather to provide nursing faculty, highly trained nursing specialists, and scholars in allied areas interested in applying this knowledge to problems of Nursing. Jurisdictionally, it would seem unwise and improper to incorporate a Department of Nursing in the School of Medicine [emphasis added].56

Meanwhile, at the University of Minnesota, the nursing faculty ­addressed the concerns raised by the hospital’s nursing service, the regents, and ­administrators that the school’s new academic orientation would lead to further ­decline in clinical nurses. As Director Fritz wrote to the Committee on Long Range Planning in the Health Sciences in September 1966, the School had “identified the most useful contributions that we might make to an augmented supply of nurses for our state and region.” Based on data—including current and projected shortages—about the state of nursing in Minnesota, the Dakotas, and Montana, Fritz noted, “the greatest block to expanding student enrollments in nursing programs of all types is the serious shortage of ­qualified



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[that is, baccalaureate and graduate level-prepared] teachers.” Although there were several institutions in the region with practical nursing and basic professional programs, the University of Minnesota’s nursing school “is the only institution in a four-state area presently able to provide preparatory programs for teachers of nursing to make possible improvement and expansion of the many other schools of nursing in this region.” Fritz thus argued that the school’s priority should be preparing the next generation of nursing educators and advanced clinical specialists.57 The nursing school promised, however, to provide other nursing programs in the state, particularly at the junior colleges, with “consultant services and continuing educational opportunities” to help them expand and establish practical nursing and associate degree programs.58 The faculty of both schools thus argued for the coordination of nursing educational hierarchies across the state to ensure a sufficient supply of nurses for the state and region, with university schools of nursing at the center. In this coordinated planning, the state’s community colleges would be responsible for preparing associate degree nurses, the 4-year universities and colleges would prepare baccalaureate nurses, and university programs would prepare advanced degree clinical specialists, researchers, and educators. As UCLA’s nursing dean, Lulu Hassenplug recalled it was the nursing school’s responsibility to set up a network of nursing education throughout the state: The state university exists for that. We were in the community as much as we were in the university. . . . [W]e thought we ought to be doing something like this to facilitate the growth of the baccalaureate and higher degree programs. We ought to be helping the whole region.

As early as 1956, nursing leaders from the Western states were working with the Western Interstate Commission on Higher Education to undertake ­regional planning for nursing.59 At Minnesota, the nursing faculty became increasingly involved in ­regional planning in the mid-1960s after the initiation of the Upper Midwest Nursing Study. This project, funded by the Hill Family Foundation, described and analyzed the quantitative and qualitative supply of nurses and projected future demand for nurses in Minnesota, Montana, North Dakota, South Dakota, the Upper Peninsula of Michigan, and the Northwestern portion of Wisconsin. With these data, the study group sought to tackle nursing shortages by better using the region’s existing supply of nurses.60 Early in 1971, the School of Nursing joined the Minnesota Nurses Association (MNA) and other state nursing schools in the upper Midwest and applied for federal funding to initiate a regional planning project. They did so in response to the

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recommendations of the National Commission for the Study of Nursing and Nursing Education, which urged states to develop master plans for nursing and nursing education.61 By 1971, all University of Minnesota health science schools were under pressure from the university administration and state legislature to take the lead in health workforce planning. That May, for example, the university vice president for legislative affairs, Stanley Wenberg, wrote to his colleagues in the university’s central administration to warn that state legislator Verne Long was looking to the university to help resolve a current problem in nursing education. Wenberg asked his colleagues: Is there some way we can get an answer to [representative Long] that responds to his concern that the University ought to give a little leadership in trying to multiply approaches to better utilization and training of health manpower particularly in paramedical fields [such as nursing]?

Long held considerable political and financial leverage at the university as chair of the Minnesota House’s higher education committee and vice-chair of the appropriations committee. His attention to the problem of nursing education was in part a response to the “many letters, calls, and visits” he had received since the beginning of the legislative session from nurses who were troubled by the difficulties they had faced in their efforts to attain advanced training. In making his request to Wenberg, Long reminded him that several times in the past weeks you have pointed out specific needs and asked us, as legislators, to address and appropriate dollars to specific programs. I would now like to ask you to direct your immediate attention to the problems [with nursing education]. . . . If, in fact, the solution to these problems can be found . . . then I want to say in the most forceful manner I know how—let’s have the answers forthcoming soon.62

By placing their educational reforms in the context of state and regional health needs, nursing educators were able to secure their institutional objectives. Chancellor Murphy’s efforts to discontinue UCLA’s School of ­Nursing failed, and after several years of conflict, both schools regarded their educational reforms a success. Unfortunately for Fritz, however, by 1968 the practical ­implications of the nursing curriculum’s shift away from clinical education were placed in stark relief. At the NLN evaluation team’s site visit that March, the team noted the “serious imbalance” in the undergraduate program whereby the curriculum placed “disproportionate emphasis on the ­psychosocial dimensions of nursing, to the serious detriment of the biophysical aspects of nursing.”63



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Their findings confirmed reports that William Shepherd, vice president for academic affairs, had received in recent years from “students in the program about the adequacy of preparation in the biophysical aspects of nursing.” Shepherd had also received reports from supervisors of the school’s graduates who “regard them as poorly prepared for beginning nursing practice.”64 That fall, 25% of the graduating class failed their state licensing exams. Although the curriculum’s defenders, including Marilyn Sime, asserted the state exams were not “measuring the new approach to nursing care. It was measuring knowledge from the old model,” the failure provoked broad-based concern among the university administration and regents and led to Fritz being fired.65

Conclusions The 1950s and 1960s were thus decades of change for the American nursing profession. A new generation of nurse educators sought to create greater professional autonomy for the nurse by introducing new models of education that emphasized science-based learning over technical skills and bedside care. They also sought to create new clinical roles for the nurse, based on advanced graduate education. Because they did so, these educators confronted resistance from an older generation of nurses who feared becoming “second class citizens” in increasingly academic nursing schools and from academic health institutions all-too-comfortable with the gendered hierarchies of the health professions on which the traditional model of hospital-based nursing education was predicated.66 The politics of nursing education reform played out quite differently at UCLA and the University of Minnesota. These differences were based in local institutional history, politics and culture, and the personalities of those ­involved. The institutional status of each nursing school within the university was particularly significant. Indeed, the changes in nursing education occurred at the same time that many American academic health institutions were being conceptualized or reconfigured as academic health centers (AHCs). AHCs are institutional umbrellas that combine all of a university’s health science schools, biomedical research institutes, and affiliated teaching hospitals and clinics. AHCs emerged as a new organizational form in the United States in the 1950s, replacing the traditional academic medical center model, which typically included an administrative alliance between the university’s medical school, hospital, and medical staff. With each health science school theoretically granted equal administrative status, AHCs were designed to dismantle the disciplinary silos that had

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­ reviously characterized the health sciences, where the educational needs of p nursing and public health were routinely subordinated to those of medicine. AHCs were intended to promote interdisciplinarity in research and education, and a team approach to clinical practice by integrating nursing, medical, dental, pharmacy, public health, and allied health care. By the late 1970s, AHCs had emerged as a dominant institution in American health care.67 UCLA’s Center for the Health Sciences was one of the first AHCs to be organized in the 1950s. It was initially established as a traditional medical center when the regents of the University of California authorized a medical school at UCLA in 1945. However, it was quickly reconceived as an AHC following the establishment of a professional nursing school in 1949 and the initiation of plans to establish schools of dentistry and public health in 1960 and 1961. In 1970, the University of Minnesota reorganized its health science schools and hospitals into an AHC. In contrast to UCLA, the development of Minnesota’s AHC required administrative, intellectual, and physical reorganization of schools and colleges of the health sciences that dated back to the late 19th century when the schools of medicine, dentistry, and pharmacy were founded. Minnesota’s nursing school was established in 1909 as the first university-based school of nursing in the country, whereas the School of Public Health and College of Veterinary Medicine were established in the 1940s. These institutional differences help explain the different politics encoun­ tered by the nursing education reformers in California and ­Minnesota in the 1950s and 1960s. At UCLA, the School of Nursing was an autonomous ­administrative unit within the university in which the dean had the same ­administrative authority as all the other UCLA deans, including the dean of the medical school. Lulu Hassenplug was a formidable leader by all ­accounts who brought to UCLA 10 years of curriculum development experience from her tenure as associate professor of nursing education at Vanderbilt ­University. As dean, Hassenplug had a direct line of authority to the university’s central administration. The school was only ever under serious threat when ­Franklin Murphy, a physician wedded to the diploma-school model of ­nursing ­education became chancellor. As Hassenplug reflected, “When you get somebody [in charge] who is not supportive, you have grave problems.”68 At Minnesota, in contrast, the School of Nursing was under the administrative authority of the dean of the College of Medical Sciences. The head of the nursing school had the position of director, not dean, and thus held substantially less administrative authority in the university. When Fritz was ­appointed director in 1959, she replaced the indomitable ­Katherine J. ­Densford, who, for 30 years, had commanded great respect and authority from those inside and outside the school. Densford’s retirement created an opportunity for the



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younger faculty—particularly those who took the lead in the curriculum ­revisions—to assert their professional interests and identities on the school. ­Indeed, when Fritz arrived at Minnesota, the curriculum revisions were ­already underway. As Florence Marks reflected, Fritz’s Achilles heal [sic] was that she didn’t rein in the faculty when it should have been done. . . . I think that she had to just say, “Okay, you have to have enough [clinical ­instruction] in there that they can pass the state boards,” and that didn’t happen. So that was a fatal error, you might say.69

Fritz’s difficulties managing the faculty may in part have stemmed from her relative lack of experience as a faculty member before arriving at Minnesota. Her most immediate experience, after all, had been directing various educational projects at the National League for Nursing. Not only would this have presented Fritz with limited experiences of managing academic personalities, it may also have imbued some of the school’s faculty with a lack of respect for Fritz’s leadership credentials. In spite of the differences, these case studies point to broader themes in recent nursing history, not least the highly contested nature of nursing education reform. During the 1950s and 1960s, a new generation of nurse educators confronted generational conflicts in schools of nursing from older faculty and clinical instructors who feared becoming “second-class citizens” in increasingly academic nursing schools. And they faced resistance from ­academic health care institutions comfortable with the gendered hierarchy of the health professions on which the traditional model of nursing education was predicted. These ­examples also reveal the ways state-supported academic health institutions—like the UCLA and the University of Minnesota Schools of Nursing—have, since the 1950s, played an increasingly critical role in ­coordinating the supply and distribution of health care professionals in a region. And in so doing, academic health institutions have served as instruments of state health policymaking.

Acknowledgments

I owe a debt of thanks to Joan Lynaugh, Julie Fairman, Cynthia Connolly, and Patricia D’Antonio for sharing their insights and expertise as I developed this article. Thank you also to the two anonymous reviewers for the Nursing ­History Review for their valuable feedback. Thanks go also to Erik Moore and Erin George at the University of Minnesota Archives, and Charlotte Brown

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at the UCLA Archives for providing excellent archival assistance. Thank you to the audiences of the 2012 annual meetings of the American Association for the History of Medicine and the Policy History Conference for their comments on earlier versions of this article. Finally, I am indebted to the retired nurses and nursing faculty whom I interviewed as part of the University of Minnesota Academic Health Center Oral History Project.

Notes 1. Sherman Mellinkoff to Franklin D. Murphy, 25 February 1963, UCLA Archives, Collection 401, Box 11, folder: Nursing School 1960–1964. 2. A. Marilyn Sime to Edna Fritz, 20 May 1968, University of Minnesota Archives, Office of Vice President for Academic Affairs, Box 30, folder: School of Nursing Review of Program 1967–1968. 3. Julie Fairman, Making Room in the Clinic: Nurse Practitioners and the Evolution of Modern Health Care (New Brunswick, NJ: Rutgers University Press, 2008), 41; see 40–53 for a detailed description of the changes in nursing education at mid-century. 4. Fairman, Making Room in the Clinic; Joan Lynaugh, “Academic Nursing Practice,” in Academic Nursing Practice: Helping to Share the Future of Health Care, ed. Lois K. Evans and Norma M. Lang (New York: Springer, 2004); and Joan Lynaugh and Barbara Brush, American Nursing: From Hospitals to Health Systems (Malden, MA: Blackwell, 1996). On the expansion of occupational divisions within nursing after World War II during the expanding use of medical technologies and increased incidence of chronic disease, see Margarete Sandelowski, Devices and Desires: Gender, Technology, and American Nursing (Chapel Hill: University of North Carolina Press, 2000), esp. 100–34. 5. This resonates with Susan Reverby’s assertion that nurses’ efforts to professionalize in the first half of the 20th century were “fractured both by patriarchal constraints from above and differences among women from within.” Susan M. Reverby, Ordered to Care: The ­Dilemma of American Nursing, 1850–1945 (New York: Cambridge University Press, 1987), 2. 6. Fairman, Making Room in the Clinic; Lynaugh, “Academic Nursing Practice”; and Lynaugh and Brush, American Nursing. 7. Esther Lucille Brown, Nursing for the Future: A Report Prepared for the National Nursing Council (New York: Russell Sage, 1948), 138–73. A second study published that same year by economist Eli Ginzberg also called for relocation of nursing schools from hospitals to universities and colleges. Eli Ginzberg, A Program for the Nursing Profession by the Committee on the Function of Nursing (New York: Macmillan, 1948). 8. Virginia Henderson, “The Nature of Nursing,” American Journal of Nursing 64, no. 8 (1964): 62–8, quote 66. 9. Ibid., 67. 10. Hildegard E. Peplau, “Interpersonal Techniques: The Crux of Psychiatric Nursing,” American Journal of Nursing 62, no. 6 (1962): 50–54, quote 53. See also Hildegard E. Peplau, Interpersonal Relations in Nursing (New York: Putnam, 1952); Fairman, Making Room in the Clinic, 43.



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11. Toward Quality in Nursing. Needs and Goals. Report of the Surgeon General’s Consultant Group on Nursing (Washington, DC: Government Printing Office, 1963), 11. 12. Mildred L. Montag and Lassar G. Gottkin, Community College Education for Nursing: An Experiment in Technical Education for Nursing (New York: McGraw-Hill, 1959); Edith Lewis, “The Associate Degree Program,” American Journal of Nursing 64, no. 5 (1964): 78–81. On the history and impact of community colleges on nursing education, see Patricia D’Antonio, American Nursing: A History of Knowledge, Authority, and the Meaning of Work (Baltimore: Johns Hopkins University Press, 2010), 168–70. 13. D’Antonio, American Nursing, 169–70. 14. Lynaugh, “Academic Nursing Practice,” 24; Cynthia Connolly and Joan Lynaugh, Fifty Years at the Division of Nursing United States Public Health Service (Washington, DC: USPHS Division of Nursing, 1997). 15. Biography of Lulu Hassenplug, http://www.mc.vanderbilt.edu/diglib/sc_diglib /biopages/lhassenplug.html, accessed October 31, 2012. See also Julie Fairman, “­Context and Contingency: The Post-World War II History of Nursing Scholarship,” Journal of ­Nursing Scholarship 40, no. 1 (2008): 4–11. 16. Lulu Wolf Hassenplug, UCLA School of Nursing’s Founding Dean, oral history interview conducted by Judi Goodfriend (Los Angeles: Oral History Program, University of California, Los Angeles, 1989). 17. Ibid., 243. 18. W. Eugene Stern to Stafford L. Warren, memorandum, 8 February 1957, in The role of the student nurse and the nursing school curriculum with respect to patient care, UCLA Archives, Collection RS300, Box 178, folder: Departments—Nursing 1957. 19. W. Eugene Stern, William P. Longmire, and Willard E. Goodwin to Stafford L. Warren, memorandum, 5 June 1957, UCLA Archives, Collection RS300, Box 178, folder: Departments—Nursing 1957. 20. William P. Longmire, Creating the Department of Surgery at the UCLA School of Medicine, oral history interview conducted by Bernard Galm (Los Angeles: Oral History Program. University of California, Los Angeles, 1988), 521–24. 21. Stafford L. Warren, memorandum, 31 May 1957, in Radical Suggestions for ­Consideration, UCLA Archives, Collection RS300, Box 178, folder: Departments—­ Nursing 1957. 22. Hassenplug, UCLA School of Nursing’s Founding Dean, 249–50. 23. Franklin D. Murphy to Foster H. Sherwood, 1 January 1967, UCLA Archives, Collection 401, Box 9, folder: I-Med 1960–1968; Foster H. Sherwood, “Nursing at UCLA,” 21 June 1968, UCLA Archives, Collection 401, Box 11, folder: Nursing School 1967–1970. 24. Forrest H. Adams et al. to Committee on Educational Policy, Budget and ­Interdepartmental Relations, Graduate Council, and the Chancellor’s Office, “UCLA School of Nursing: A Position Paper,” 23 August 1968, UCLA Archives, Collection 401, Box 11, folder: Nursing School 1967–1970. 25. Colin Young to Foster H. Sherwood, 19 February 1969, UCLA Archives, Collection 401, Box 11, folder: Nursing School 1967–1970. 26. Hassenplug, UCLA School of Nursing’s Founding Dean, 337–42. 27. For a comprehensive history of the University of Minnesota School of Nursing see Laurie K. Glass, Leading the Way: The University of Minnesota School of Nursing, 1909–2009 (Minneapolis: University of Minnesota School of Nursing, 2009).

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28. Edna L. Fritz, “Faculty Selection, Appointment, and Promotion in Collegiate Nursing Programs” (EdD dissertation, Teachers College, Columbia University, 1965). http:// pocketknowledge.tc.columbia.edu/home.php/viewfile/12030, accessed October 31, 2012. 29. On the demonstration project see Edna Fritz, Toward Better Nursing Care of ­Patients with Long-Term Illness (New York: Division of Education, National League of Nursing, 1956). 30. Oral History Interview with A. Marilyn Sime, interview by Dominique A. Tobbell, April 15, 2010, University of Minnesota AHC Oral History Project, 6. The University of Minnesota Archives permits the use of excerpts from the oral histories that are part of the University of Minnesota Academic Health Center Oral History Project. 31. Brown, Nursing for the Future; Peplau, Interpersonal Relations in Nursing; Peplau, “Interpersonal Techniques”; Henderson, “The Nature of Nursing”; J. Arthur Myers, Masters of Medicine: An Historical Sketch of the College of Medical Sciences, University of Minnesota 1888–1966 (St. Louis: Warren H. Green, 1968), 541–44, which explicitly acknowledges that the reforms were based on Brown’s work. 32. Sime interview with Tobbell, 11. 33. Oral History Interview with Florence Marks, interview by Dominique A. Tobbell, April 13, 2010, University of Minnesota AHC Oral History Project, 41. 34. Oral History Interview with Marie Manthey, interview by Dominique A. Tobbell, October 12, 2010, University of Minnesota AHC Oral History Project, 5–6. 35. Ibid., 12–16. 36. Oral History Interview with Ruth Weise, interview by Dominique A. Tobbell, July 28, 2010, University of Minnesota AHC Oral History Project, 15. Some of the medical faculty expressed similar concerns about the inadequate clinical preparation of nursing students; see, for example, Oral History Interview with John P. Delaney conducted by Dominique A. Tobbell on 27 March 2012, University of Minnesota AHC Oral History Project, 16. 37. See, for example, “Recommendation for Establishing Consultative Support and Continuing Education Services from the U of MN for the Furtherance of Practical Nursing Education and for Development of Programs in Nursing Leading to an Associate Degree in the State of MN, Concurrent with Disestablishment of the University’s Program in Practical Nursing,” ca. 1966 or 1967, University of Minnesota Archives, Office of the Vice President of Academic Administration, Box 22, Folder: Medical Sciences—Programs 1966–1967. 38. Edna Fritz to William G. Shepherd, 18 April 1966, University of Minnesota Archives, Office of the Vice President for Academic Affairs Papers, Box 23, Folder: Medical Sciences Nursing Programs 1966–1967. 39. “Recommendation for Establishing Consultative Support and Continuing Education Services.” 40. Oral History Interview with Eugenia Taylor, interview by Dominique A. Tobbell, May 27, 2010, University of Minnesota AHC Oral History Project, 16–21, quote 16. 41. Edna Fritz to Robert Howard, memorandum, 19 February 1965, in Discontinuance of the Practical Nursing Program, University of Minnesota Archives, Office of the Vice President for Academic Affairs Papers, Box 23, folder: Medical Sciences Nursing Programs 1966–1967. 42. Florence Brennan et al. to Robert Howard, 27 March 1963, Office of Vice President for Academic Affairs, Box 30, folder: School of Nursing Review of Program 1967–1968. 43. Fritz, Toward Better Nursing Care of Patients with Long-Term Illness. 44. Marks interview with Tobbell; quotation from Edna Fritz to William Shepherd, 25 March 1968, Office of Vice President for Academic Affairs, Box 30, folder: School of Nursing Review of Program 1967–1968.



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45. Marks interview with Tobbell, 46. 46. Fairman, “Context and Contingency.” 47. For a summary of these studies see, Lynaugh and Brush, American Nursing, 8–9. 48. Toward Quality in Nursing. 49. For a study of health workforce needs, including nurses, in Minnesota see Osler L. Peterson and Ivan J. Fahs (Health Manpower Study Commission), Health Manpower for the Upper Midwest: A Study of the Needs for Physicians and Dentists in Minnesota, North Dakota, South Dakota, and Montana (St. Paul, MN: Hill Family Foundation, 1966). 50. “A Report on Nursing Education in the University of California as Related to the Needs of California and the West,” 7 January 1957, UCLA Archives, #RS300, Box 178, folder: Departments—Nursing 1957. 51. Ivan J. Fahs and Kathryn Barchas, Nursing in the Upper Midwest: Focus on the State of Minnesota (Minneapolis: Upper Midwest Research and Development Council, 1969), 24. 52. Brown, Nursing for the Future; Ginzberg, A Program for the Nursing Profession; and Margaret Bridgman, Collegiate Education for Nursing (New York: Russell Sage, 1953). 53. “A Report on Nursing Education in the University of California.” 54. George A. Pettitt to deans, memorandum, 23 March 1949, UCLA Archives, #RS300, Box 47, folder: Medical Education in California 1949–1955. 55. The Master Plan had grown out of a series of studies of California public higher education conducted in the 1940s and 1950s, A Master Plan for Higher Education in California, 1960–1975 (Sacramento: California State Department of Education, 1960); Glenn S. Dumke, “Higher Education in California,” California Historical Society Quarterly 42, no. 2 (1963): 99–110. 56. Sidney Roberts et al. to Franklin D. Murphy, 2 April 1962, in Report of the Ad Hoc Committee on Nursing, UCLA Archives, Collection 401, Box 11, folder: Nursing School 1960–1964. 57. Edna Fritz to Elmer Learn, 1 September 1966, University of Minnesota ­Archives, President’s Office, collection 841, Box 231, folder: Medical School, School of Nursing, 1960–1969. 58. Edna Fritz to O. Meredith Wilson, 30 September 1966, President’s Office, collection 841, Box 231, folder: Medical School, School of Nursing, 1960–1969; “Recommendation for Establishing Consultative Support and Continuing Education Services.” The first two associate degree programs in Minnesota were established in 1964 at Hibbing Junior College in Hibbing and St. Mary’s Junior College in Minneapolis; by 1969 there were four ­associate degree programs in the state. See Fahs and Barchas, Nursing in the Upper Midwest, 5. 59. Hassenplug, UCLA School of Nursing’s Founding Dean, 277–79. WICHE was enacted in 1953 by the Western states of New Mexico, Montana, Arizona, Utah, Oregon, Wyoming, and Colorado as a way of efficiently coordinating and sharing resources among the states’ higher education systems. WICHE was focused in particular on ensuring that the states without their own health science schools could work with their Western colleagues to ensure that enough health care professionals would be produced for the entire region. California joined the compact in 1955. 60. Fahs and Barchas, Nursing in the Upper Midwest. 61. Jerome P. Lysaught, An Abstract for Action: National Commission for the Study of Nursing and Nursing Education (New York: McGraw-Hill, 1970); Ruth M. Lunde to Isabel Harris, 11 February 1971, University of Minnesota Archives, School of Nursing Collection, Box 31, folder: 512 Planning for Rural Nursing.

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62. Stanley J. Wenberg to Lyle French et al., 7 May 1971; and Verne E. Long to Stanley J. Wenberg, 29 April 29, University of Minnesota Archives, President’s Office, collection 841, Box 231, folder: Medical School, School of Nursing, 1971–1980. 63. William G. Shepherd, Statement to the School of Nursing Faculty, 22 March 1968, Office of Vice President for Academic Affairs, Box 30, folder: School of Nursing Review of Program 1967–1968. 64. Ibid. 65. Sime interview with Tobbell, 16. 66. Weise interview with Tobbell, 21. 67. For a fuller description of the emergence of AHCs, particularly at the University of Florida and the University of Rochester, see Fairman, “Context and Contingency,” 54–85. 68. Hassenplug, UCLA School of Nursing’s Founding Dean, 332. 69. Marks interview with Tobbell, 43.

Dominique A. Tobbell, PhD Program in the History of Medicine University of Minnesota 505 Essex Street, SE 510A Diehl Hall Minneapolis, MN 55455

“It’s Been a Long Road to Acceptance”: Midwives in Rhode Island, 1970–2000 Simone M. Caron Wake Forest University

Abstract. A resurgence of midwifery came to Rhode Island in the 1970s. Midwives acted as modern health care professionals to conserve a traditional woman-centered birth, but the battle was long and arduous, from Dr. Ellen Stone attempting to eliminate midwives in the state in 1912 to doctors using the death of 2 home birth infants in the 1980s to undermine the growing presence of professional nurse-midwives in the state. Midwives prevailed when the state legislature passed measures in 1988 and 1990 increasing the power and authority of midwives, and when a federal grant in 1993 allowed the University of Rhode Island to open the first training program for nurse-midwives in the state.

In 1971, the American College of Obstetricians and Gynecologists (ACOG) endorsed nurse-midwives. Four years later, the first such nurse-midwife came to Rhode Island. Mary Dowd Struck received her bachelor’s degree in nursing from Salve Regina University in Newport in 1968, where she was a student of Carol Reagan Shelton, a Sister of Mercy from 1955 to 1970 and later a ­professor of nursing and a women’s health activist.1 Struck earned her ­master’s degree in nurse-midwifery from Columbia University and certification to practice from the American College of Nurse-Midwives in 1973. She attempted to procure a license to practice midwifery in Rhode Island but was unable to do so. The last time the state had licensed a midwife was in 1934; the state legislature had not updated the statute since then.2 Struck’s efforts initialized the revitalization of the lost practice of midwifery as a modern profession in Rhode Island. She joined with the Rhode Island Women’s Health Collective (RIWHC) as modern agents to conserve a traditional woman-­centered birth and to promote women’s health. They encountered resistance from the Rhode Island Medical Society (RIMS), whose members felt threatened by women as medical competitors. Two factors led to the ultimate acceptance of Nursing History Review 22 (2014): 61–94. A Publication of the American Association for the History of Nursing. Copyright © 2014 Springer Publishing Company. http://dx.doi.org/10.1891/1062-8061.22.61

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midwives as legitimate health professionals: a shortage of obstetricians and a well-­organized campaign by the RIWHC that was able to take advantage of consumer demand for more birth options. Much has been written on experiences of midwives in the rural South and, to a lesser extent, in Wisconsin, Chicago, and the Harlem neighborhood of New York from the Progressive Era to World War II. Scholars have found that African-American midwives in the South from 1920 to 1950 were crucial in spreading health care to indigent women and children in rural areas, and ­helping public health nurses establish clinics, immunization programs, and prenatal and postnatal care. Some scholars have concentrated on ­Mexican American midwives in the Southwest or Japanese American midwives in Hawaii, and the balance between cultures these women worked to achieve.3 Laura Elizabeth Ettinger addresses the development of nurse-midwifery as a profession from the 1920s through the 1960s.4 What is not as common is work on urban New England in the latter part of the twentieth century. This article examines the emergence in Rhode Island of a new breed of professional nurse-midwives in the 1970s, the resulting backlash from obstetricians, and the ultimate working relationship between doctors and midwives by the 1990s. Rhode Island provides an opportunity for a microanalysis of the transformation of nurse-midwifery into a respected element of health care.

Early Regulation and Organization State regulation of midwifery in Rhode Island began in the early twentieth century. In 1912, Dr. Ellen Stone worked to eliminate midwives in the state but was unsuccessful for two reasons: the state had a shortage of trained obstetricians and cultural barriers between the large immigrant population and white elite doctors led many pregnant women to seek out midwives from their own ethnic community. Stone employed scientific investigations in keeping with progressive reformers to advance her agenda: she investigated conditions and educated the public about the “problem” of midwives, portraying them as ignorant, unclean, and superstitious. She then called on legislators to solve the problem: if the state depended on midwives, the state should regulate and license them.5 With regulation in place in 1918, the rhetoric of the “evils” of midwifery subsided, and the State Board of Health wrote positive reports on midwives’ skills throughout the 1920s. By the mid-1930s, the trend toward hospital births hit Rhode Island as it did across the nation, and the number of midwives declined as it did across the Northeast and ­Midwest.



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­ idwives  ­virtually disappeared from public discourse and state health deM partment reports on maternal and infant health. Although numerous factors played a role in this decrease, the growing notion of midwives as relics of an outdated past in an era of “modern” hospital birth was central. When Struck attempted to gain a license in 1975, only two midwives were licensed in the state. Both were elderly lay midwives whom the health department had given grandfather rights to renew their licenses annually, although Adeline Denerisie of Warren had not attended births for years. Lillian Aronne of Bristol (Denerisie’s niece) was highlighted in a 1976 story in the Providence Evening Bulletin as “the last practicing midwife in Rhode Island.” She had moved to Rhode Island from New York, where she had received her midwifery license and had practiced in Chinatown and the Bowery. Aronne had delivered more than 3,000 infants throughout the state, including ­Shelton’s third child, born at home in 1976. Dr. Joseph E. Cannon, state director of health in the 1970s, opposed lay midwives as relics of the past. In fact, the same day the Bulletin ran the Aronne story as the last midwife, another article announced her retirement, clarifying that the state would not issue new licenses to lay midwives.6 Whether the state forced her to retire or she decided to do so given her age and the writing on the wall is not clear. Aronne disagreed with Cannon. She argued that “trained and experienced midwives have a very good track record.” Women preferred the “comfort of having their babies delivered at home, in familiar surroundings. It was that way for generations . . .; women have been taking care of it for years and years and years.” Modern medical advancements boasted high-tech machines, but such gadgets were unnecessary “if doctors know what they’re doing . . . . It’s no wonder some of them keep getting sued. They’re meddling with nature. I don’t and I’ve never had to worry about being sued.” The reporter supported Aronne, arguing that midwifery was making a comeback, evolving from “the commonplace to the peculiar and into the nearly fashionable.”7 This evolution had been taking place slowly. Dr. Grantly Dick-Read published Childbirth Without Fear in 1944, which questioned the dominant paradigm that birth was pathological posed by Dr. Joseph DeLee in his prominent obstetrical text of 1921.8 Elisabeth Bing and Marjorie Karmel cofounded Lamaze International based on notions advanced by Dick-Read and on the theories of Ferdinand Lamaze and Pierre Vellay on breathing as a means of relieving pain.9 Interest in natural childbirth as well as in decreasing infant mortality led to early education programs to train midwives: the Manhattan Midwifery School opened in 1925, the Maternity Center Association in New York launched the Lobenstine Midwifery School in 1931, and the Frontier Nursing Service inaugurated the Frontier Graduate School of Midwifery in

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Kentucky in 1939. By the 1950s, seven such schools existed, including the major university medical centers of Columbia, Johns Hopkins, and Yale.10 In 1944 the nurse-midwifery section of the National Organization of Public Health Nursing further challenged DeLee’s notion, promoting childbirth as normal, not pathological. In 1955 the American College of Nurse-Midwives (ACNM) incorporated as the professional organization with the Bulletin of the American College of Nurse-Midwifery as its official organ, and ColumbiaPresbyterian Hospital allowed nurse-midwives to deliver infants—the first mainstream medical institution to do so. By 1970 ACNM certification in nurse-midwifery educational programs emerged.11 The women’s movement coalesced with the drive for patients’ rights and for homeopathic and natural alternatives to allopathic medicine, leading to momentum to demedicalize and deinstitutionalize childbirth.

The Push for Change in Rhode Island National developments in feminism, patients’ rights, and natural birth can be analyzed in a case study of Rhode Island. Robert and Mary Jane Bohlen of Foxboro, Massachusetts, formed a chapter of Homebirth, Inc. in 1974; by 1976, New England had nine chapters and 350 members. Cannon found that five to six babies a month were born at home in Rhode Island by 1976.12 Aronne still attended some home births, despite living at the Benjamin Church Manor for the elderly; she continued to be “in demand today by families who want their children born at home.”13 Home births could be attended by a ­doctor, but physicians generally charged $750 plus the cost of an ambulance to stand by in case of emergency.14 Aronne found that “most doctors won’t do it [home birth]. They can’t be bothered. They don’t have the time.”15 With her retirement and the growing demand, three nurses in Rhode Island trained to become certified midwives.16 They gained support from the RIWHC, founded in 1975 by Hillary Ross Salk, Carol Reagan ­Shelton, ­Elizabeth Edgerly, and others as an outgrowth of the Boston Women’s Health Collective. Similar to the latter organization, of which Salk had been a ­member, the RIWHC worked to make the medical profession more responsive to women’s health: they pushed to adopt lumpectomies over mastectomies; to promote research on infertility and menopause; and to question estrogen replacement therapy. The RIWHC became a leading crusader for midwifery.17 With no law to regulate the practice, the Health Department passed an interim ruling that allowed a certified nurse-midwife (CNM) to



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deliver in accredited medical ­institutions as long as the facility’s administrators approved her and she worked under a licensed physician. The lack of legislation, however, made hospitals leery: Rhode Island’s Women and Infants Hospital (WIH), the major maternity center for Southeastern New England, prevented a CNM from delivering an infant despite the interim ruling.18 Yet WIH did respond to women’s demands for changes in birth practices. Rhode Island consumers had begun to patronize Sturdy Memorial Hospital in Attleboro, Massachusetts, because it was homier than WIH, where labor took place in a double room with no shower or toilet and birth occurred in the operating room. Home Birth of Rhode Island pushed WIH to establish the Alternative Birth Center (ABC), which Shelton argued helped change WIH somewhat from an institution concerned with what was best for doctors to one that accommodated women’s demands.19 Renovations brought air-­ conditioned soundproof rooms with access to showers and bathrooms. Each room was “tastefully decorated” to mimic a bedroom rather than an institution, allowing childbirth to be treated “as the family affair that it has always been.” Wayne Worcester, reporter for the Providence Evening Bulletin, believed these renovations along with the move to license nurse-midwives represented “the peak in official accommodation to the home birth movement.”20 At its height in the 1980s, the hospital’s ABC had nearly 200 births per year.21 Medical administrators seemed responsive to women’s desires for a more natural birth atmosphere. A conference in February 1978 at WIH discussed this consumer push for midwives. Dr. Bertram H. Buxton, Brown University professor and ­director of medical education at WIH, argued that teaching hospitals and other health institutions should “integrate” professional midwives “into the reproductive health and care team so that medical students, residents, nurses and others may learn to work with them and use their talents in the most efficient ­manner.” Dorothea Lang, CNM and former president of the ACNM, spoke at the conference. Midwives were crucial, she argued, to prenatal and postnatal care, as well as to “general infant care.” With 80 percent of the world employing midwives for births, “delivery by a midwife is the norm.” A professional midwife was “a key member of the modern perinatal team.” By 1978, approximately 150 nurse-midwives graduated annually in the United States, reflecting the growing demand for their services. By later that year, 46 states, including Rhode Island, allowed them to practice.22 Rhode Island’s own law allowing the practice of midwifery passed in March 1978; it empowered the Health Department’s Division of Professional Regulation to license nurse and non-nurse-midwives who had graduated from a 2-year accredited midwifery school and passed the ACNM ­certifying exam.

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As an alternative, a midwife could demonstrate to the Advisory ­Council on Midwifery, a five-member panel of the Health Department, that she had equivalent education and experience. The Council qualified midwives for licensing and advised the state Health Director on disciplinary matters. Licensed midwives could provide prenatal and postnatal as well as obstetrical care “in cases of normal childbirth,” including performing and repairing episiotomies, in consultation with an obstetrician. Midwives could not perform cesarean sections, deliver breech births, or deliver with forceps. In high-risk cases of high blood pressure, diabetes, severe anemia, drug addiction, or a history of premature labor, the midwife could not deliver but could be present as an advocate and supporter. The law did not require birth to occur in the hospital, although all but one licensed midwife delivered only in hospitals. Homebirths had to ensure immediate transfer capabilities to a hospital should an emergency occur, and midwives had to be backed by an obstetrician on call in case medical complications arose. The law also allowed midwives to provide gynecological services to nonpregnant women: they could perform pap smears and breast exams, treat vaginal infections, and provide prescriptions for birth control and other limited drugs if first approved by the consulting physician.23 The law, according to Shelton, was “progressive” because midwives did not have to be nurses, but over the next decade no midwives who were not also nurses obtained licenses.24 With no educational programs in Rhode Island, nurse-midwives trained elsewhere. Struck obtained her license and practiced at WIH. The Providence Journal not only gave the law positive coverage but also ran supportive articles on midwives. In a full page story in 1978, reporter Bert Wade interviewed historian Judy Barret Litoff of Bryant College, author of American Midwives: 1860 to the Present. Litoff argued that turn-of-the-century obstetricians attempted to eliminate midwives because of economic competition and because critics portrayed most midwives as “inferior” Southeastern European immigrants. The “revival of midwifery” in the 1970s was a result of public acceptance of nursing as an established profession and of midwifery as a mainstay around the world. Wade recommended that interested readers contact Rhode Islanders for Safe Alternative Child Birth.25 One alternative birth option was a new freestanding birth clinic. The first, La Casita, opened in 1951 in Santa Fe, New Mexico, but closed in 1969 because of decreased funding.26 In 1972, Sister Angela Murdaugh, a ­Franciscan nun with a master’s degree in nurse-midwifery from Columbia University, opened a similar clinic in the Rio Grande Valley. It served primarily “poor, migrant Chicano women, barely out of their teens—truly high-risk ­pregnancies,” yet the infant mortality rate was less than half that of the state of Texas.27 The first



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urban center, the Childbearing Center, emerged in New York City in 1979.28 In Rhode Island, New Beginnings: A Free Standing Alternative Birth Center, opened in Warwick in 1981 with Jeanne Fink as CNM and Dr. ­Marguerite Barbara Vigliani as a medical codirector. Dr. Christos H. Erinakes hailed the center as a “safe and viable alternative” that could “help curtail the ever-­ escalating health care costs” because the average stay was twelve hours or less. Yet it closed by 1984, not because of lack of consumer demand, but because of financial barriers. Nurse-midwives employed at the center could not bill directly for their services; reimbursement had to come through a physician.29 To help fill the gap, Shelton, Roberta Hazen Aaronson (cochair of the RIWHC), and other RIWCH members met with administrators at Rhode Island Group Health Associates (GHA) to discuss incorporating midwives into the practice. As Shelton recalled, “the advocacy of the RIWHC going and talking to the powers that be about midwifery really helped get this thing going.”30 GHA recruited Linda Nanni, who had been working at Group Health Association, a health maintenance organization (HMO) with a viable midwifery practice in Washington, DC; health officials in the District of ­Columbia touted this inclusive health care facility based on collaborative practice with physicians as the “wave of the future.” The GHA asked Nanni to bring this model and “energy” to its organization, an invitation she attributed to the RIWHC who were members of the HMO as well. Nanni connected with Christine Pfeifer, a CNM practicing at Kent County Hospital, with whom she created the Rhode Island Chapter of the American College of Nurse-Midwives (RI-ACNM); Pfeifer served as the first president and Nanni as the second. Nanni also encouraged other midwives from the District of Columbia and new graduates from the University of Pennsylvania and Yale University to settle in Rhode Island.31 By 1985, there were 16 licensed midwives in the state. Obstetricians, according to Nanni, “tacitly” collaborated with midwives. Nanni struggled “a bit with individual members of the OBGYN department” at GHA: some male (and female) obstetricians were very supportive whereas others were not. Gradually, physicians “embraced” midwives as an integral part of women’s health care. In the early years, patients could elect to make an appointment with a physician or a midwife; 40 percent chose a midwife. As the obstetric shortage worsened, GHA changed its policy: all pregnant women saw a midwife for their initial consultation and then chose to continue with her or see an obstetrician. Midwives gained 85 percent of patients with this system. Many of these women had not consciously sought a midwife, according to Nanni; in fact, some initially considered them part of a “voodoo” culture that provided “substandard care.” Yet once they met a midwife, they realized that “we were

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reasonable and skilled professionals.” Midwives educated women about their options and made them an “integral part of their own care.”32 The press assisted in this education. The Journal spotlighted Ann Mason, a 51-year-old CNM. When giving birth to her children in the 1950s, she “had to work hard to find a physician who would let” her deliver naturally. Later as a nurse, she witnessed a birth where the doctor so “heavily medicated” the woman that she “didn’t know what she was saying, what she was doing, the medical staff around her was making jokes.”33 In 1974, Mason assisted in a home birth in Providence and realized it “was the best thing,” although she later rejected home births as “needlessly risky.” She studied nursing at Salve Regina College and graduated from Rutgers University with a degree in nursemidwifery in 1983. She obtained a position at OB-GYN Associates in Providence with privileges to deliver at WIH. The goal of the Journal article was to dispel the notion of midwives delivering babies “out in the bush somewhere.” Midwifery was “being with a woman in labor, helping her to be comfortable, avoiding as much technology as possible, but taking good care of the woman and her baby, keeping things as normal and low-key as possible.” The reporter, Elliot Krieger, placed Mason on equal footing with doctors with whom she collaborated: “like the doctors . . . Mrs. Mason has patients of her own. She sees them and examines them throughout pregnancy, attends them throughout the childbirth and gives them full checkups and exams after delivery.” She too had phone calls waken her to attend births in the dead of winter. In the end, Krieger portrayed Mason as a “calm woman” who “talks with great care” and “loves her work.” The tone of the article was positive, demonstrating support for midwifery as a legitimate and professional approach to childbirth. This apparent era of good feeling hit turbulence when the Health Department sponsored a conference on June 29, 1987 to consider nurse-midwives as the solution to the shortage of obstetricians. Numerous obstetricians opposed their practice. Jean Hicks, director of New Visions for Newport County—a health center on Aquidneck Island—said this stance was part of a larger aversion on the part of Newport physicians to expand low-income women’s access to health care; these same physicians refused to accept Medicaid patients because reimbursement caps were too low.34 In South County, obstetricians’ desire “to maintain control of the obstetrical care” led them to “refuse . . . to consider the possibility of working with a nurse-midwife” despite the ­shortage.35 Rhoda Perry, director of the Woonsocket Health Center, faced an “obstetrical crisis” caused in part by the gutting of the federal National Health Service program that had subsidized medical school loans for physicians ­willing to work in health clinics. Perry could only offer ob-gyn services based on the goodwill



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of two private obstetricians in Northwestern Rhode Island. She was afraid to approach them to serve as consultants to practicing midwives as well as to ask Woonsocket Hospital to grant delivery privileges to midwives because she believed such a request would alienate them, leaving her with no doctors to serve her low-income patients. When Dr. John Murphy, president of the Rhode Island Chapter of the American College of Obstetricians and Gynecologists (RI-ACOG), pointed out that these two obstetricians would be overwhelmed with approximately 800 births in 1988, Perry responded that she was “sensitive to what” he was saying, “But I also know the political situation in my community and how doctors in the community feel.”36 CNMs could ease the shortage, “but the latter is still viewed with skepticism by most healthcare providers.”37 Although Perry supported midwives, she was unwilling to challenge the existing power structure in the Northwest region of the state. Yet the conference drew numerous advocates for the expansion of the use of midwives. The keynote speaker was Pixie Ellsbery, director of the nursemidwife obstetrical service at North Central Bronx Hospital, where Shelton had conducted her dissertation research while a graduate student at Brandeis University. Ellsbery’s program helped reduce low birth weight—a key factor in infant mortality—from as high as 17 percent for the Bronx as a whole to 8 percent for infants born with midwives in her program in 1986; this improvement came despite the fact that her program served primarily “poor” ­clients, 25  ­percent of whom had drug abuse complications. Ellsbery’s program employed 25 nurse midwives backed by fourteen obstetricians for high-risk births. Roberta Hazen Aaronson, professor of social welfare and women’s studies at Southeastern Massachusetts University, argued that midwives would not only solve the shortage of doctors but also offer women a safe and natural alternative to high-tech, male-centered birthing practices. The audience of nearly 100, primarily women, supported midwives because they believed the care they received was more personal and comprehensive than with doctors. Midwives’ approach was more holistic, with not only prenatal care but also with nutrition, exercise, and general encouragement to a healthy life during and after pregnancy.38 This appeal and the shortage led to an increase in midwife-assisted births from 122 births (less than 1%) in 1983 to 1,094 births (7%) in 1988.39 The tension between opponents and advocates of midwifery deepened over proposed legislation in 1988. Representative K. Nicholas Tsiongas, the only physician in the state legislature, had worked with Aaronson earlier on a bill to cover medical costs of uninsured pregnant women. He came ­forward to champion the midwifery cause. As a “progressive” legislator in “good standing with the leadership” and a Democrat in a heavily Democratic state, he was a ­respectable advocate who “really stuck his neck out” for midwives.40

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He ­discussed with Aaronson in February 1988 two bills he planned to introduce: one would allow direct payment by health insurers to midwives rather than have them act as salaried employees of an HMO or work under contract through supervising obstetricians, thereby allowing midwives to practice more independently; the other would allow midwives to prescribe limited drugs without prior obstetrician’s approval. These two ideas had been priorities of the RI-ACNM. Aaronson wrote to Christine Pfeiffer, president of the RI-ACNM, to suggest the chapter hire Aaronson to coordinate a lobby for the campaign “to give more autonomy” to midwives.41 Nanni recalled that ­Aaronson was a “politically savvy” lobbyist: “she was right on the ball because she was so immersed in the issues.”42 While prioritizing improvements in women’s health care, Aaronson adjusted additional rhetoric depending on the target audience. She emphasized the shortage of obstetricians to concerned legislators: in 1984, there were no midwives at GHA; in 1988 nine midwives there delivered 60 ­percent–70 ­percent of all deliveries; across the state, there were only 2 midwives in 1978 but 17 by 1988, who delivered 10 percent of all babies.43 Aaronson adopted a different tactic—the cost-effectiveness of midwives—when addressing insurers and other business interests: midwives had lower caesarean rates and shorter hospital stays, and the Institute of Medicine found them “particularly effective” in preventing low-weight births.44 “Quality of care for women” was the main motivation for Shelton, not the shortage or cost-effectiveness, but she realized the usefulness of this rhetoric in gaining allies for their cause.45 In addition to the “highly proactive stance” of Tsiongas, Aaronson coordinated a campaign that included several organizations,46 “influential people,” and “satisfied customers.” State Attorney General James E. O’Neil lobbied on behalf of the bills; his wife had had three midwife-attended births. The CEO of Ocean State Health Maintenance Organization agreed not to oppose the bills; his wife had had positive experiences with midwives. Joseph ­DeAngelis, Speaker of the House, endorsed the legislation. Some social and health ­service agencies backed the bills in part because 40 percent of obstetricians in the state refused new Medicaid patients but midwives accepted them. Many ­patients of midwives called and wrote to representatives and descended on the state house during the hearings. “Their actions,” according to Aaronson, “were probably the campaign’s most effective aspect because of the power of many voters lobbying their senators and representatives in an election year.” The ACNM lent its mantle of respect, launching an educational campaign among legislators to dispel myths and point out the positive impact of midwives on maternal and infant health.47 At the hearings, the RI-ACNM argued that the bills “would be instrumental towards solving the obstetrical crisis in the State.” Dr. Christos H. Erinakes testified about his seven years working with ­midwives



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in Kent County; they deserved “due recognition and fair reimbursement for their services as does any professional.” CNMs were the “best providers of care for the normal childbearing family.” Passage of the bills would allow the state to recruit more CNMs to “fill the gaps presently existing in the obstetrical area” and to develop freestanding birth centers as a low-cost “safe and viable alternative to . . . ever-escalating health care costs.”48 Despite this support, the RIMS was steadfast in its opposition. Blue Cross lobbyist Joseph Scanlon joined the RIMS, arguing that direct reimbursement would cost more money and no consumer demand warranted coverage of midwifery services. In response, Aaronson mobilized other RIWHC members to write Douglas McIntosh, President of Blue Cross, demanding direct reimbursement. They also secured an economist to testify at the hearing about the “possibly self-serving nature of physician opposition” and the costeffective nature of midwives in prenatal and birthing care. Aaronson organized meetings with the state’s two largest insurance companies—Blue Cross and Ocean State Health Maintenance Organization—to emphasize that 20 states already allowed reimbursement, as did Aetna, Prudential, CHAMPUS, and ­Medicaid. These meetings “effectively neutralized” insurance opposition.49 Although Journal reporters continued to support midwives, at least one editorial staff member opposed the empowerment of midwives. “Everyone is agreed that the shortage of obstetricians is a problem in our state and that something should be done about it,” the editorial argued. “But increasing the powers of midwives, as two bills currently in the House recommend, does not seem to be the answer.” The root of the opposition was “many physicians’ fear” that the bills would encourage midwives to deliver babies independently. Implied was the threat to obstetricians’ revenue stream. Qualms about economic loss were couched in a safety framework, alleging that midwives would injure mothers and infants: the bills were “potentially harmful” because they would enable “less qualified people” to control births and would “increase unsupervised, home or non-hospital births.” The editorial claimed “not . . . to denigrate midwives,” but that even “the most gifted midwife is helpless in the face of a medical emergency in a private home without hospital equipment. A physician on call, which would still be required, is often not enough.”50 The irony of this editorial is that despite the law, which allowed for home births, only one licensed midwife attended home births; all others delivered in hospitals. Although the editorial rejected Tsiongas’s bills to empower midwives, it endorsed another bill by Tsiongas to provide $12,000 a year toward medical school loans to doctors willing to practice in one of the state’s 14 health clinics to avoid “an imminent crisis in obstetric care.” This crisis ­resulted from a large percentage of obstetricians who refused to accept new

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Medicaid patients or practice in clinics, and from the dismantling of the ­National Health Service program that had subsidized medical students willing to work in clinics.51 Replacing this national program with a state program, according to the editorial, “seems a much healthier way of trying to solve the obstetrician shortage.”52 Dr. Richard G. Bertini, president of the RIMS, thanked the editors for their “balanced and perceptive editorial” on addressing the obstetrical shortage not by empowering midwives but “by attracting more obstetricians.”53 This tactic also allowed doctors to maintain their tight grip on control, power, and income. Advocates of the bills also penned letters. Carol Reagan Shelton, by this point Assistant Professor of Nursing and Women’s Studies at Rhode Island College and doctoral candidate in public policy at Brandeis University, wrote to express her dismay at the Journal editorial. It endorsed an outdated view of a midwife as an “uneducated, peasant woman who delivers babies at home” while perpetuating the belief that births must take place with a doctor, a belief based on “long-standing propaganda.” She argued that “the demise of midwifery during the early decades of this century arose out of a well-organized anti-midwifery campaign supported by the medical community” more concerned with “power, control and financial remuneration, and less out of concern for the public health of women and children.” This same tactic was being employed again now that midwives pushed for more inclusion. Shelton played well the anti-medical establishment card and the growing public disaffection with the medical monopoly doctors had achieved and were desperate to maintain. She offered a sophisticated analysis of the gender power politics at play, appealing both to feminists and to general readers who were increasingly indignant regarding doctors’ increasing wealth at the public’s expense. She contended, “it seems that medicine will embrace midwifery as long as midwifery knows its place; that is, as long as the relationship is one of dependency and capitulation.” Most industrialized nations placed midwives at the center of state-sponsored maternal/child health care systems; the United States was an exception, and the nation ranked seventeenth in infant mortality among these nations. Midwives and doctors should be working together to save infants, not bickering over compensation and control. Shelton criticized both the RIMS and the RI-ACOG for falsely claiming the bills would increase home births; nothing in the legislation suggested such a trend. Shelton concluded that with infant mortality as the mark of a nation’s health, the country needed to rely on midwives, “the professional most suited to assist women in the childbirth process.”54 Although some obstetricians supported midwives in theory and in the context of the shortage, few agreed with their usurpation of obstetric expertise.



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A Setback for Midwives: The Death of Two Infants In the midst of this legislative battle, two infants died in home births, the first deaths involving a midwife since licensure in 1978. The Rhode Island Board of Medical Licensure Discipline worked with the Advisory Council on NurseMidwifery, which held hearings to investigate the deaths. An infant born at home in Burrillville on January 24, 1988, was transferred in critical condition to WIH’s neonatal intensive care unit; he died 7 weeks later on March 20. An infant born at home in Exeter on April 7 died later that day after transport by rescue squad to Kent County Memorial Hospital immediately after her birth. The midwife in both cases was Adele Alexandre, a native Rhode Islander who had practiced as a lay midwife before attending the University of Mississippi to attain her CNM degree. She returned to the state and had offices in Providence and Westerly. She was the only midwife of 17 certified in Rhode Island who attended home births; all others attended births in hospitals by choice or employer mandate.55 The midwifery community, according to Nanni, was “very excited” that Alexandre offered a legal home birth option to women, but finding willing physicians to serve as backup was virtually impossible.56 Supporters of Alexandre surrounded her at the hearings and gave testimonies to the press. As Nanni argued, home birth advocates, although a small group (only about 2% of births took place at home), were “loud and active,” leading to an “outcry from the home birth community whether they knew her or not.”57 Tom O’Brien, a 33-year-old carpenter, and Barbara Daily, a 29-year-old midwife in training under Alexandre, had their son born at home with Alexandre. Daily told reporters, “we would do it again and we would choose the same midwife.” O’Brien agreed: “We couldn’t have gotten the kind of personalized care we got in any other way.” Hope Moffat, a 24-year-old mother whose son was born with Alexandre, took the opportunity to criticize the medical monopoly on hospital births: “I would just like the powers that be in the community to know that there are people who are confident of the ability of midwives to provide competent care outside an institutional setting and without a doctor on the premises.”58 Karen and Joseph Escher had Alexandre attend the birth of their son in January 1988. As Karen stated, home was “the natural place . . .; doctors see pregnancy as not really natural any more but a problem that they have to take care of in the hospital.” Joseph concurred, adding, “The more we read about it, the safer we thought it was to have him at home. There was a lot less intervention.” Karen’s father supported home birth, arguing that “modern” medicine viewed birth as “some sort of medical malignancy that can only be dealt with by a doctor in a hospital with millions

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of dollars’ worth of modern equipment.” Rhonda Rockwell of Peace Dale had delivered three of her children in the hospital but Alexandre attended her fourth at home. In the hospital, Rhonda felt “like a card and a number. The doctor’s just there to catch [the baby] and then run.” She acknowledged the need for some hospital births but believed home birth should be an option for women with uncomplicated pregnancies.59 Three of the activists for empowering midwives had home births: Aaronson had her second child at home; Shelton had Alexandre attend her fourth child’s birth in 1979; and Nanni had her first child at home, although she delivered her second child at the ABC because birth there was as noninterventionist as at home.60 Couples choosing this option were concerned with control over their birth experience, the desire for less invasive procedures, and the conviction that birth was natural, not pathological. Most home births occurred without incident. These two deaths, however, spotlighted midwifery and home births in particular, leading other midwives in the state to be “gravely concerned” that the tragedies would undermine progress midwives had been making. Infant deaths during births attended by physicians were individual misfortunes that did not reflect on the doctors’ skills, yet deaths with a midwife reflected poorly on all midwives. Nanni feared the public would not realize that these deaths were unprecedented. Dr. H. Denman Scott, director of the State Department of Health, believed the deaths could lead to a tightening of the regulations to prohibit midwives from delivering infants at home.61 Donna Policastro, a nurse and activist, believed Alexandre’s actions threw a “wrench in the political wheels.” Although Aaronson argued that Alexandre had “some good skills” and was “a pioneer,” she was “the wrong type of person to set up her own practice” because she was “not the most organized person.” Shelton concurred: Alexandre was “competent but careless with paperwork and that really did her in.” She spent more time with her patients than with forms and documents, which led her to have a “lot of supporters.” That none of the parents of the infants who died sued Alexandre was “telling.”62 The RIMS “absolutely” used these deaths, shamelessly some claimed, to challenge the bills before the legislature.63 Dr. Donald R. Coustan, director of maternal and fetal care at WIH, met with Newell Warde, PhD, spokesperson for the RIMS, to discuss the “folly of homebirth.” Warde “adamantly opposed” home birth, as did Mark Montella, another RIMS lobbyist.64 Warde “directly linked” these two deaths to the bills under consideration, arguing the deaths legitimated RIMS opposition to the legislation.65 Tsiongas, a doctor himself, “blasted” the RIMS for this tactic. Warde’s assertions, Tsiongas argued, “were misleading and self-serving comments by the medical society.” His bill did not loosen the requirements for midwives to work in ­consultation with



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o­ bstetricians in the event of complications. Tsiongas contended that RIMS resistance had less to do with safety issues than with economic self-preservation: allowing midwives to practice with direct compensation and with the ability to prescribe limited drugs would encourage more midwives to settle in Rhode Island, thereby undercutting obstetricians’ practices and thus their incomes. Dr. Thomas A. Vest, chair of RI-ACOG and obstetrician from West ­Warwick, found Tsiongas’s assertion incredible given the shortage of obstetricians in the state: “We are all too busy as it is. I can’t think of any obstetrician who is twiddling his thumbs.” RIMS president Dr. Richard G. Bertini argued that he, Vest, and Warde opposed the bills because they believed such laws would weaken the consultative relationship between doctors and midwives and encourage home births, which they considered dangerous to both mother and infant. Coustan concurred: what frightened him most about home births was the possibility of “disasters or near disasters” in healthy women that could develop within minutes an acute catastrophe, such as postpartum hemorrhage or strangulation in the birth canal, emergencies that could “happen both at home and in the hospital” but in the latter setting doctors could “deal with these things more quickly.” Nanni accused these doctors of misrepresenting what they knew to be the intent of the bill. “This home birth issue is being sensationalized,” she argued. “With the passage of this bill, we are not going to be practicing any differently than we do now. It is a reimbursement issue solely. We are committed to working in licensed health care facilities—hospitals and birth centers . . . [and] to consulting and collaborating with doctors when needed.” Linking the bills with the infants’ deaths was a ploy to contest legislative change.66 Although this battle over legislation continued, the investigation into the deaths proceeded. The Advisory Council on Midwifery, chaired by Mary Dowd Struck with Nanni as a member, met behind closed doors with armed guards from the Capitol Police; the Health Department requested police protection after crowds showed up in support of Alexandre, along with reporters and television crews from three stations. She faced no criminal charges.67 On advice from her lawyer Jennifer Wood, Alexandre refused to testify.68 Struck sent a recommendation approved by the Council by a four-to-one vote to Dr. Scott, calling for the revocation of Alexandre’s license.69 Scott upheld the decision and revoked her license “for violations of medical practice.” Both infants were full term, of normal weight, with no “apparent abnormalities of their hearts, lungs or other organs.” Both died of asphyxia. Scott confirmed that Alexandre’s records leading up to the birth and the birth itself contained “major league” departures from standardized medical care. Moreover, she failed to work in consultation with an obstetrician as required by law. Although she listed Dr. Jan Penkala for the Burrillville case and Dr. ­Marguerite

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Vigliani for the Exeter case as consulting obstetricians, neither doctor had been contacted during the pregnancy or birth. Alexandre’s records demonstrated that both mothers had developed health issues early in their pregnancies that precluded them from safe home births; in fact, Scott argued that Alexandre should have referred them to the high-risk unit at WIH. ­During labor, the Exeter mother developed high blood pressure while the fetal heart rate slowed irregularly: such symptoms, according to Scott, should have led to immediate hospitalization. In the Burrillville case, the mother suffered from ulcerative colitis as well as anemia. Moreover, her water had broken 30 hours earlier, yet ­during this 30-hour period Alexandre did not record temperature, maternal blood pressure, or fetal vital signs. The records indicated, according to Scott, that “the progress of labor was clearly abnormal, yet no medical consultation was obtained and she was not transferred to a medical facility.” In neither case did Alexandre record what had transpired during the birth.70 The Council’s investigation of Alexandre was not her first time. Early on, she practiced as an unlicensed lay midwife. After she obtained a license in 1985, the Council brought her in later that year for not working “in an acceptably close consultative relationship with a doctor.” The Council “reprimanded” her but allowed her to keep her license. Irene Wielawski, the medical reporter for the Providence Journal who covered Alexandre and the infants’ deaths, concluded that Health Department officials had “little power to prevent her” from returning to practice without a license unless they could prove she was officially attending births.71 Given the number of supporters who turned out at her 1988 hearings, she probably could have continued to attend home births among couples willing to swear the birth took place at home by accident. The Alexandre case led to a debate over birth and the role of the state. The revocation of her license eliminated the only legal home birth attendant, a fact that saddened the midwifery community given the number of couples “philosophically committed to home birth.”72 Supporters considered the state censuring of Alexandre as an “attack on home birth.”73 Some called it a “witch hunt”: Shelton believed the media purposely used “absolutely unattractive” pictures of Alexandre who was a “heavyset woman” to hark back to nineteenth-century “immigrant midwives” and reinforce “old stereotypes.”74 Nanni ­considered her “an odd duck” and “a loner” who did not participate in the peer review process that had been established to keep practitioners honest. She thus “let us down” because the midwifery community had supported her but now felt “somewhat betrayed”; the deaths “soured” the public, state, and medical community on homebirths.75 Others turned their anger at the Advisory Council on Midwifery, labeling it a “kangaroo court.” Some condemned doctors, believing economic



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motivation drove the attack: the “medical establishment” was simply “worried about losing money to midwives.” The Council saw the situation differently, insisting that eliminating the home birth movement was not their intent. Struck reiterated that the investigation dealt with the malpractice of an individual midwife: “Whether she was practicing at home or in a health care facility, her practice was substandard and her outcomes would have been poor.” Scott concurred: The risks were so substantial with this midwife that we had no other choice but to take this action. All of her patients have to know that this is the judgment of her peers and those who reviewed the record.76

Judy Judson, a certified childbirth educator, was “satisfied with the decision to revoke Alexandre’s license” because CNMs must screen patients carefully and call doctors at the first sign of a problem. That “Alexendre didn’t practice this way is shameful and frightening.”76 Officials acknowledged that Alexandre was part of a growing home birth movement since the 1970s, but much of this growth occurred extralegally. Practicing midwifery without a license was a felony, yet between 60 and 80 home births a year occurred in the state, with many couples not asking the midwife whether she was licensed. Struck witnessed approximately six babies or women rushed to WIH annually as a result of home birth complications by an unlicensed midwife. Although hospital personnel contacted officials, prosecutions did not follow because proving a home birth as the intent was too difficult: women claimed their sister or mother delivered the infant, or that the birth came on too suddenly to drive safely to the hospital. These women often fabricated such stories to protect the unlicensed midwife from prosecution.78 Advocates of midwives looked to accommodate couples who preferred a home birth while providing the security the medical and state officials deemed warranted. As the coordinator of nurse-midwifery services at GHA and spokesperson for the RI-ACNM, Nanni believed home births should be available to low-risk women if they so choose: We feel as nurse-midwives, that a woman has the right to self-determination, and if a woman wants to have the baby at home, and we can find no reason to dis­ courage that, then we need to provide quality care for her at home.

Otherwise women would turn to unqualified substitutes. Her preference, however, was for an alternative birthing center, which was “the best of both

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worlds. It’s a very low-tech, home-like place, but very close to the resources of the hospital if needed.” The growth of such birthing centers reflected hospital attempts to answer women’s demands. The WIH-ABC was a “compromise between home birth and a clinical hospital setting.” Although doctors could use this center, only one did so, leaving it to midwives. WIH also had 16 “LDR” rooms where labor, delivery, and recovery took place in the same setting but within the confines of the hospital. Dr. Samir Moubayed, senior partner at OB-GYN Associates in Providence, had worked with midwives for years and he too wanted to comply with women’s demands, but not at home because there were too many unexpected “disasters or near disasters” that could happen. The birthing centers and LDR rooms allowed the feeling of home with the safety of medical technology if needed. His experience with midwives had “always been very good and very pleasant.” He found them to be “very dedicated women and very professional.” He concluded that “certainly there’s a place for them in obstetrics.”79 Yet the conflict continued between the RIMS and midwives over the two pending bills. Twenty-four representatives from the Midwifery ­Legislation Coalition protested outside the RIMS building on April 25, 1988, to “denounce” the “self-serving” efforts of the RIMS “in spreading misinformation and perpetuating myths about the practice of midwives.” Midwives, they contended, had outcomes “equal to, or sometimes better than, those of ­obstetricians/­gynecologists.”80 Spokeswoman Shelton argued that “it is irresponsible for the Medical Society to imply that physicians are the only health care workers capable of giving quality care, especially in these times of shortages in the obstetrical field.”81 At the hearings, midwives and RIMS “clashed”: Aaronson argued that 21 other states, including surrounding Massachusetts, Connecticut, and New Hampshire, allowed direct reimbursement. Montella, Coustan, and Veset countered that the bill would allow midwives “too much independence” and exacerbate medical problems with deliveries. Representative Neil Corkery (Democrat-Providence [D-Prov.]) reiterated that neither bill would change the mandate that midwives must work in conjunction with an obstetrician. Nonetheless, Coustan contended, it “clearly makes home births easier and more available.” Tsiongas called Coustan’s statement an “unconscionable” misrepresentation of the bills; his legislation would allow midwives to work more efficiently by prescribing certain drugs from a list authorized by the state health director rather than seeking prior approval from an obstetrician, thereby addressing the “crisis in availability of prenatal care.” Direct payment, according to Tsiongas, ­represented “equal compensation for equal work—and that’s what we’re all about in an equal society.” Aaronson argued that the RIMS



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was falsifying the efficacy of midwifery: in countries where midwives played a primary role in prenatal, birth, and postnatal care such as Sweden, Iceland, and Holland, infant mortality rates were lower than in the United States, where obstetricians overwhelmingly dominated the field. Deborah Drew Smith of the RI-ACNM asserted that the RIMS intentionally distorted the purpose of the bill: midwives would continue to collaborate with obstetricians; the bill would simply “give credit where credit is due” for the actual delivery, “upgrade the status of midwives,” and allow midwives to solicit more clients.82 Public support for midwives was obvious in letters to the editors. The Journal published 10 letters endorsing midwives as “specialists” and labeling criticism of them as “outrageous.” Deborah Drew Smith blasted the media for denigrating midwives, portraying their care as “potentially harmful to patients” rather than emphasizing the “high-quality, cost-effective care” they provided. Karen M. Foley of Narragansett lambasted the media for “its ‘backwoods’ prejudice against midwives.” Cynthia Siegel, also of Narragansett, charged that health officials and the RIMS were “so obviously prejudiced against midwives” as to “use this unsubstantiated case against one midwife to buttress their opposition to pending midwifery legislation.” Eleanor ­Howard of Portsmouth wrote “to encourage the practice of, and participation in, midwifery” despite the “unfortunate deaths,” which “should in no way deter our legislators from going ahead with the passage of these bills.” Jillian Van ­Norstrand acknowledged the heartache felt when any infant dies but feared that the RIMS and state officials were using the two infant deaths to launch a witch hunt that ignored “possible environmental factors” that could explain the high infant mortality in the state: “Let’s open our eyes and look at the whole truth, not only the small part of it that those in power would have us see.”83 These women considered the use of the unfortunate deaths as nothing more than gendered politics in a power play to leave male authority intact. Three days later, Philip Terzian, editor of the editorial pages of the ­Providence Journal, wrote an Op-Ed column in which he equated midwifery with uncivilized and backward behavior. Midwifery struck him as “foolish, and home birth as irrational.” Childbirth at home was “a matter of gambling against treacherous medical odds—and no amount of piped-in music, wicker furniture, interested neighbors, or video recorders can mitigate the perils for mothers.” If mothers’ lives were the only ones at risk, he would not oppose midwives, but “as the case of the defrocked midwife sadly illustrates, it is usually the infants who assume liability.” In addition to his safety concerns, he considered the issue to be a battle between the sexes for control. Women ­contended that male control of obstetrics and gynecology subjugated women, an argument he could not “seriously believe.” Doctors opened themselves up

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to this conflict by “radically” changing their image from “the kindly general practitioner . . . who would sit through the night with a dying Uncle Fred, to Ivan Boeskys in white: rushed, unsympathetic, squeezing every penny from a multitude of customers.” Midwives positioned themselves to fill the emotional vacuum left by doctors’ cold bedside manner: they were in the “business of holding hands, offering comfort, and relieving distress.” The existence of midwifery advocates did not make choosing this option “valid or sensible. Zeal, after all, is no substitute for judgment.” Women’s rejection of medical technology for midwifery was “disturbing and astonishing in a civilized world.”84 Other journalists entered the fray. Mark Patinkin, author and nationally syndicated columnist for the Journal, adopted a middle ground position. He opposed home birth because unexpected problems could arise, such as evidence of meconium that had occurred in his own wife’s experience the previous month. The hospital was able to employ “the most sophisticated suctioning devices” to ensure a healthy live birth for their infant. In comparison, one of the infants who died at home with Alexandre also had meconium present; the official report stated it was a “key factor in its death.” Although he respected the “loyalty” of Alexandre’s supporters, he believed it was misplaced. Instead, supporters should admit mistakes were made that had “tainted” not only Alexandre but also “all midwives in the state.” He cautioned readers to recognize that midwives were “not a strange holdover from a more primitive time” but were “certified professionals” who offered “a legitimate choice. They are not the issue here. The issue is home birth.”85 Alan Rosenberg, the assistant features editor of the Journal, ignored the latter issue and submitted an Op-Ed piece describing his personal experience with a midwife who attended his son’s birth at the ABC at WIH. He wrote to dispel the extraordinary amount of nonsense being talked about midwives by people who . . . have never met one, don’t know anything about them, and don’t particularly care to know. Such people, comfortable in their prejudices, label midwives ‘amateurs’ lost in a world of professional medical practitioners.

The midwife who assisted his wife held a master’s degree, kept as metic­ ulous records as any doctor would, and monitored both maternal and infant health throughout the pregnancy. He appreciated being part of a “team” that worked together to bring about a positive birth experience.86 Dr. Herbert Rakatansky, former RIMS president, disagreed. He wrote that efforts to expand the role of nonphysicians in medical care represented “a regression in attempts to improve the quality of care” because proposed new regulations “would allow persons with less education and training” to



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fulfill duties that should be carried out by doctors. He warned that if the bills passed, Rhode Islanders could “expect a decrease in the general quality of care available.”87 His letter attempted to undermine advocates’ notion that midwives would help decrease maternal and infant mortality by providing care to underserved populations of women. A few weeks after this spate of editorials, the direct reimbursement bill failed. Although the House overwhelmingly approved it, the Senate Health and Welfare Committee rejected it because of strong opposition by the RIMS and the state health department. Several reasons explain the defeat. Scott had met with Aaronson and other advocates and had initially agreed to remain neutral on the bill, but ultimately he “assumed an adversarial position” when it reached the Senate because, according to Aaronson, “he believed that it was inconsistent with the team approach to health care delivery and that physicians would no longer head the obstetric team.”88 In addition, the midwifery coalition’s “shoestring budget” was not enough “to take on the medical establishment and their full-time lobbyist.”89 The tragic deaths of the two infants influenced some senators to oppose the bill. For others, the bill upset the apple cart regarding health professionals. Senator James S. D’Ambra (D-Prov.), for example, pointed to physical therapists, psychologists, opticians, dieticians, and physician’s assistants who had submitted similar bills to increase their professional status with direct reimbursement. The RIMS thus felt under siege. Aaronson concluded that “It was inevitable that the medical society would oppose the bill. It was a turf battle with the doctors.” She was especially upset that Scott “double-crossed” them, but she vowed to regroup and develop “strategies for diffusing the home birth issue” the following year.90 One small victory was the passage of the second “less controversial” bill that allowed midwives to prescribe medicines from an approved health department list.91 The House HEW Committee attributed the victory to “the most visible grassroots lobby” seen for quite some time.92 In addition, neither the RIMS nor the health department opposed the prescriptive bill.93 One year later, the bill for direct reimbursement was again before the Senate Health, Education, and Welfare Committee. By 1989, there were 18 licensed midwives, all of whom delivered in hospitals, not homes. Aaronson organized a letter-writing campaign. Proponents of the bill argued that it would lend “greater professional status” to midwives; “address the lack of obstetrician availability”; increase medical care “to the indigent”; and decrease health care costs. Six physicians sent letters: five worked at GHA and the sixth was in private practice in Warwick with two CNMs on staff, including ­Christine Pfeifer. Two of the doctors had employed midwives for their own births. ­Lieutenant Governor Roger N. Begin wrote that legislators should recognize “­

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­ urse-midwives as a full partner in the health care system.” Michael F. Moore, n Senior Vice President of Client Services at Potter Hazlehurst and father of a child born at home, argued that physicians opposed the bill because “they look at midwives as competition” given that they proved “more cost effective maternal and infant health care.” Moreover, the bill would lower the “shockingly high Cesarean section rate” and infant mortality. Aaronson emphasized a legal concern: obstetricians signed insurance forms for babies not delivered by them but by midwives. Similarly, Cynthia D. Burke, consumer representative on the Advisory Council on Midwifery, criticized the current arrangement as “unethical” because the RIMS delegated medical responsibility to another profession yet maintained financial compensation. Professor Elton Rayack of the University of Rhode Island extended the critique to the American Medical Association, which attacked “legitimate” health professionals who represented “a competitive threat to the medical profession.” Rayack cited a 1980 antitrust case in which the U.S. Court of Appeals found that two insurance plans in Virginia violated antitrust law because they mandated reimbursement for psychologists be made through a physician.94 Dr. Tsiongas, again the sponsor of the bill and still the only doctor in the state legislature, framed the argument in an equal rights perspective. Midwives delivered a “great number of births in Rhode Island” and deserved compensation from insurance companies in the same manner as doctors. Midwives would still collaborate with doctors in difficult cases, but they should be allowed to establish their own practices rather than work under doctors’ financial control.95 The RIMS “vigorously opposed” the bill and, once again, it failed to pass.96 The RIMS attributed its defeat to “the midwives’ refusal to compromise” on the RIMS’ amendments to preclude reimbursement for home deliveries and to mandate at least one prenatal visit to the collaborating physician.97 The coalition ascribed the defeat to the RIMS’ desire to “maintain an economic monopoly” and to keep “women in their place.”98

Legislative Success and Empowerment By 1990, midwives were victorious when the legislature finally approved direct reimbursement. Compromise with the RIMS was largely responsible for the change: the law prohibited reimbursements for home births. With this amendment, “the powerful Rhode Island Medical Society withdrew its longstanding opposition.” The “bruising battles” with the RIMS over the law brought “new legitimacy” to midwives.99 Not everyone agreed with the ­compromise, but



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Aaronson reflected that without it the bill most likely would not have passed. She “did not have a difficult time agreeing” because she tended to be “pragmatic.”100 Other aspects played a role in the victory as well. During this third year of the campaign, the director of the health department “appeared” to drop the issue because of more pressing concerns such as budget cuts as well as effective “neutralization” of the “vocal and visible opposition of the insurance companies” by the RIWHC coalition. Aaronson made “no contact with him during the 1990 campaign year so that he would not be reminded of the issue.”101 Aaronson also worked to get the bill before different committees headed by chairs strongly in support of it even though the bill did not technically belong before them: the Senate Corporations Committee and finally the Senate Finance Committee. Senator John Richard Patterson represented the district in which Aaronson lived and “had enough clout to ask for the bill” before his Finance Committee. He did not care about the issue but was up for reelection against stiff opposition and thus helped get the bill passed because he “was interested in pleasing his constituents.” Lastly, Aaronson admitted the shortage of obstetricians “probably helped.”102 Irene Wielawski reflected in 2011 that this 3-year battle could be summed up as a “strong feminist movement colliding with the medical establishment” with a great deal of “misunderstanding fueling polarity.”103 The bill, along with the growing popularity of midwifery, brought the number of midwives to 25 in 1990; all of them were salaried employees of either a medical practice or a clinic.104 More change arrived that year with a new academic teaching model implemented at Brown University and WIH. Dr. Don Coustan, chair of obstetrics and gynecology at Brown’s medical school and WIH, recruited Diane Angelini, EdD, CNM, in 1990 to become director of the Division of NurseMidwifery at WIH. She agreed to leave Brigham and Women’s Hospital in Boston because she had known Coustan from Yale New Haven Hospital and believed she could collaborate with him in this new venture. The setup was unique at the time in that administrators located it in the Department of OBGYN, not the Department of Nursing. Although historian Laura Elizabeth Ettinger has found that most nurse-midwives remained in nursing, executive director of Rhode Island State Nurses Association Donna Policastro argued that midwives used nursing as a means of legitimacy to remain midwives but “never really aligned themselves with nursing in the state” and did not belong to the nursing associations.105 Also unique was the fact that midwives provided education to medical students and residents, providing a midwifery approach to labor management and deemphasizing unnecessary interventions; by 2012, most medical schools used midwives as educators.106 Instilling “midwifery expertise” to physicians, according to Nanni, helped the medical community

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respect midwives as “team players” working together to provide optimum health care to women.107 The end result, in Angelini’s view, was “an excellent working relationship” among midwives, residents, and obstetricians in the Department of OBGYN. Dr. Patrick Sweeney, director of medical education at WIH, hailed the program: “students love it” because midwives “are more patient and better teachers.” The success of this “innovative” and collaborative program, according to Sweeney, allowed Brown and WIH to serve as a model for the rest of the country.108 In the wake of these changes, the Journal ran a two-part story on the positive and negative aspects of midwifery. Realistically, midwives answered the acute shortage of obstetricians in the state. Although they legally could assist births at home, none of them did so, either because they considered it unsafe or because they believed the logistical arrangements of medical backup were too daunting. Personally, midwives answered women’s desire for natural rather than medicalized birth, and for an active role in creating birth plans. As Sheila Henry told reporters, the midwives “were very supportive. . . . They would say, ‘This is the situation, these are your options, how do you want to proceed?’ I did feel I was in control.” Pfeifer argued that doctors took control of the situation and delivered the woman of her baby, versus midwives who empowered women to deliver themselves. Midwives saw fewer patients but spent more time with each one, versus doctors who saw more patients but stayed with the patient only during the last phase of labor. Nanni saw doctors intervening too quickly rather than allowing labor to progress at its own pace. Although midwifery continued to gain popularity, Nanni found that the stereotype of them as “old women wearing black dresses and scarves with lots of warm folk wisdom but no professional training” was slow to die.109 The reality was that nurse midwives were experts who emphasized natural methods, but did not shun medical advancements, including pain medication or drugs to induce labor, when needed. The newspaper article gave equal time to obstetricians who continued to have reservations. Dr. John J. Coughlin, chair of the RI-ACOG, believed one concern was that if a woman employed a midwife but complications arose, the woman would meet the obstetrician for the first time during the crisis of labor rather than having built a trusting relationship throughout the pregnancy. He predicted that midwifery would appeal to a vocal but small percentage of women or to women in areas underserved by obstetricians. Dr. Roger J. Ferland, a Providence obstetrician and member of the ACOG and RIMS, had worked with midwives in the past but his current partner refused to allow it. He found that sometimes, midwives acted more in the role of “patient advocate than caregiver.” They “so badly want a picture book delivery for their patient, they sometimes become blind” to developing complications. In a case



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he worked with a midwife, the woman had labored too long; he wanted to intervene but the midwife refused. She “wanted little to do with” him because he “was messing up the karma in that room.” The baby was born with low Apgar scores. He believed there was “nothing wrong” with women “who want to feel in control of the situation” as long as they know “when to back away.” He suggested midwives handle “simple births” and leave complicated births to him: he did not gain “professional satisfaction dealing with a normal, uncomplicated labor and delivery.”110 Here seemed to be the crux of the difference between the two forms of professionals. Midwives gained great satisfaction in assisting women to give birth naturally and simply whereas doctors believed their talents and training were best put to use in “modern,” medicalized, interventionist procedures. Advocates for midwives labored not only to bring more birth options to women but also to improve maternal and infant health overall. At the same time the RIWHC worked for midwifery legislation, it also pushed for state-funded health care for uninsured pregnant women. In 1987, a coalition of consumer organizations, activists, and health professionals worked to extend insurance to women with too much money to qualify for Medicaid but not enough to afford private insurance. Fifteen percent of all pregnant and 32 ­percent of non-White pregnant women did not receive prenatal care in their first trimester in 1984. Infants born to these women were three times more likely to be born low weight; were 20 times more likely to die before their first birthday; and faced a greater risk of cerebral palsy, mental retardation, and learning ­disabilities. The RIWHC pointed out that Rhode Island had a higher infant mortality rate than three other New England states. As spokesperson, Aaronson argued that midwives were “an important strategy for further reducing infant mortality in Rhode Island and closing the gap between Black and White ­babies.” She believed midwives provided the “best prenatal care” for low-income women. Shelton felt a “personally strong” connection between the antipoverty and midwifery campaigns because her husband Henry Shelton had been a long-time advocate for the poor, serving as director of the George Wiley Center for poverty in Pawtucket. Similar to the midwife campaign, Tsiongas was the main sponsor of the bill, and its passage created the Rite Start Program. In 1990, RITECare expanded access to maternal and child health care. These efforts were successful because several influential allies joined the cause, including the Children’s Defense Fund and the Department of Health, which “enthusiastically” supported this campaign unlike its opposition to the midwife efforts.111 Although many midwives actively joined maternal and child health campaigns, the same is not true for reproductive rights movements in the state. Although the RIWHC was supportive of choice, it “was not a major part” of

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their efforts; they were more concerned with cautioning women about estrogen replacement and with birth alternatives. Although most midwives were personally prochoice, most did not take a public stance. Shelton argued that midwives were “not going to go out on a limb, especially in a place like Rhode Island,” to get involved in such a controversial issue given the intensity of the battles they already faced. As Nanni stated, “we had to walk a line and I tended to stay out of the political aspects.” Some midwives were nuns who practiced in Catholic hospitals; combining advocacy for midwifery and choice was not viable.112 Working to improve maternal and infant health among the indigent was much less controversial. Midwives dedicated themselves to total and comprehensive health care for pregnant women and infants regardless of socioeconomic status. They continued to receive positive press coverage and increase their numbers. By 1993, 40 ­licensed nurse-midwives in the state assisted at ten percent of births. Twentyfive of the 40 had admitting privileges at WIH. Although midwives in other areas of the country had helped increase access to health care in underserved inner ­cities, most nurse-midwives in Rhode Island served middle-class educated women. Five midwives worked with the WIH outpatient clinic that served “the needy,” but most of the community health centers continued not to employ midwives for fear of alienating the few obstetricians willing to work at such centers.113 To help midwives make inroads at community health centers where the demand for prenatal care was critical, the federal government granted $684,537 to educate nurse-midwives in a two-year master’s program beginning in fall 1993 at the University of Rhode Island (URI) College of Nursing. This grant—jointly written and implemented by WIH and URI—combined classes with clinical training, and gave preference for admittance to students committed to working with the poor. To qualify, students needed a bachelor’s degree in nursing and at least two years “experience in a maternity setting and skills in physical assessment of newborns and adults.” URI was one of fifteen successful grants from a pool of more than 100 applicants. The U.S. Department of Health and Human Services asserted that state cohesiveness in dealing with maternal–child health was the major factor in gaining the grant. URI’s partnership with WIH also helped: this nationally ranked hospital attended more than 10,000 births a year, making it a sustainable setting for clinical training for nurse-midwives. Moreover, Rhode Island was home to a large population of medically underserved women who could benefit from additional services from increased numbers of midwives. URI was the first public institution in New England to offer this program, offering much lower tuition to women seeking this career than Boston University or Yale University, where most New England women had gone for education to this point.



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This grant was a “dream come true” for WIH. Mary Dowd Struck, who had become an administrator at WIH in 1986, argued that this educational program helped her “improve access, especially for poor women.” ­Numerous nurses at WIH were “dying to become midwives,” but had not wanted to move away or commute to attend school. Angelini was hopeful that this program would allow the state “to meet the growing challenge in women’s health care.”114 The grant added legitimacy to the growing numbers of midwives. As Struck concluded, by this time doctors “have seen midwives in action and know that we’re partners, not threats to them.” In 1997, URI received a second federal grant for $825,000 to continue the program. In 2000, URI was one of only six schools nationally to receive a three-year federal grant for $825,149 to expand the graduate program in midwifery as a means to meet the obstetric and gynecological needs of poor, uninsured, or rural women. Specifically, the grant allowed URI to use long-distance learning to establish an outreach branch at the University of Vermont to train midwives to serve Vermont’s rural population—the largest in New England. It also expanded the URI Center for NurseMidwifery at Pawtucket Memorial Hospital, founded in 1999 and directed by Professor Holly Powell Kennedy of URI. Professor Margaret M. McGrath, one author of the grant, argued successfully that nurse-midwives are the most costeffective providers of health care.115 In 2002, URI received its fourth federal grant for $810,839; total federal funding over nine years was $3.14 ­million. The program had a 100 percent passing rate on the national midwifery certifying exam, graduating 45 nurse-midwives who served in hospitals, university medical schools, and clinics for the indigent and Native Americans. Professor Judy Mercer, director of URI’s nurse-midwifery program at this point, argued that the grant allowed them to serve “needy” and rural populations as well as train the next generation of professional nurse midwives.116 Most midwives practicing in the state by 2012 had been trained in the URI program, creating a strong community of women providing crucial health care.117

Conclusion The success of midwives in Rhode Island can be explained by several factors. The efforts of Aaronson and Shelton, on behalf of the RIWHC, brought necessary legislative change to open the doors to midwives. Nanni captured patients who would not have sought out midwives without the GHA policy of requiring a preliminary midwife office visit. Angelini showcased midwifery expertise to obstetrical residents over a period of two decades, leading to a

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large group of practicing obstetricians who consider midwives true coworkers in health care to women. The collaborative academic teaching model at Brown and WIH brought attention to Rhode Island as a place where midwives were integral members of obstetric health. Angelini argued that the midwives in private practice also benefited from this model “because there has been so much support from the academic people at Brown and WIH” that “the struggle has been less for them.” Angelini admitted that the shortage of obstetricians initially justified the use of midwives to instruct residents, but with no dearth of physicians in 2012 the instructional program has grown. She believed that midwives “are so well accepted now it’s just kind of the norm.”118 Residents, according to Sweeney, are “so comfortable” with midwives as “part of the team” that the image of the doctor as “king” has been undermined “considerably.”119 Kent County Hospital, Pawtucket Memorial, and WIH all had collaborative working relationships between doctors and midwives. Last, the federal grant to URI provided a core of educated and dedicated women. The transformation of midwifery into a respected element of health care in Rhode Island did not come easily. The contentious battle over legislation to empower midwives threatened male doctors who were accustomed to dominating obstetrics. The latter were willing to use the deaths of two infants born at home to defeat the bills, despite the fact that neither midwives nor bills were calling for home births. This red herring attempted to couch the obvious gender tensions between doctors and midwives. The compromise bill that rejected reimbursements for home births cleared the only critique the RIMS could publicly corroborate. The midwives’ campaign gained support because not only of women’s demands for natural childbirth that eliminated “saddle blocks” and epidurals but also of the critical shortage of obstetricians in the state. Advocates effectively used midwives’ devotion to lowering maternal and infant mortality among socioeconomically underserved women to divert attention from the power issue of the bills to concerns over racial and class equity in health care. Over the next two decades, the reputation of midwives increased not only statewide but also nationally. Struck became a teaching associate in obstetrics and gynecology at Brown in 1994 and was senior vice president for Patient Care Services at WIH for 20 years until her retirement in 2006. She also coauthored The Post-Pregnancy Handbook with Sylvia Brown.120 By 2008, WIH had established the Mary Dowd Struck Award for Excellence in her honor.121 Angelini served as senior editor for the Journal of Perinatal and Neonatal Nursing and associate editor of Women’s Health Journal Watch. She had been elected a fellow to the ACNM in 1996 and to the American Academy of Nursing in 2001.122 In fall 2010, Brown University promoted Angelini to clinical professor of obstetrics and gynecology. The alumni magazine praised



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her ­accomplishments, stating that during her tenure as director of nurse-midwifery at WIH since 1990, the program had “become a national model for the role of midwifery in medical education.”123 In 2011, the ACOG awarded Angelini’s program “Honorable Mention” for 20 years of successful academic collaborative practice model in medical education.124

Acknowledgments

“I am grateful to the Griffin Fund in the History Department at Wake Forest University for financial support to travel to Rhode Island to conduct research. Special thanks go to Roberta Aaronson, Diane Angelini, Linda Nanni, Donna Policastro, Patrick Sweeney, Newell Warde, and Irene Wielawski for ­allowing me to interview them and for being so gracious in sharing their insights, ­memories, and records with me.”

Notes 1. Author interview with Carol Reagan Shelton at her home in Cranston, Rhode Island, June 4, 2012. 2. Felice J. Freyer, “Grant to URI Reinforces Acceptance of Midwives,” Providence Journal, June 8, 1993, A1. 3. Judith Walzer Leavitt, “Birth and Anesthesia: The Debate over Twilight Sleep,” Signs 2 (1980): 147–64; Nancy Schrom Dye, “Modern Obstetrics and Working-Class Women: The New York Midwifery Dispensary, 1890–1920,” Journal of Social History 20 (Spring 1987): 549–64; Linda V. Walsh, “Midwives as Wives and Mothers: Urban Midwives in the Early Twentieth Century,” Nursing History Review 2 (1994): 51–65; Charlotte Borst, Catching Babies: The Professionalization of Childbirth, 1870–1920 (Cambridge, MA: Harvard ­University Press, 1995); Susan L. Smith, Sick and Tired of Being Sick and Tired: Black ­Women’s Health ­Activism in America, 1890–1950 (Philadelphia: University of Pennsylvania Press, 1995); ­Leslie Reagan, “Linking Midwives and Abortion in the Progressive Era,” Bulletin of the History of Medicine 69 (1995): 569–98; Susan L. Smith, Japanese American Midwives: ­Culture, Community, and Health Politics, 1880–1950 (Urbana: University of Illinois Press, 2005). 4. Laura Elizabeth Ettinger, Nurse-Midwifery: The Birth of a New American Profession (Columbus: Ohio State University Press, 2006). 5. Ellen A. Stone, “The Midwives of Rhode Island,” Providence Medical Journal 13 (March 1912): 58. Stone received her BA from Radcliffe College in 1895, her MA from Brown University in 1896, and her MD from Johns Hopkins University Medical School in 1900. She was Superintendent of Child Hygiene in the Providence Department of Health and a member of the Committee on Midwifery of the American Association for the Study and Prevention of Infant Mortality.

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6. Wayne Worcester, “Midwifery Is a Lost Practice Being Revived,” Providence Evening Bulletin, December 27, 1976, A1; “Last Lay Midwife Has 3,000 Babies Behind Her,” Providence Evening Bulletin, December 27, 1976, A8. 7. “Last Lay Midwife Has 3,000 Babies Behind Her,” A8. 8. Joseph B. DeLee, The Principles and Practice of Obstetrics, 3rd ed. (Philadelphia: Saunders, 1921), v. 9. Elizabeth Bing, “A Lamaze Pioneer Tells Why She Believes in and Promotes ­Preparedness and Family-Centered Maternity Care,” Lamaze for Parents (1990), http:// www.lamaze.org/ElizabethBing (accessed January 7, 2013). 10. “Nurse-Midwifery in the United States,” HSMHA Health Reports 86 (May 1, 1971): 418–20; Ettinger, Nurse-Midwifery, 15, 32, 121–28. 11. Kathryn Sibbold and Elizabeth Ping, “Historical Development of Nurse Midwifery and Birth Centers in America,” 6 November 2010, http://www.academia .edu/365880/Historical_Development_of_Nurse_Midwives_and_Birth_Centers_in _America (accessed January 7, 2013). 12. Worcester, “Midwifery Is a Lost Practice Being Revived,” A1. 13. “Last Lay Midwife Has 3,000 Babies Behind Her,” A8. 14. Worcester, “Midwifery Is a Lost Practice Being Revived,” A1. 15. “Last Lay Midwife Has 3,000 Babies Behind Her,” A8. 16. Worcester, “Midwifery Is a Lost Practice Being Revived,” A1. 17. Shelton interview. 18. Worcester, “Midwifery Is a Lost Practice Being Revived,” A1. 19. Shelton interview. 20. Worcester, “Midwifery Is a Lost Practice Being Revived,” A1. 21. Author interview with Patrick J. Sweeney at the RIMS in Providence, Rhode Island. By the 21st century, the ABC had lost much of its allure. Nancy Policastro argued that it “took more time” and thus doctors “did a lot of overriding” because “logistically it did not suit” them; “midwives did not have a loud enough voice.” Sweeney argued that the new delivery rooms were much homier so there “was not a stark difference” between the ABC and the new WIH rooms. Author interview with Nancy Policastro at RIMS, June 4, 2012. 22. “Medical Chief Says Midwives Are Integral to Health Care,” Providence Journal, February 26, 1978, B8. 23. “New Regulations Go into Effect Today,” Providence Journal, March 27, 1978, A5; Karen Lee Ziner, “Midwives, Doctors Debate Quality of Delivery; Baby Deaths Spotlight Controversy,” Providence Journal, April 24, 1988, B1. 24. Shelton interview. 25. Judy Barrett Litoff, American Midwives: 1860 to the Present (Westport, CT: Greenwood Press, 1978); Bert Wade, “Midwife History Inspired Her Book,” Providence Journal, March 22, 1978, B4. 26. Ettinger, Nurse-Midwifery, 161, 165. 27. Johnette Rodriguez, “The Parent Trap: The High Cost of Being Born in the U.S.A.,” NewPaper (March 16–23 1988): 3. 28. Ettinger, Nurse-Midwifery, 189. 29. Erinakes to Chairman Frank J. Fiorenzano of Senate HEW Committee, 26 March 1988, MD Testimony Letters, in Roberta Hazen Aaronson Files, given to author June 2012 (hereafter Aaronson Files).



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30. Shelton interview. 31. Author interview with Linda Nanni conducted by phone, May 22, 2012. 32. Nanni interview. 33. Elliot Krieger, “Up Front with Ann Mason, Nurse-Midwife of Barrington,” Providence Journal, February 10, 1985, M4. 34. “On Easing the Obstetrician Shortage,” Providence Journal, April 8, 1988, A18. 35. Rodriguez, “The Parent Trap,” 3. 36. Irene Wielawski, “Some Health Care Workers Reject Midwives to Ease Doctor Shortage,” Providence Journal, June 30, 1987, A18. 37. Rodriguez, “The Parent Trap,” 3. 38. Wielawski, “Some Health Care Workers Reject Midwives to Ease Doctor ­Shortage.” 39. Felice J. Freyer, “‘The Midwives Were Wonderful’: How to Select the Best Care Available for Pregnancy and Childbirth,” Providence Journal, April 2, 1991, A3. 40. Aaronson interview; Author interview with Donna Policastro at RIMS, June 4, 2012. 41. Roberta Hazen Aaronson, “Grassroots Strategies for Promoting Maternal and Infant Health,” BIRTH 18 (June 1991): 94–95, 97; Roberta Hazen Aaronson to Christine M. Pfeiffer, 2 March 1988, CNM Meetings File, Aaronson Files; Fact Sheet Given to Legislators, Aaronson Files; and Aaronson interview. 42. Nanni interview. 43. Aaronson, “Grassroots Strategies,” 94–95, 97; Aaronson to Pfeiffer, 2 March 1988. 44. Aaronson, “Grassroots Strategies,” 94–95, 97; Aaronson to Pfeiffer, 2 March 1988; and Fact Sheet Given to Legislators. 45. Shelton interview. 46. Cesarean Prevention Movement, Coalition for Consumer Justice, RI Business Group on Health, RI-ACNM, RIWHC, RI Working Women, and Women’s Political Caucus; Aaronson Files. 47. Aaronson, “Grassroots Strategies,” 94–95, 97; Aaronson to Pfeiffer, March 2, 1988; and Fact Sheet Given to Legislators. 48. RI-ACNM, “Position Statement,” March 1988; Shelton, “Testimony,” April 5, 1988; Erinakes to Frank J. Fiorenzano, March 26, 1988, all in Testimony File in ­Aaronson Files. 49. Aaronson, “Grassroots Strategies,” 95–97; Fact Sheet Given to Legislators. 50. “On Easing the Obstetrician Shortage.” 51. RI had nine National Health Service doctors working in clinics, but six of their contracts were about to expire with no replacements. Katherine Gregg, “Bill Offers Doctors Loans Paid off by State for Work at Clinics,” Providence Journal Bulletin, n.d., n.p., Aaronson Files. 52. “On Easing the Obstetrician Shortage.” 53. “Richard G. Bertini, Letter to the Editor, Providence Journal, April 18, 1988, n.p., Aaronson Files. 54. Carol Shelton, “Giving Deserved Recognition to Midwives,” Providence Journal, April 25, 1988, A8. 55. Irene Wielawski, “Infants’ Death Spark Probe of Midwife,” Providence Journal, April 12, 1988, A1. 56. Nanni interview. 57. Ibid.

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58. Irene Wielawski, “Investigation of Infant Deaths Begins,” Providence Journal, April 14, 1988, A3. 59. Ziner, “Midwives, Doctors Debate Quality of Delivery,” B1. 60. Aaronson interview; Shelton interview; Nanni, e-mail message to author, July 18, 2012. 61. Wielawski, “Investigation of Infant Deaths,” A3. 62. Aaronson interview; Shelton interview. 63. Aaronson interview. 64. Author interview with Newell Warde, RIMS, Providence, June 4, 2012; Policastro interview. 65. Wielawski, “Investigation of Infant Deaths,” A3. 66. Ibid.; Ziner, “Midwives, Doctors Debate Quality of Delivery,” B1. 67. Irene Wielaswki, “Midwife Council Meets in Private to Discuss Infant Deaths,” Providence Journal, April 23, 1988, C8; Ziner, “Midwives, Doctors Debate Quality of ­Delivery,” B1. 68. Nanni interview. 69. One person abstained. “Panel Concludes Review of Midwife,” Providence ­Journal, April 26, 1988, A3. 70. Irene Wielawski, “Midwife Loses License,” Providence Journal, April 28, 1988, A1; Irene Wielawski, “Midwife in 2 Infant Deaths Loses License Because of Violations,” Providence Journal, April 27, 1988, A1. 71. Wielawski, “Midwife Loses License,” A1. Alexandre graduated from Cranston High School in 1966, and attended Rhode Island College (1966–1972) and Community College of Rhode Island (1979–1981). She received her CNM from the University of ­Mississippi. She relocated to Florida, where in 1992 she was a registered nurse and certified midwife attending home births. In 2011, she was president and director of the Natural Childbirth Center, Inc., in Margate Florida. Classmates.com; http://articles.chicagotribune .com/1992-01-26/business/9201080211_1_nurse-midwives-midwife-birth-assistant; http://articles.sun-sentinel.com/1995-08-20/news/9508180201_1_mother-and-childnew-mothers-moms/2; http://www.corporationwiki.com/Florida/Coconut-Creek/adele-jalexandre-P2593794.aspx (all accessed July 14, 2011). 72. Nanni interview. 73. Irene Wielawski, “Midwife’s License Revocation Removes R.I. Home Birth Option,”Providence Evening Bulletin, April 29, 1988, A1. 74. Shelton interview. 75. Nanni interview. 76. Wielawski, “Midwife’s License Revocation,” A1. 77. Judy Judson, Letter to the Editor, Providence Journal, May 19, 1988, n.p., ­Aaronson Files. 78. Wielawski, “Midwife’s License Revocation,” A1. 79. Ziner, “Midwives, Doctors Debate Quality of Delivery”; Alan Rosenberg, “­Midwives Help Parents Make Their Own Choices,” Providence Journal-Bulletin, May 6, 1988, n.p., Aaronson Files. 80. Midwifery Legislative Coalition, “For Release,” April 25, 1988, and “Press Conference,” April 25, 1988, both in “Midwifery Campaign and Clippings File,” ­ Aaronson Files. 81. “Panel Concludes Review of Midwife,” Providence Journal, April 26, 1988, A3.



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82. Katherine Gregg and Kevin Sullivan, “House Panel Hears Debate on Bills That Aid Midwives,” Providence Journal, April 6, 1988, A7; Scot MacKay, “Medical Group At Odds with Midwives,” Providence Journal, May 12, 1988, C5. 83. “Childbirth, Midwives and Medical Care,” Letters to the Editor, Providence Journal, April 28, 1988. 84. Philip Terzian, Op-Ed Column “Of Medicine and Midwives,” Providence Journal, May 1, 1988, B10. Terzian had been assistant editor of the New Republic, assistant editorial page editor of the Los Angeles Times, and editor of the editorial pages at the Providence Journal (1986–1992). He worked as a reporter and editor for U.S. News and World Report. Since 2005, he has been literary editor of the Weekly Standard, a conservative magazine in Washington, DC. In email correspondence in 2011 asking if he had changed his mind about the “amateur” nature of midwifery, Terzian responded, “I wouldn’t change a word of this column—except, perhaps, to update the Ivan Boesky reference to, say, Bernie Madoff.” He continued to believe that “to deliberately turn away from medicine to folk remedies” was “irrational and irresponsible.” Philip Terzian, e-mail message to author, July 15, 2011. 85. Mark Patinkin, “Moment of Birth Needn’t be at Home to be Unspoiled,” ­Providence Journal-Bulletin, May 4, 1988, B1. 86. Rosenberg, “Midwives Help Parents Make Their Own Choices.” 87. Dr. Herbert Rakatansky, “A Decline in Quality,” Providence Journal, May 18, 1988. 88. Aaronson, “Grassroots Strategies,” 95; Aaronson interview. 89. Letter to Friends of Midwives from Aaronson, March 10, 1989, in Aaronson Files. 90. “Midwifery Legislative Committee,” 5 April 1989, CNM Meetings Files, in Aaronson Files. 91. Scott MacKay, “Senate Panel Kills Midwife Bill,” Providence Journal, May 26, 1988, B5; Nanni interview. 92. Letter to Friends of Midwives from Aaronson, March 10, 1989, in Aaronson Files. 93. Aaronson interview. 94. All letters in Testimony File, in Aaronson Files. 95. Scott MacKay, “Insurance Payments for Midwives Urged,” Providence Journal, June 22, 1989, E12. 96. Aaronson, “Grassroots Strategies,” 95. 97. “Legislative Wrap-Up: On Balance, Pretty Good,” Rhode Island Medical News 3 (July 1989): 7. 98. “Addendum to Midwifery Testimony,” n.d., Public Hearings/Strategies File, in Aaronson Files. 99. “It’s Been a Long Road to Acceptance,” Providence Journal, April 2, 1991, F6; Felice J. Freyer, “Grant to URI Reinforces Acceptance of Midwives,” Providence Journal, June 8, 1993, A1. 100. Aaronson interview. 101. Aaronson, “Grassroots Strategies,” 95–96. 102. Aaronson interview. 103. Irene Wielawski, e-mail message to author, July 14, 2011. 104. “It’s Been a Long Road to Acceptance,” F6; Freyer, “Grant to URI,” A1. 105. Ettinger, Nurse Midwifery, 4; Policastro interview. 106. Diane J. Angelini, Barbara O’Brien, Janet Singer, and Donald R. Coustan, “Midwifery and Obstetrics: Twenty Years of Collaborative Academic Practice,” Obstetrics and Gynecology Clinics of North America 39, no. 3 (2012): 335–46.

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107. Nanni interview. 108. Angelini interview; Shelton interview; Nanni interview; author interview with Patrick Sweeney at RIMS, June 4, 2012. 109. Freyer, “‘The Midwives Were Wonderful,’” A3. 110. Ibid. 111. Aaronson, “Grassroots Strategies,” 93–95; Aaronson, “Improving Prenatal Care in R.I.,” Providence Journal, May 27, 1987; “Prenatal, Maternity Care Bills Get BroadBased Endorsement,” Providence Journal Bulletin, April 14, 1987, A9; Aaronson quote in Katherine Gregg, “Bill Offers Doctors Loans Paid Off by State for Work at Clinics,” Providence Journal Bulletin, n.d., n.p., Aaronson Files; Aaronson interview; Shelton interview. 112. Shelton interview; Nanni interview. 113. Freyer, “Grant to URI,” A1. 114. Ibid. 115. News Bureau, “Federal Government, Pawtucket Hospital Recognize URI Graduate Program in Nurse-Midwifery,” URI News Release, February 28, 2000, http://www.uri.edu/news/releases/html/00-0228-01.html (accessed May 22, 2012). ­Kennedy left URI for UC-SF to become inaugural Helen Varney Professor of Midwifery at Yale School of Nursing in July 2009. She served as president of the ACNM 2010–2013. 116. “URI Graduate Program in Nurse-Midwifery awarded $810,839,” URI News Release, September 23, 2002, http://www.uri.edu/news/releases/html/02-0923-04.html (accessed May 25, 2012). 117. Nanni interview. 118. Angelini interview. 119. Sweeney interview. 120. Sylvia Brown with Mary Dowd Struck, Post-Pregnancy Handbook: The Only Book That Tells What the First Year After Childbirth Is Really All About . . . Physically, ­Emotionally, Sexually/Sylvia Brown with Mary Dowd Struck (New York: St. Martin’s, 2002). 121. http://us.macmillan.com/author/marydowdstruck, http://www.womenandinfants .org/body.cfm?id=89&action=detail&ref=250, both accessed 20 July 2011. 122. http://research.brown.edu/research/profile.php?id=1100923639, accessed 20 July 2011. 123. “Promotions,” Brown Medicine: A Magazine for Alumni and Friends of the ­Warren Alpert Medical School of Brown University, (Fall 2010), http://brownmedicinemagazine .org/view/article.php?cw=cGFnZTE0MTU9MSZlbnQxMzE1ND1QQUdFJmVudDk0 PTI0MiZjbnRwYWdlMTMxNT0xJmlzczk0PTEw, accessed July 20, 2011. 124. ACOG 2011 Issue of the Year, given to the author by Angelini, 6 June 2012.

Simone M. Caron, PhD Chair and Associate Professor of History Wake Forest University 1834 Wake Forest Road Winston Salem, NC 27109

THE FUTURE OF HEALTH CARE’S PAST: A SYMPOSIUM IN HONOR OF JOAN E. LYNAUGH, PhD, RN, FAAN

Setting the Stage Julie A. Fairman University of Pennsylvania School of Nursing Barbara Bates Center for the Study of the History of Nursing

Good things and ideas sometimes take a while to get going. About 3 years ago, Patricia D’Antonio and I began to think about a way to honor Joan Lynaugh, our friend and mentor, and came upon the idea of a festschrift. A festschrift is typically a volume of learned articles or essays by colleagues and admirers, serving as a tribute to a scholar. We decided to add another component, the symposium that would honor Joan’s influence in the field of nursing history, including her work to develop the Barbara Bates Center for the History of Nursing, which is celebrating its 25th anniversary this year. This, we believed, would be entirely appropriate given Joan’s importance in the development of nursing history as a disciplinary approach to the understanding of hospitals, health care in general, as well as women’s work and ­policy. The anniversary of the History Center also played into this theme—the center serves as ­research center, a home for nursing history scholars and as an archival repository that supplies the data to conduct historical ­studies. Over time, we presented our ideas to our colleagues, Cynthia Connolly, ­Barbra Mann Wall, and Jean Whelan; our Dean, Afaf Meleis; as well as our colleagues ­Arlene Keeling and Barbara Brodie from UVA who confirmed and supported our ideas. There are, I think, several ways to set the stage for this festschrift, this wonderful day of scholarship and ideas. The path we chose, and this was a collaborative endeavor, was to focus on themes that characterize Joan’s ­contribution to the field of nursing history—through her development of a Nursing History Review 22 (2014): 95–101. A Publication of the American Association for the History of Nursing. Copyright © 2014 Springer Publishing Company. http://dx.doi.org/10.1891/1062-8061.22.95

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thought collective of nursing history scholars and scholars across disciplines, the development of the history center where these scholars can gather and their work can be anchored, and her mentorship, which can be seen in the two generations of nurse historians on the program who have studied with Joan and her former students (of course, we are always students). We learned and continue to learn much from her—she taught us to control the abstract by organizing historical data on index cards (and now we tend to Zotero or Refworks or Endnote), to quickly read the overwhelming number of books that are part of the historical endeavor, and to learn to love and accept the ambiguity of history when our nursing course work was situated in the positivist tradition. She keeps us grounded, committed, and excited about what we are doing and helps us keep our heads when we feel we have been slighted ­because we are historians and not quantitative or qualitative researchers—she always said that she could explain nurses to historians but not always history to nurses (although here at Penn, we are quite lucky to have colleagues who do ­understand), and that in the end we knew the critical nature of our work. She didn’t just teach us history—she taught us how to live and grow into inclusive and respectful women and men. Because of her, we learned to introduce and include students in conversations we might be having with colleagues as well as the value of promoting our colleagues’ work as much as our own. We also learned the finer, more practical points of “doing history,” such as that we cannot—must not—exceed the 20–min time frame for our presentations. That would intrude on other speakers’ time. We remember these and many more lessons as we teach each new generation of scholars. Nursing is a practice profession and a scientific discipline, and history is critical to its identity, cultural meaning, and relevance. I’m not saying this in a self-conscious way but as a strong declaration to remind us that all our scholarship and research—no matter the method— is based on historical evidence and historical thought. History provides meaning, and this meaning is infused into any area that we might want to study. It shapes how we ask our questions about clinical issues and how we identify variables in quantitative studies or how we frame our thematic strands in qualitative studies. It would be difficult to study AIDS, women’s health, or workforce issues if we didn’t think about them through the broader lens of time and place; the changing social, political, or cultural context; and meaning of therapeutics, or global politics. Now, think about how studies done ahistorically might look if done without consideration, even subconsciously of historical context. They would fall flat, and have limited importance except for that one subject group at that time and place.



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One of the many things we learned from Joan was the intellectual pleasure that comes from the discovery of connectedness and pattern of events in time and within interpretive frameworks. As Joan notes, “What happens in the present is not an accident. It has a past”—the past in effect anchors these modern issues in a framework broader than the here and now. That is what Joan is so good at—helping fledging historians and even those of us with ­experience to see that history is about finding the data, constructing meanings, and accepting the absence of absolutes. And perhaps most powerfully, history is about the ability to construct an argument to explain the past to understand the present. History is critical for understanding modern nursing as a practice discipline and for situating nursing as a lens for examining broader historical questions relating to health policy, women’s work, immigration policy, to name a few. History provides the purposeful blending of historical knowledge and nurses’ everyday realities of interacting with patients and families as well as a lens for examining present day situations. But it is not enough to tell a story, As Joan and Susan Reverby wrote many years ago, that would be boring—the key is to make it part of the understanding of larger issues, events, and poli­ cies. And they asked, “What do we really learn about an organization, and episode or an innovation unless we can relate it to larger human events and concerns.” For the time, this was an extraordinary statement. Until the mid1980s, most nursing history was professional history, written to reflect professional concerns. During this time some historians of medicine, labor, and women began to be interested in nursing, perhaps as a reflection of the more general debate over the orientation of contemporary health care, and interest in women’s rights and women’s work, and the perils of technology. Their work helped shape Joan’s ideas of where the discipline needed to go. She believed nursing history had an obligation to challenge the traditional “great nurse” narrative. Her story emphasized the actual care of patients and the nurses who delivered that care and the importance of using history to ask and think about broader historical questions. She taught us how to mesh historical analyses with clinical experience. But the idea of developing a research center to nurture and support the work of nurse historians and interdisciplinary scholars came only after much thought, and it involved the generation of good, sustainable ideas; being at the right place at the right time; and having a collection of other scholars who shared her interests and passions. I will give you an early example that shows the combination of wisdom, fortuitous location, and a group of like-minded characters that exemplifies Joan’s career. She attended the University of Rochester and received

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her ­Bachelor of Science in Nursing in 1961 and her master’s in 1968. The ­University of Rochester at that time was part of an academic health center that was an incubator for creative interdisciplinary education and practice. As Joan recalled how she got involved with an early experiment of expanded nursing roles: I had been working with [physician] Nate Lassman for several months . . . he had already started working with some of the clinic nurses, teaching them clinical decision-making . . . I said, I would like to start seeing some patients with him and just see what I could do with them.

Eventually, she became part of what she referred to as the “Clandestine Clinic,” an under the radar practice of nurses and physicians working together that also included Barbara Bates. This astute ability to recognize opportunities, establish relationships, and take chances has served Joan well and characterizes many of her later accomplishments. We see an important example of this in the medical nurse practitioner program she and Barbara Bates developed in the early 1970s at Rochester. This program has given us the internationally renowned Bates’ Guide to Physical Examination and History Taking, the hand drawings of which were modeled on those found in Peterson’s Guide to Birds—Joan, Barbara, and their colleagues were avid birders. Joan left Rochester in 1976 for the University of Kansas, where she studied under historian Regina Morantz Sanchez, and completed dissertation research on the history of the Kansas City General Hospital. She had not yet finished the PhD program when Claire Fagin, then Dean of the School of Nursing, heard about her work on the nurse practitioner program and persuaded her to come to the University of Pennsylvania to start the Primary Care Family Nurse Practitioner Program. One of Claire’s chief selling points was Joan’s opportunity to work with Charles Rosenberg and Rosemary Stevens, then professors in the University’s Department of History and Sociology of Science. Charles and Rosemary became her strongest supporters and advisors when she and like-minded colleagues, Ellen Baer and Karen Buhler-Wilkerson, also in the School of Nursing, began to develop ideas about the power of nursing history to understand the work and worth of nursing. Added into this equation was the possibility of developing a nursing history research center at the school. In 1982, Dean Claire Fagin appointed an ad hoc History Committee to consider options for creating a larger historical presence in the School of ­Nursing. Over the next year, the Committee discussed plans without coming to an acceptable recommendation, and some time passed without a clear



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r­ esolution to the matter until Joan and Barbara Bates embarked on one of their long road trips. As Joan would later recount: In the summer of 1984, after several years of committees and discussions, we were still not quite clear about the form of our history initiative at Penn. That June I had a paper to give at the ANA meeting in New Orleans, so Barbara and I decided to drive there, by way of Kansas City and Santa Fe. Now, as many of you know, there isn’t much to do between Wichita, Kansas and Santa Fe, New Mexico, so we talked about work and history. And from that discussion, the general form of the Center emerged: preserving documents, doing research, and, above all, teaching new generations of scholars. The idea was, do it all. Barbara was absolutely optimistic and confident that such a center would succeed. She loved history and was a talented historian herself. She thought the three of us (faculty members Drs. Joan Lynaugh, Karen Buhler-Wilkerson and Ellen Baer) and Penn could bring it off. And, she ­invested heavily (and anonymously).

When they returned, Claire agreed with their plan and appointed a steering committee to design and oversee the project. Four critical elements needed to be present to succeed: faculty, space, documents, and most importantly, money. The Penn School of Nursing already had a core group of strong historians to lead the scholarship and research component—the triad of Karen, Ellen, and Joan. There was unused space on the rear third floor of the building so it was determined that this area would be renovated with support from several alumni associations and individuals, to house the Center, thus providing a state of the art archival and research environment. Here is where the development of Barbara Bates Center for the Study of the history of nursing plays a crucial role and is so nicely intertwined to a celebration of Joan. The Center archives provides data—in fact, data that would probably be long gone if not for the vision of the three founding members. Training schools long closed, hospital records saved from the trash by nurses who understood their importance, personal papers that were not thought to be important—these are just some of the collections that are preserved in the Bates Center. The center formally opened in 1988, and as news of the Center began to spread, there began to be a flurry of activity that led to the advancing and disseminating of nursing historical knowledge. Indeed, one of the earliest goals of the Center, which remains intact today, was creating a new generation of scholars that would be equipped with a full range of historical and multidisciplinary scholarship. Doctoral students with an interest in nursing history were an integral part of the Center from the beginning. Dr. Meryn Stuart, of the University of Ottawa, for instance, was the first graduate of Penn in nursing history in 1987. Not far behind her was a cadre of doctoral students, who over

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the past 25 years have contributed greatly to historical scholarship on nursing and health care history. Today, these graduates hold prestigious positions in academia and related fields. Today, the Barbara Bates Center for the Study of the History of Nursing represents the largest repository of primary source materials and rare books about the history of nursing in the United States. It holds an extensive ­collection of materials from the 19th to mid-to-late 20th century hospital-based nursing schools, visiting nurse societies, voluntary nonprofit associations, professional groups, and the personal papers of 20th century nursing leaders and practicing clinicians. We have a growing collection related to ethnic and minority nurses and nursing organizations. The Center also possesses a substantial collection of glass slides, textbooks, pamphlets, photographs, audio tapes, and films and a smaller amount of fabric and artifact holdings. The entire collection comprises more than 1,900 linear feet. The Bates Center collections have been used by a wide-ranging group of interdisciplinary scholars to highlight nurses, too often historically invisible, as absolutely central to the history of women, heath care institutions, and healing work with vulnerable populations. The Bates Center has an international reputation of eminence, and scholars around the globe use its collections. Its rich resources have provided the building blocks for a multitude of important and award-winning books, articles, and dissertations on topics ranging from international nursing, home-based nursing, care of the critically ill, institutional nursing, private duty and public health nursing, ­evolution of the nurse practitioner role, nursing in disasters and epidemics, professionalism, and the role of race, place, and identity in the development of a new work arena for women. Center faculty and students continue to produce innovative research as well as create, plan, and produce new programs designed to disseminate knowledge of nursing history. The Center is currently involved in several web-based and social media projects, which will bring the collections to a global audience in the years to come. In addition to the center, Joan has created a scholarly infrastructure to support the history of nursing across the globe. She served as the first editor of the Nursing History Review (1991–2001) that provided a much-needed forum to exchange ideas and to bring our scholarship to a wider audience. She consulted in the formation of new nursing history centers such as those at the University of Virginia, University of Ottawa, University College ­Dublin, and Manchester University (England). And because Joan seems to know everybody in the entire world, she has served as a connecting point between established, beginning, and potential scholars in the history of nursing and health care.



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Joan’s scholarship, through her writings, establishment of the Bates ­ enter, the nurturing of a new generation of nursing history scholars, and the C connections she has made across disciplines and the world sets the stage for today’s symposium. Her historical work broadly rendered stands as a superb example of the power of history to create a shared sense of mission among very different groups of nurses. Joan Lynaugh’s understanding of history as part of the “cultural DNA” of the profession has influenced an entire generation of students, scholars, and clinicians here and abroad, many of which are part of today’s program. I hope you will enjoy what my colleagues and I, particularly Cynthia Connolly and Barbra Mann Wall, have created for you. Julie A. Fairman, PhD, RN, FAAN University of Pennsylvania School of Nursing Room 2003 Fagin Hall 418 Curie Blvd. Philadelphia, PA 19104–4217

PANEL 1: THINKING BEYOND PROFESSIONAL BOUNDARIES AND INTERNATIONAL BORDERS

Boundary Crossings in the History of Health Care John Harley Warner Yale University

My assignment here is to map changes in the history of health care as a field in the last 30 years, setting the stage, I think, for the constitutive role ­nursing ­history has played in this sea change. The Symposium organizers told me I had a fixed amount of time and my quick math tells me I can take up to 30 ­seconds per year. That might have been sufficient but I am also told we have to be ­provocative. So, I want to do three things. I first want to characterize that moment around 30 years ago: Where did our shared field stand around the time when this Center was created? Then, I will lightly sketch the kinds of change that have transformed the field. And finally, just bullet point (no more) some of the concerns about the field we’re facing. The phrase “the history of health care” 30 years ago (in the late 1970s and early 1980s) was highly polemical. It was a rallying cry for a new way of thinking about and writing history, embroidered on banners waved at the barricades and inscribed in the prefaces to books with titles like Medicine without Doctors and Beyond ‘the Great Doctors’. In that “new social history” impulse, the master narratives of an earlier medical history were identified with exclusionary stories that privileged orthodoxy, progress, and white male elites. In their stead, scholars who proselytized for the new “history of health care” began to produce a whole host of alternative narratives that incorporated various institutions, practices, and voices. At  stake were which historical questions about health and health care were worth asking, who was best suited to come up with answers, and what work history should do. It was a heady moment. Nursing History Review 22 (2014): 102–106. A Publication of the American Association for the History of Nursing. Copyright © 2014 Springer Publishing Company. http://dx.doi.org/10.1891/1062-8061.22.102



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And it did transform the field. And let me just point to three of the kinds of hard-won change we now tend to take for granted: attention to the marketplace, to patient agency, and to practice. Reflecting the broader impulse to look beyond elites, historians of health care turned their attention to the ­variety of healers who coexisted (and often competed) in the medical marketplace. They focused on healers other than regular physicians—practitioners who had been invisible or marginalized in an older canon, including midwives and other women healers but also anti-orthodox practitioners like homeopaths, botanics, and hydropaths, and a rich array of health reformers. This marketplace was a site of economic but also ideological competition (and, more ­subtly in later historical work, negotiation). These histories were also peopled with a different cast of characters—diverse in gender, race, ethnicity, class, and religion. It altered our baseline understanding of the kinds of sources of health care and advice people could turn to, in sickness and in health. At the same time, there were calls to rewrite the history of health care from the patient’s perspective. It was not just a matter of shifting perspective, though, but also looking for the agency of patients in shaping their own health culture and the health care system. Taking their cues partly from the women’s health movement, consumer movement, and rights movements, historians listened carefully for voices inflected by gender, race, region, and ­political ideologies. Just as historians sought out other healers, they also worked to recover how individual, socially situated laypeople made choices, how they looked to and contested professional authority, and how they exercised agency as ­patients, clients, and consumers. Yet one final hallmark of the new history that emerged in the 1980s was a preoccupation with practice: the practices of healing, of research (including research ethics), of policy making, of keeping people healthy—or cities healthy. We never set aside a history of ideas or of innovation. But there was a new valuation of the everyday—how technologies were actually used on a workaday level, how institutions (from hospitals to home health services) actually operated, the experience of life on the wards (including not just the exceptional but the repetitive dailiness of working routines), what it meant to live inside an adolescent body or aging body, the experience of giving birth or being ill, and the practices of teaching and learning in the laboratory or at the bedside. These have been exciting transformations to witness. But the program says we’re also supposed to “raise provocative questions.” So I tried the exercise of standing back and asking: What are the concerns about the field I most often hear voiced? Are there anxieties worth listening to as we think about its larger sweep? Let me just point to three. The first is that the field has grown fragmented: that synthesis has given way to a proliferation of case studies and that we have

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lost sight of the big picture. It’s true that increasingly, the focus of research has tended to be local—in this country, on the United States (more and more on the 20th century, especially in the period after World War II), and with few attempts to produce anything like a synthetic history of health care. Much of the most exciting scholarship has insisted, rightly, on the specificity of local cultural contexts and meanings, often exploring local knowledge. In teaching, many of us find ourselves at an uneasy juncture between the accomplishments of microhistory and aspirations for some larger, maybe transnational, connected history. These are real concerns. Yet, I think that far from becoming narrow or parochial, what’s happened is that our work has been deliberately decentered in ways that have been intellectually healthy. In part, instead of somehow sacrificing a meaningful “big picture” or synthetic (canonical) “grand narrative,” we’ve recognized that the master narrative with which we once worked derived a lot of its narrative power, coherence, and seeming clarity precisely because it excluded the diversity and complexity of what we would now want to encompass in “history of health/health cultures.” At the same time, two moves have helped reposition our studies of the local, the daily, on a wider stage: first, starting in the 1990s, the preoccupation with the history of colonialism and imperialism (not just in matters of health), and second, in the past decade, the move to globalizing the field as part of the larger impulse to global history. Students in my graduate seminar have quipped that our aim for historical practice might be reduced to a version of the environmentalist bumper sticker: namely, “think globally, write locally.” A second concern I hear is that the field has grown too detached from the health professions, a curious echo of earlier protests that it was too dominated by them. Over time, efforts at mainstreaming the field within history have been powerfully successful. And possibly one consequence is that integration has made separatism seem unnecessary outmoded. So, here, let me tell you a story to make a broader point. When I took my first postgraduate steps, one mission of my generation was to free the field from its medical past—to escape the putative stranglehold of medicine, its institutions, and practitioners. In struggles over which stories were worth telling, what work those stories should do, and which audiences were most worth reaching, partly at stake was the question of whether history or medicine should set the agenda. Over the ensuing decades, the movement to redirect medical history away from medicine toward history has been stunningly successful (in some ways, I’d suggest, rather too successful). The more it has joined the historical mainstream, the less its practitioners have needed to rely on separate institutions where they can discuss ideas, publish work, secure jobs, or mentor students.



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Well, not all that many years ago, all this combined with local circumstances at Yale in compelling me to confront head on some of the fundamental dilemmas involved in repositioning medical history in relationship to medicine. I have long been based partly in a medical faculty, in a freestanding History of Medicine unit. Much of my teaching is in our interdepartmental undergraduate and graduate program in History of Science and Medicine. But the very success of our Program prompted a thoroughgoing review of where in a university medical history should be located, institutionally and intellectually. Given my generation’s aim of mainstreaming this field in history, frankly it was satisfying to be approached and asked in effect: “You’re a historian: Wouldn’t you like to move, maybe move your whole operation, into history, where surely it belongs?” Truth be told, when I was fresh out of graduate school I would have jumped at the opportunity. That is precisely why my hesitation was more than an episode in one person’s mid-career crisis. Put bluntly, the prospect of severing my workaday ties to medical culture radicalized me. I had to articulate—to others but most especially myself—an answer to the unspoken question lurking just beneath the surface: “Why on earth would a historian worth his or her salt want to be ‘stuck’ in a professional school?” The answer for me turned upon reciprocity between medicine and history. Pressing clinicians, researchers, and students to understand the contingency of current ideas, assumptions, institutional arrangements, and to consider alternatives, is satisfying—as is showing students what it is to think about medical issues like a historian (how we use our tool kit). But more than this, interaction with medical culture can be a valuable resource in crafting and answering questions—and not merely in some functionalist sense of deliberately setting out to contribute to current debates. Often we do ask what are fundamentally medical and public health ­questions: What is disease? What is the relationship between health and civil liberties? And at a time when there’s a sense that the system is in crisis, these questions particularly have to do with the nature of the health care enterprise and character of health professionals—their overlapping roles as ­healers, researchers, workers, reformers, and citizens (important questions about identity). Being embedded in a medical school hardly defines my research program, but it is one source of creativity. Historians no longer have any reason to fret over the specter of ­medical domination, or to rally around calls that our field be mainstreamed in ­history: we did that. But the sheer success of our field in establishing its place within history does, I think, pose challenges to its interface with the health

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­ rofessions, clinicians, and professional schools, which I’ve grown convinced p is an important part of our field’s vitality. The last concern I’ll mention has to do with relevance, and you hear this voiced in two very different ways. It is heard in the complaint that the field sacrificed its relevance when social history, with its overt activist animus and political salience, gave way to cultural history. Or, conversely, it comes up in the concern that the field is too oppressively governed by demands for ­relevance—for instrumental use and measurable impact. Both beg the question, Relevant for whom? And how? Just as we’ve populated health history with multiple actors who were marginal in stories told 30 years ago, we’ve also broadened our audiences—­ clinicians, historians, and scholars in a whole range of cultural studies—as well as wider publics. Often the issue of relevance is a red herring precisely because any meaningful historical question is framed in dialog with wider communities in the present, not just the past—and if the answers don’t speak to those communities, then it’s just not very good (or very interesting) history. Contemporary debates about clinical practice, resource allocation, and health policy—Obamacare or Romneycare—help generate our questions. At the same time, other questions come from the discipline of history—from fields like labor history, business history, history of sexuality, art history—and that helps keep our field in dialog with other practitioners in the humanities. And were there time (and there isn’t) to dwell on just one example of how cultural studies and cultural history have informed new questions, analytical tools, and ways of thinking clearly “relevant” to current issues of policy, ethics, and social justice, I’d want to cite disability history. Collectively, we have multiple sources of questions, multiple audiences, and multiple metrics for gauging “relevance”—and we move back and forth among them. This kind of boundary-crossing is part and parcel of what makes health care history so vital. And to my mind, that’s all key to the singular ­richness of this field and of the institution, community, and legacies that we’re celebrating here today. John Harley Warner, PhD Section of the History of Medicine Yale School of Medicine P. O. Box 208015 New Haven, CT 06520–8015

Tiptoeing Towards a History of Nursing in Europe Anne Marie Rafferty King’s College London

In preparing this brief talk or “walk” as I’d like to think of it on this nursing history tour of Europe, I’d like to approach my task from the point of view of the flaneur. By that I mean my perspective will be of one who experiences the city of nursing history by strolling around, focussing on what takes my fancy as a way of navigating the scholarly field. If it falls into Baudelaire’s category as one who loiters, I hope it is loitering with good intent. Clearly, given my allotted time, this is not the place to provide an encyclopedic overview of the forces that have shaped the field and the extent to which that has gone ­beyond professional boundaries or international borders. My remit rather is to comment on some of the trends in nursing history in Europe. But that begs the question of which Europe to take as the starting point for our tour? The ­Europe of language groups? Of geography? Of political geography? Of ­cultural kinship? Of religion? Any excursion into the history of nursing in Europe ­immediately raises questions about definitions. Delving into the historical vaults of Spain, Portugal, France, Germany, Italy, Denmark, the ­Netherlands, and ­Scandinavian countries demands a facility for those languages. Clearly, this is beyond the scope of anyone less than a superhumanpolyglot and would demand a much more collaborative and comparative approach than I can offer here. What I can do is to map some of the macro themes that I have gleaned partly from work published in English and partly from talking to my friends and colleagues, opinion formers in the field: Anne Summers, Celia Davies, Sioban Nelson, and Christine Hallet who all send greetings and birthday wishes. One major development that will certainly make this task easier in the ­future is that a new European Nursing History Network has just been launched by Christine Hallett and colleagues from Ireland, which pulls in colleagues from the Bosch Institute in Germany along with the UK Centre for the History of Nursing. It looks like English may be the lingua franca but hopefully Nursing History Review 22 (2014): 107–113. A Publication of the American Association for the History of Nursing. Copyright © 2014 Springer Publishing Company. http://dx.doi.org/10.1891/1062-8061.22.107

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the network will help to bring work currently buried to light and help to set out a new scholarly agenda for the future. In addition, some countries have active groups, networks exchanging research and resources—the Portuguese link strongly with their Latin American colleagues. Hiades, nursing history journal, was started in 1994 by the Andalusian Nursing Association. There is a history of nursing society in Denmark which is hosting an international conference this year and a nucleus of scholars in Norway so there are healthy signs of life and I wish the new European Union network every success.

Religion As far as the “big picture” is concerned, three macro themes stand out: ­religion, war, and politics—indeed the great taboos of the dinner table ­conversation. Of particular relevance for our purposes, and perhaps the most significant differentiator between continental European and Anglo Saxon historiography, is the greater and earlier emphasis on the relationship between religious and secular nursing. Nursing plays its part in the great dramas of life and features in those settings where the church has played a prominent, if not the dominant role as a provider of health care. In catholic countries, the separation of church and state occurred at different times and the impact that this has had on changing approaches to welfare policy have been analyzed by commentators in France, Spain, and Italy. Of particular interest is the influence that this shifting political dynamic has had on shaping the role and development of the profession and how the profession in turn seized the opportunity to align itself with wider political movements such as the claim to citizenship. Within this debate, gender played a crucial role—its elastic, even latex-like, qualities stretched between the coordinates of ecclesiastical ­essentialism on the one hand (devotion, self-sacrifice, and ­subordination) counterbalanced by its more radical opposite assertion (autonomy and ­authority) on the other. Clearly, crude dichotomies have their limitations and subtle pairings of these opposites can be found in the religious mix. Indeed, the strongest example of this “third space” is the secularization of nursing in the Third Republic in France where nursing formed the fulcrum of the debate on femininity magnetizing the twin poles of attributes of femininity applauded by the Church and those promoted by the secular modernists— science and ­technology. ­Katherine Schultheiss’s work stands out as exemplary in portraying this complex struggle between these characteristics, none of which quite behaved according to type. As she demonstrates, this was not a



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simple battle of opposites but rather a more complex choreography of conflicts and hybrid set of characteristics migrating and shifting shape as cultural and political pressures allowed. On the Protestant side, more nuanced and subtle analyses of the role of deaconesses has emerged from Germany and Denmark. Like their catholic counterparts, deaconesses are revealed as canny capitalists combining commerce with clinical acumen in the creation of a catechetics of care. What ­Susannne Kreutzer and Karen Nolte on the German side and Suzanne ­Malchau Dietz demonstrate with Denmark is how resistant the dual model of body and soul–parish nursing of the Deaconesses was in West Germany to secularization and how they unfurled in the United States much earlier. Malchau Deitz dissects out the role of sisterhoods from the Counter-Reformation but reveals such women not simply to be biddable conformists but counter culturalists. Sisters were capable of practicing against the grain subverting their own image “under the wimple.”

War The second major theme is war and the impact that national and international conflicts have exerted on the practice and professional boundaries of nursing as well as the engagement of nurses in humanitarian activity. This is set against the backdrop of Anne Summer’s brilliant study of British women as military nurses during the Crimean and Boer Wars. Much more recently, Christine Hallet’s elegant study of nursing told through the writings of nurses in World War I—containing trauma. Germany has produced and stimulated significant output, much of it centered on World Wars and nursing under the Nazi regime. I am not sure, though, whether anyone has quite captured the emotional intensity of Hilde Steppe’s original research and writing. Certainly, her presentation at our first international conference in the history of nursing at Nottingham in 1993 had us all mesmerized—you could have heard a pin drop. Several other studies of nursing in concentration camps have been published since. But this tragic episode in our history has received much more attention than the Franco-Prussian War, Napoleonic Wars, the war for Italian Unification or French-Algerian Wars. There is some work and a recent PhD thesis by Isabel Solanos Anton on nursing under Franco and the Spanish Civil War from the Spanish side. Stefania Bartoloni has written on Italian War and Red Cross nursing in her Italiene alla Guerra I’assistenza ai ferti 1915–1918. In French-speaking Switzerland, Joelle Droux has written on I’Assistante au

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Fonds National de la Recherche Scientifique’ et “Personnel Soignant et Roles Sexuels: Les Itineraries d’une Contagion,” in which she discusses the ambivalence of the hospital as a site for public and emancipated roles for women. The grande dame of French history, Francoise Thebaud has a chapter entitled “Les Anges Blancs” in her La Femme au Temps de la Guerre de 14.

Politics War and international conflicts not only create conditions for humanitarian relief work in which nursing is likely to play a prominent role but are also often the engine for change in reforming health systems. In French nursing, the complex provincial and central dynamics of welfare reform provide the backdrop for Genevieve Charles’ L’infirmiere en France d’hier a Aujourd’hui; Yvonne Knibiehler with Veronique Leroux-Hugon, Odile Dupont-Hess, and Yolande Tastayre produced Cornettes et Blouse Blanches: Les Infirmieres dans la Societe Francaise, 1880–1980. In Spain, mental health nursing, the portrayal of nursing in the media, Spanish Civil War and education, and the transition from Franco Regime to democratic state demonstrates how political systems themselves have shaped the profession and the content of its work and educational preparation for the role. Nurse historians have explored the vexed relationship between nursing practice and totalitarian regimes but rarely has such analysis ventured further into the terrain of ­political science and theorizing impact of political systems on practice. More work is needed in this area. This, however, is the sketchiest of surveys, a mere soupconette and flavor of what lies in store for the flaneur in nursing history. There is further work being undertaken beyond national borders in missionary nursing and nursing in ­colonial contexts from the United Kingdom by Helen Sweet and myself and colleagues at King’s College; Rosemary Wall, and Jessica Howell on the professional diaspora from the British Empire and consequences for circular migration on nursing in the National Health Service; and Elisabetta Babini on film. We have compelling portraits of psychiatric nursing from Switzerland and Austria via Sabine Brauschweig and Carlos Watzka and it is gratifying that there has been a slight shift in emphasis toward home care from institutional settings. But there remains a glaring gap in getting to the grass roots of practice. We could slice and dice the field in different ways. Rather than taking a transverse slice, we could look at trends over time in terms of the volume and typology of papers given at international conferences. But perhaps the key question is what really has changed in the past 25 years? Has anything



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changed? Is the critique offered by Celia Davies in her groundbreaking ­Rewriting Nursing History still valid—that nursing history was mainly written by nurses for nurses?

Footnotes The answer, my friends, is not blowing in the winds but in our favorite spot for historians—the footnote. If we look at nursing history literally from the bottom up—from the bottom of the page, that is, and the point of view of the humble footnote—what does that tell us about our sources, our craft, and most particularly those authors and approaches that have shaped and influenced the field and how we think about nursing over the past quarter century? The reason for focussing on footnotes is that they matter to historians—even to the extent that some historians might be considered footnote fetishists (only by fellow fetishists of course)! But the footnote is the metric by which we judge a historian’s mettle, for it is here that one declares one’s sources, praises, or critiques predecessors, where the apparatus of argumentation and authority meet. The significance of the footnote will not be lost on those of us who may have opined that nursing is often a footnote in history. But perhaps being a footnote in somebody else’s history could be quite a positive place to be. That for me would be the test—how and where we land up in the footnotes. My own view is that our footnotes are richer and more robust methodologically now than they were 25 years ago. One of the reasons that our footnotes are better is because of the institutional support afforded by places such as the Bates Center where scholars can not only congregate and sometimes huddle for support but also stretch and reach out to others. But it is not just institutional support, it is a question of leadership, having a vision, and planning for the long-term sustainability and, crucially, the success within succession. Joan, Karen Buhler-Wilkerson, and Ellen Baer—that powerful trifeminate led where no women had gone before (yes, there is a star trek element to it only because they are all stars). The vision laid down here and which, ­generationally, others have followed now with Patricia D’Antonio, Julie Fairman, Jean Whelan, Barbra Mann Wall, and Cynthia Connolly is fundamentally a mind-set, attitude, and set of practices toward scholarship. For the project conceived here and faithfully followed was a liberal as much as a liberating one and that vision and set of values is in no small measure ­attributable to Joan’s own quest academically, politically, and practically.

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Acknowledgments Having highlighted the footnote, I’d now like to turn to the acknowledgments page. Those of us who have had the privilege of working with Joan have benefitted from that ethos and the collegiality, the firm friendship that goes with it. For being involved with the Center is being in it for the long haul. One of the hallmarks of Joan’s leadership is bringing kindred spirits on board and Joan had the foresight to link early on with historians of medicine seeing them as our natural allies. So much so that the history of nursing in the ­Anglophone world is unimaginable without the scholarly support and shelter provided by historians of medicine—such as Charles Rosenberg and John Harley ­Warner in the United States, and Charles Webster (my and Anne ­Summer’s thesis supervisor), Maggie Pelling, Roy Porter, and Colin Jones in the United ­Kingdom—all lent sympathetic ears and offered cafeteria ­conversations to budding nurse historians. Charles’s supervision of his students, Karen and Pat, indeed support for the very early days of the Center was critical. The Cambridge and University of Pennsylvania Press’s series that published Susan Reverby’s revolutionary monograph and Julie Fairman’s work were all part of a broader intellectual and cultural ferment and milieu that drew support from history of medicine and further inflected it with a variety of different ­perspectives drawn from gender, labor, social history, science, and technology studies. So we see a direct line of descent from the social history of medicine to nursing so much so that they can be described as symbiotic, bound in holy patrimony. Joan must take a hefty chunk of credit for giving intellectual leadership and mentorship to successive generations of historians. Not only should we applaud this happy situation and the laying down of a legacy but also owe Joan and others after her a great debt of gratitude for having the foresight to think ahead and ensure a successful succession plan was in place through Karen and now Julie’s superb stewardship of this historical hearth. Many of us have gravitated toward and found an academic home and had the privilege to collaborate on projects at the Center thanks to Joan. The International Council of Nurses (ICN) history project was a multidisciplinary team effort that drew on a wide range of scholarship from international relations to women’s history, social history, and political history—teamwork is not easy anywhere but a pretty rare trick to pull off in history. It was a lot of fun too. Perhaps that ICN project could be a model of going beyond professional boundaries and international borders for Europe. There is a great opportunity to take the map of Europe and analyze it in a comparative and collaborative



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way, to look for those points of articulation, draw on national approaches, and forge them into something intellectually exhilarating, exciting, and new. It also became clear to me during that project that the power of Joan’s ­political skills were navigating the choppy waters of institutional history, which she did with characteristic flair and finesse. For this was a politics borne of generosity, and taking a risk with relatively untried and tested younger ­scholars. I can say this as someone who has benefited greatly from Joan’s mentorship and wisdom and collegiality and in whose career the Center has been invaluable, indeed Penn has been invaluable. The early links forged with Linda Aiken’s work, another nursing “great,” provided the ideal bridge for me ­between history and policy and one that has been strengthened over time. But top of my list in the acknowledgments page, Joan, I want to pay tribute to your generosity of spirit as well as your vision and inspiration. I don’t know where you get that quiet magic—that charm—but it sure does works like a puck potion. So keep the magic and the ink flowing. Happy birthday, Joan! Anne Marie Rafferty, CBE, RN, DPhil (Oxon), FRCN, FAAN, FKC, FQNI Professor of Nursing Policy and Director of Academic Outreach, Florence Nightingale School of Nursing and Midwifery, King’s College, London James Clerk Maxwell Building 57, Waterloo Road London SE1 8WA

Panel 2: Challenging Conventions

International Nursing History: The International Council of Nurses History Collective and Beyond Geertje Boschma University of British Columbia School of Nursing

In taking on, coordinating, researching, and eventually writing a ­centennial history of the International Council of Nurses (ICN), the Barbara Bates ­Center for the Study of the History of Nursing embarked on an exciting, much needed, and also challenging project. The Center was only in its early phase of development when Joan Lynaugh, then director, agreed to take up the challenge of writing a more global nursing history. Under her skillful and energizing academic leadership, a team of international nursing history scholars worked on the book Nurses of All Nations from the early 1990s until its eventual publication in the ICN’s centennial year, 1999. The exciting part of the experience was—probably very similar to what the ICN membership had also experienced all along—to become part of an international community of scholars and professionals. Furthermore, it was inspiring to debate ideas, ponder approaches, and, to explore the topic, to link with an international network of people familiar with international developments. Many of these people were or had firsthand involvement in international nursing affairs and health initiatives. We were fortunate to learn from many experts where to find documents and with whom to talk to. We visited many organizations and archives. We traveled around the globe and met many nurses from the most diverse places and contexts in the process. The project went beyond national and cultural boundaries in that we did not seek to write a history of individual national nursing organizations. Rather, we set it our goal to establish an international perspective on nurses’ professional identity and diversity. We were as much Nursing History Review 22 (2014): 114–118. A Publication of the American Association for the History of Nursing. Copyright © 2014 Springer Publishing Company. http://dx.doi.org/10.1891/1062-8061.22.114



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interested in understanding what had been the “glue” that had bound nurses from around the globe together in one international professional organization for so long, and we were curious to explore what had made the ICN meaningful to nurses who profoundly differed in race, ethnicity, religion, language, culture, nationality, and lived in very different political, economic and social contexts.1 We traced five perspectives throughout the book, including the subtle changing self-image of the ICN; its responses to issues of race, class, and gender; the meaning attached to nursing and the profession; nursing diplomacy and organizational survival; and personal friendships and travel. The ICN started out as a small organization in the broader context of the women’s movement. For almost a century, the ICN has sustained its place as an important and meaningful organization for nurses from around the world. From the outset, its main goal has been to unite nurses worldwide through a confederation of national nursing organizations. The confederation addressed matters important to both the profession of nursing and people’s health. ­Motivation, commitment, and enthusiasm banded nurses together ­despite turbulent social and economic changes, hardships of war, and profound c­ ultural differences. The organization itself was founded in 1899; it was the initiative of the British nurse and suffragist Ethel Gordon Manson, later Mrs. Bedford Fenwick, a prominent leader of the British Nurses Association (BNA). The professional welfare of nurses, the interests of women, and the improvement of the people’s health were intertwined goals for the founders of the ICN. But the new organization also reflected relations of cultural dominance of the time, rooted in colonialism and white supremacy. Although the organization’s goal was to unite nurses internationally, the founding leaders all originated from Western Europe and North America, reflecting colonial relations of cultural dominance. Nursing as a respected, paid professional occupation for women from the middle class was a new phenomenon at the end of the 19th century. Health care profoundly changed as a result of industrialization and urbanization and shaped the demand for nurses. Scientific advancement of medicine triggered the rapid development of modern hospitals and led to the foundation of hospital schools for the professional training of nurses. The development of professional work for women coincided with the goals and interests of the women’s movement. The founding members of the ICN were part of a growing number of women who were active in social and health care reform and who simultaneously sought to improve women’s social position and obtain the right to vote.

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Although the First and Second World Wars profoundly interrupted nurses’ efforts to organize internationally, efforts to meet the demand for ­military nurses also decisively influenced nurses’ search for professionalism and better education. In the 1950s, the ICN leadership shifted away from Anglo-European dominance as a result of a new internationalism. This change came with the introduction of new member associations from a broader contingency of nations. Better economic circumstances and conditions for women’s work further enhanced nurses’ ability to create organizations in Africa, Asia, South America, and Latin America. In the latter half of the 20th century, the ICN built connections with new international organizations, such as the World Health Organization. It also grew into a more politically aware and activist organization, issuing position statements and seeking to influence international affairs. Such efforts created new tensions and conflicts. Setting an international political stand sometimes conflicted with a national nursing organization’s internal policies. Tensions between international standards further spurred debate. Furthermore, international migration of nurses and uneven distribution of nursing expertise raised important questions around recruitment and retention of nurses. By the end of the 20th century, the ICN was a thriving organization, continuing to provide leadership and assistance in helping its members address pressing health care needs. As an international research team of scholars exploring these international relationships, we clearly also experienced the challenges of writing international nursing history. Whose history were we writing? And from whose perspective? Why in English? We were necessarily limited and bound by our own subject locations as scholars coming from particular countries and mastering a particular language. In our methods and interpretation— as Joan eloquently put it in one of her later reflections on the value and importance of international nursing history—we had to search for “common working ground.”2 This challenge reflected a tension not unlike the one nurses within the ICN also had experienced. In establishing unity within the ICN, nurses had to work together to find common working ground while simultaneously negotiating their differences. What we offered in writing the ICN history in terms of expertise, interpretation, and construction of meaning was influenced by similar pressures of cultural dominance, diversity of values, and inequities that also had constructed the organization we studied. Internationality or global relations cannot be understood independent from the local and time-bound context and influences that shape them. On the other hand, the very craft of historical scholarship provided us with an avenue to help avoid superficial judgment or quick and (too) easy generalizations.3 In working as a team, we applied the skills, methods, and standards



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of the community of historical scholars. These standards guided us to question our assumptions, to ask for critique, and to use historical concepts and categories to frame our analysis and to become aware of our own diversity in the process of interpretation. History is about examining, interpreting, and explaining happenings, people, events, and viewpoints in their own context and time. Constructing meaning from historical evidence comes with the responsibility to be cautious. “While contemplating this matter of finding ‘common working ground,’ I can’t help but reflect on how easy it is for each of us to mistake own ways for universal ways,” Joan carefully pointed out.4 Good international nursing history helps us avoid this trap.5 We need international nursing history, but we also expose our work to scholarly critique. As a collective of nursing history scholars, we need to serve as each other’s peers and critique each other’s work. Maintaining high standards is important not only to the community of academic researchers and scholars but also to the health professions and the wider public who reads our work, and whose “subject matter” we take up as we analyze the history of nursing and health care. Nursing history is not necessarily a happy or comfortable story, but rather an essential one. Nursing, like health care, “faithfully mirrors both the unattractive and the uplifting aspects of the human experience,” Joan and Barbara Brush noted in their introduction to the ICN history.6 We found that experience reflected while writing the history of the ICN. International nursing history scholarship continues to offer further analyses of past experiences in nursing and health care that can help us better understand and think historically about the present. Intersecting differences of race, class, and gender continue to shape and constrain ideals of striving toward justice, equity, and inclusiveness in nursing and health care, both nationally and globally. Health and health care for all is still very much an ideal. While writing international nursing history cannot resolve these inequities, it can do much toward constructing our collective memory and helping to understand such tensions as well as think critically about them.

Notes 1. Barbara L. Brush and Meryn Stuart, “Unity Amidst Difference: The ICN Project and Writing International Nursing History,” Nursing History Review 44 (1997): 121–4. 2. Joan E. Lynaugh, “Common Working Ground,” in New Directions in the History of Nursing: International Perspectives, ed. Barbara Mortimer and Susan McGann, 194–202 (London and New York: Routledge, 2005).

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3. Ibid. 4. Ibid., 200. 5. Boschma, G., “Writing International Nursing History: What Does It Mean?” Nursing History Review 16 (2008): 9–11. 6. Brush and others, Nurses of All Nations, p. xiii

Geertje Boschma, RN, PhD University of British Columbia School of Nursing T201–2211 Wesbrook Mall Vancouver, BC V6T 2B5 Canada

History and Nursing History at Penn in the 1980s Naomi Rogers Yale University

Looking back at my time at Penn, I realize how young I was. I arrived as a graduate student in September 1980 eager to become part of a wider and deeper intellectual community than I had known as an undergraduate in ­Melbourne, Australia, and determined to study the history of this new country which I saw as more exciting than either Australian or British history. I was welcomed into a caring community of fellow graduate students both in the History department and in the department of the History and Sociology of Science.1 Penn History graduate students had a single required course in their first year: History 700, which my advisor Charles Rosenberg was teaching that year. Around the table were a range of students: some like me fresh out of college; some who had sampled the paid workforce and felt that a history PhD would give them a perspective they could not otherwise find; and a few “odd balls” who were (in my eyes) older and out of place. One of these was Barbara Bates. She was tall, a little ungainly, with short gray hair, soft spoken, and to my surprise Rosenberg treated her with great respect. Only gradually did I learn that she had written a clinical best seller, had been a teacher of nursing and medical students for some years, had helped to design a community health program at the University of Rochester—that she was, in fact, far more senior in a wider academic world than any of the rest of us.2 Also around the table was Ellen Baer, a nurse practitioner who had just joined Penn’s n ­ ursing school.3 What I did not realize about Barbara until sometime later was that she was a physician. To me she looked like a nurse. It was only when I met Joan Lynaugh that I realized I had no idea what a “nurse” really was. Joan was a fireball. She looked like Sancho to Barbara’s Don Quixote and in some ways I think she was often the realist, turning Barbara’s tilting at windmills into a pragmatic agenda. But in other ways they were both dreamers. They had come Nursing History Review 22 (2014): 119–125. A Publication of the American Association for the History of Nursing. Copyright © 2014 Springer Publishing Company. http://dx.doi.org/10.1891/1062-8061.22.119

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to Penn as a way of making a mark on the world of health care and health training where they hoped their long-standing commitment to social justice and professional equity would find academic respect.4 Both were very private people—it was a long time before I was invited to their main line home. Barbara was interested in the history of tuberculosis; a topic that seemed to me in the early 1980s rather old fashioned (again, let me remind you how young I was). It was true that an interest in infectious disease was on the rise—fueled by AIDS—but Barbara wanted to look at an earlier era where patients spoke a language of healing and therapy that was not very different from their physicians and nurses, and where families desperately sought to return their loved members to health but yet hold onto a fragile financial stability threatened by the loss of wages occasioned by a stay in a sanatorium. Barbara published her dissertation as a book in 1992, the same year I published mine, which was another study of disease (an epidemic of polio framed by the early AIDS years). Both of us sought out the voices of patients, families, and ordinary health practitioners but Barbara, I think, achieved that far more successfully than I did. In her work you hear the agony of the sufferers and see tuberculosis as a disease with both clinical and emotional sides.5 Just as I was finishing graduate school, Joan, Barbara, and Ellen founded the Center for the Study of the History of Nursing at Penn. The Center took the whole of the early and mid-1980s to come together. Nursing history was then not part of “serious” history; it had long been celebratory, somewhat hagiographic. It is a sign of tremendous change that Julie Fairman, the current Bates Center director, has the title “Nightingale Professor” and the name does not have any of these connotations. Only a few historians outside the nursing profession were studying nurses: Susan Reverby, ­Barbara Melosh, and Darlene Clark Hine. Their research interests stemmed from feminism as well as labor and civil rights history.6 Penn, though, was a special place. Rosenberg was writing his critical history of hospitals in which he made nursing and nurses central in the making of the modern ­American hospital. He had already published his provocative piece on Florence ­Nightingale in 1979 (as part of a festschrift for George Rosen) arguing that one of the reasons she had been so successful as a hospital reformer was that she did not believe in germs.7 Most of all, Nancy Tomes, one of Rosenberg’s students, had published “A Little World of Their Own” in a respectable medical history journal in 1978. It was such a striking article that Judy Leavitt chose to reprint it in her new collection Women and Health in America in 1984 along with articles by Reverby, Clark Hine, and Melosh.8 Tomes also published a study of the history of nurse registration battles in New York State in the early 20th century in Ellen Lagemann’s collection Nursing History: New Perspectives, New



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Possibilities.9 These were important signs for Rosenberg’s younger students like me, suggesting that a focus on women professionals and on the work of caring for patients was legitimate and appropriate, perhaps even cutting edge, in the making of an academic historian’s career. The same year that Leavitt’s collection came out, the American Association for the History of Nursing had its first stand-alone conference, sponsored partly by the University of Virginia School of Nursing, another major supporter of the new nursing history.10 Thus, long before the founding of Nursing History Review, this kind of history was being written based on thoughtful—sometimes very critical—scholarship about nurses, nursing practice, gender, and health care. In 1985, Garland Publishing issued a catalogue announcing a 32-volume series on The History of American Nursing to be edited by Susan Reverby. On the catalogue’s cover were blurbs by Claire Fagin (the dean of Penn’s nursing school who had brought in Joan, Barbara, and Ellen Baer) praising the series as “an essential guide to the richness, diversity, and conflict that has shaped nursing’s development”; praise from women’s and labor historian Alice KesslerHarris, then in the history department at Hofstra University, who noted that nursing was “a crucial area of women’s work”; and Charles Rosenberg who ­assured potential buyers that the series “provides a wealth of insight into an area of growing interest to social historians and sociologists as well as to professionals in the field of nursing itself.”11 Reverby had not yet completed her major book on nursing work but she had published a chapter in Health Care in America, the influential and feisty collection she and David Rosner had edited in 1979. Reverby’s piece on “The Search of the Hospital Yardstick: Nursing as the Rationalization of Hospital Work” looked at professionalizing nursing as a distinctive kind of health care practice which played a crucial and not necessarily progressive role in shaping the modern hospital.12 Reverby wrote a long introduction in the 1985 Garland catalogue and referred to her forthcoming book under the tentative title The Nursing Disorder: A Critical History of the Hospital-Nursing Relationship. This series, Reverby declared, was more than “an attempt to insert nursing into the history of the American health care system.” Nursing had long had “an integral yet shifting position as women’s work in the health care hierarchy” and thus “provides us with special historical insights [into] . . . the transformation of American health care through the eyes of a subordinated women’s occupational group, struggling within the vise of gender to establish its own autonomy.” Among the themes the series would illuminate would be nurses’ efforts to balance autonomy and altruism; a history of professionalization with gender “taken into account”; the division of labor in the health care system; and how “physician authority and power have been created and sustained.”13 The Garland series reprinted books on

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African American midwifery (Folks Do Get Born, 1946); Louise ­Alcott’s Civil War Hospital Sketches; the 1923 Goldmark Report; guides for the licensed practical nurse, the private duty nurse, and the tuberculosis nurse; pamphlets from East Harlem Health Center Demonstration of the 1920s; an anthology of Black Women in Nursing introduced by Darlene Clark Hine; an anthology of American Nurses in Fiction introduced by Barbara Melosh; the memoirs of a nurse who “Served in Bataan”; and a New-Deal-funded history of nursing in ­Kansas called Lamps on the Prairie. To intrigue readers further, the catalogue was ­illustrated by photographs of student nurses in 1905 standing by a ­patient in a hospital bed at the Mary Thompson Hospital in Chicago; a woman physician visiting a Philadelphia tenement alley in 1916; and a visiting nurse (a white woman in a dress and formal cape with a straw hat) tending to an African American man’s ulcerated leg in Boston in 1905 as his wife sat next to him in what was probably their kitchen.14 I recently discovered this Garland catalogue in an old folder from my Penn graduate school days. In this same folder, I found a review essay I had written as a graduate student for Judith McGaw’s course on the history of technology that I took in 1982 or 1983. In my essay that I called “Shadows in Nursing History,” I boldly compared older kinds of nursing history written in the light of Nightingale’s lamp to a very different emerging field. In the older style, nursing historians, I said, “sought to legitimate the autonomy and importance of their place in the hospital with a past full of self-conscious, independent female healers.” The technical expertise nurses would “supposedly gain from this training” was intended to “enable them to participate fully in the elaboration of modern medical practice in the hospital.” In my essay, I placed Joan Lynaugh—whom I called a “professional nurse educator and historian”—along with early nursing reformers such as Nutting, Dock, and Stewart. According to all of these reformers, I argued, “this knowledge is power.” I was also critical of many 1970s feminist historians who, I argued, “may not be writing from within the hospital but neither can they escape it; the image of the hospital as the center for medical diagnosis and therapy, the context of nurses’ work and organization, is overpowering.” But I loved Nancy Tomes’ Pennsylvania Hospital study, which I saw as a “watershed in nursing history” written by someone who “is neither a practitioner nor a graduate.” Tomes showed that this school was just one of several career choices for both working-class and middle-class women. Indeed, “new medical practices and their shaping and institutionalizing by hospital manager and physician play an almost insignificant role in the organization of nursing work.” Instead, the critical influences in this “little world of our own . . . seem to be the varied class and cultural values of matron, nurse and patient.”15 I quoted ­approvingly



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the insights of Jo Ann Ashley’s 1976 Hospitals, Paternalism, and the Role of the Nurse to reinforce my claim that “writing nursing history is a political act. It is about power and control, as well as concern and care” and that “the myth of the hospital . . . is that it was ever—and remains—an institution where patient care was placed before education and economic functions.”16 Too often, I agreed with Ashley, the hospital’s shadow has hidden “the experiences of nurses who worked outside official institutions, whose voices were not powerful enough to catch the ears of nursing historians seeking to edify and refine the nursing profession and its modern practitioners.”17 It is a shock for me today to see that my graduate school folder also included a review by Charles Rosenberg of Celia Davies’ 1980 collection Rewriting Nursing ­History for Sociology of Health and Illness in which he makes a number of the same ­arguments.18 One point that I did not raise in that essay concerned the growing awareness in the 1980s that many nurses disliked feminist claims of sister­ hood that nonetheless denigrated nursing as traditionally feminine and low status (see Ellen Baer’s important op-ed piece on “The Feminist Disdain for Nursing” published a few years later in the New York Times).19 When I realize how hard it is for me to figure out how influential ­Barbara, Joan, and the Center have been in my life, I can see that in many ways this influence is caught up with my development as a young historian. My training at Penn in the 1980s introduced me to the integration of social history in the history of medicine; a rethinking of “medical” history to include the history of the patient; thinking about health professionalism as a shifting and conflicted category; the importance of valuing social justice in the organization and ­delivery of medical care; and asking why professionals like nurses had long been “invisible” in histories of medicine and what difference it makes to bring them into view—along with other women and other “forgotten” people. I see how profoundly I took my intellectual and social cues from Charles ­Rosenberg: he admired and respected nurse historians and the kind of historical and academic work they came to Penn to do. I watched him participate in the early workings of the Center when it was only a small group of historically minded Penn nurses—giving guest lectures and seminars, advising students— and as I became a senior graduate student, I tried to do that too. Now, in my own work I am trying to bring a renewed attention to the patient and to the care of the sick, to nursing work, which, as Cynthia Connolly once reminded me, is both “High Tech and High Touch.” I have been able to bring many themes together in my recent book on Sister Elizabeth Kenny, an Australian nurse (not a nun) who challenged physicians, nurses, and physical therapists to think about the care of patients paralyzed by polio in new ways and got enormous support from patients, their families, and the American public.

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In my revisions of this work, I have benefitted enormously from the advice from many of the Center’s current historians whom I count among my friends and academic colleagues. Although I sometimes feel that the Nursing History Review has been around for far longer, it began only in 1993. But the kinds of nursing history it publishes and seeks to inspire is just the kind of history that both Joan and Barbara hoped to inculcate in their own profession and in wider academic and policy communities. I think, as we look around, we can see that’s just what they did achieve.

Notes 1. For additional reflections on this period see Rogers “Explaining Everything: The Power and Perils of Reading Rosenberg,” Journal of the History of Medicine and Allied Sciences 63 (2008): 423–34. 2. Barbara Bates, Guide to Physical Examination and History Taking, first published in 1974. In 1967, Bates moved to the University of Rochester School of Medicine to oversee the training of medical residents and to participate in the Rochester Regional Medical Care Program in Western New York. 3. Ellen Baer became involved with the nurse practitioner movement in the early 1970s. She taught practitioners at Lehman College, City University of New York before joining the faculty at the Penn School of Nursing in 1980. At Penn, she was the associate director of the Barbara Bates Center for the Study of the History of Nursing. Baer is the Wallace Gilroy Visiting Professor of Nursing at the University of Miami and Professor Emeritus of Nursing at the University of Pennsylvania; in 2011, the Center’s reading room was renamed in her honor. 4. Joan Lynaugh was recruited to Penn’s Nursing School in 1980 to direct the School’s new initiative in primary care nursing. 5. Bates completed a master’s degree in history at the University of Kansas in 1978. She published Bargaining for Life: A Social History of Tuberculosis 1876–1938 in 1992. 6. Susan Reverby Ordered to Care (1987), Barbara Melosh The Physicians’ Hand (1983), and Darlene Clark Hine Black Women in White (1990). 7. Charles E. Rosenberg, “Florence Nightingale on Contagion: The Hospital as Moral Universe” in Rosenberg ed. Healing and History: Essays for George Rosen (New York: Science History Publications, 1979), 116–136. See also Charles E. Rosenberg’s The Care of Strangers (1987). 8. Nancy Tomes “‘Little World of Our own’: The Pennsylvania Hospital Training School for Nurses, 1895–1907,” Journal of the History of Medicine 33 (1978): 517–21; Women and Health in America, ed. Judith Walzer Leavitt, (Madison, WI: University of Wisconsin Press, 1984). 9. Nancy Tomes, “The Silent Battle: Nurse Registration in New York State, 1903–20,” in Nursing History: New Perspectives, New Possibilities, ed. Ellen Lagemann, (New York, NY: Teachers College Press, 1983) 107–132. 10. Laurie Glass, “AAHN: In the Beginning,” AAHN Bulletin 59 (1998): 4–6.



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11. Garland Publishing [catalogue] “The History of American Nursing” 32 volume facsimile series edited by Susan Reverby, 1985, cover, Rogers personal collection. 12. Susan Reverby “The Search of the Hospital Yardstick: Nursing as the Rationalization of Hospital Work” in Health Care in America: Essays in Social History, ed. Susan Reverby and David Rosner, (Philadelphia, PA: Temple University Press, 1979) 206–225. 13. Susan Reverby “Editor’s Introduction” Garland Publishing [catalogue] “The History of American Nursing” 32 volume facsimile series edited by Susan Reverby, 1985, cover, Rogers personal collection, 2–3. 14. Garland Publishing [catalogue] “The History of American Nursing” 32 volume facsimile series edited by Susan Reverby, 1985, cover, Rogers personal collection, 6–7, 9, 10. 15. Naomi Rogers, “Shadows in Nursing History: A Review Essay” (for Judith McGaw, 1983), Rogers personal collection. 16. Naomi Rogers, “Shadows in Nursing History: A Review Essay” (for Judith McGaw, 1983), Rogers personal collection, paraphrasing Jo Ann Ashley Hospitals, Paternalism, and the Role of the Nurse (New York: Teachers College Press, 1976). 17. Naomi Rogers, “Shadows in Nursing History: A Review Essay” (for Judith McGaw, 1983), Rogers personal collection. 18. Charles Rosenberg “Review Article: Recent Developments in the History of Nursing,” in Rewriting Nursing History for Sociology of Health and Illness, ed. C. Davies (London: Croom Helm, 1980; reprint March 1982), 86–94, Rogers personal collection. 19. Ellen D. Baer, “The Feminist Disdain for Nursing” [Op-ed], New York Times, February 23, 1991. See also Baer “Do Trained Nurses . . . Work for Love, or Do They Work for Money?: Nursing and Altruism in the Twenty-first Century,” Nursing History Review (2009) 17: 28–46.

Naomi Rogers, PhD Program in the History of Science and Medicine Yale University

Inspiration and Guidance Arlene Keeling University of Virginia

Thank you for inviting me to join this panel and this program in honor of Joan. And, thank you Joan, for all that you have done for me and my career. With the exception of my mentor and friend Barbara Brodie, who introduced me to the world of nursing history in the first place, no one has influenced my career as much as you have! Little did I realize how much my professional life would change with my first presentation at the 5th Annual American Association for the History of Nursing (AAHN) conference. It was 1988—almost a quarter of a century ago! Then a second year doctoral student, I was presenting at AAHN for the first time—and was quite nervous as I recall. My topic was “The Human Side of High Tech Care: A History of Coronary Care in the United States, 1941–1970.” Julie Fairman’s talk on the history of ICU nursing in the United States preceded mine, and as I approached the podium, I distinctly recall thinking that there was no need for me to give my paper at all since she had come to the same conclusions as I had and had covered the topic very nicely. Nonetheless, I muddled through and afterward met Dr. Joan Lynaugh, who made very positive and supportive comments. Her comments, combined with my growing interest in nursing history from Barbara Brodie’s course and my attendance at AAHN meetings, led me to an increasingly strong feeling that I should be doing nursing history rather than a clinical research project in ­cardiac nursing for my dissertation. However, in my opinion in 1988, the timing was wrong; it was simply too late to change focus. Here I must segue to note that over the course of my career, I’ve looked to Joan’s editorials in Nursing History Review for inspiration and guidance—and on rereading them in preparation for this talk, was struck by her comments on “timing.” As she noted in one editorial: “As a historian, I am inclined to believe that, while timing may not be everything, it is a crucial variable in human affairs.” In my case, whether or not it really was not good timing is open to debate, but I stayed with clinical cardiac nursing for my dissertation. Nursing History Review 22 (2014): 126–131. A Publication of the American Association for the History of Nursing. Copyright © 2014 Springer Publishing Company. http://dx.doi.org/10.1891/1062-8061.22.126



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I graduated with a PhD in 1992, the same year that Barbara Brodie, Sylvia Rinker, and I opened the Center for Nursing Historical Inquiry. And, as Barbara will tell you later today, Joan Lynaugh played a pivotal role in its inception, advising us to focus on an active Center that fostered scholarly inquiry rather than hosting a museum. To us, from Day 1 the mission was clear: we needed grants and publications to prove the worthiness of nursing history as an area of study. Joan alluded to the necessity for scholarly publications in her very first editorial in the Nursing History Review writing: “The first volume . . . marks a significant next step toward assuring vigorous and useful scholarship in nursing history”—in other words, what “counted” would be peer-reviewed publications in a journal whose impact factor could later be measured. Convinced that in addition to publications in well-respected journals, I would need external funding to assure the validity of my new focus on history, I applied for a K01 from the National Institute for Nursing Research—a postdoctoral fellowship to prepare me as a nurse historian and to study the history of coronary care nursing. I turned to Joan to serve as the external ­mentor. According to Barbara Brodie, who no doubt had been working on this behind the scenes: “Joan Lynaugh thinks you might have some potential and has agreed to work with you.” Months later, I received news of the grant, and was of course delighted with the funding, but somewhat amazed at the congratulations I was receiving from my colleagues at Penn. Being a very new assistant professor, I actually didn’t really understand the significance of the K award. I was just happy to get the funding and begin a new phase of scholarship. That said, the grant opened the door to a unique and very gratifying professional relationship with Joan Lynaugh. From Joan I learned to write. Again, quoting another of her editorials: “. . . the task of writing is to make the narrative live for the reader in the same way it thrills us as we discover it. Good history tells the whole story, usually in chronological fashion with a beginning, middle, and end. It is a big challenge to set the time, get the facts right and in their proper context, and to do it in such a way that the reader clings to the story.” She also said: “I make no claim that this is easy!” And I would agree. I also learned to write in the active voice, and to ask myself if my history is (to quote Joan again) “any good—that is . . . good enough to read for fun?” In addition, I learned to make visible the invisible, for that is often the unique contribution of nurse historians to health care history. Although nurses represent the largest group of health care providers in the world, their gender, race, and class have often left them unnoticed in the great histories of medicine.

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Their visibility and the credit nurses should receive becomes the major argument I make in my work on the history of the Coronary Care movement in the United States. The title of that manuscript is “Sharing the Stage: A History of Coronary Care Nursing,” and I will be presenting it next spring here in Philadelphia in a conference celebrating the 50th anniversary of the coronary care unit (CCU). As Julie Fairman and Joan have argued: what was “intensive” about intensive care units and, in this case, intensive CCUs was the nursing—yet for the most part, the histories of coronary care focus on the famous cardiologists who ran them. Specifically, in the United States physicians Hughes Day and Lawrence Meltzer have been widely praised. In fact, several historians have credited the pair for creating a new role for nursing in the 1960s.1 Those histories overlook the contributions of thousands of nurses who worked in CCUs. One documented interview with Dr. Hughes Day particularly got my ­attention. When he was being praised for his success in developing coronary care in Kansas, Day noted that “half of the credit goes to Lawrence Meltzer”—who opened a CCU at Presbyterian Hospital in Philadelphia about the same time.2 Perhaps it was the way that Day phrased it—giving “half the credit” to Meltzer, rather than “to the nurses!” On reading those words, all I could think of were the words in the musical production of My Fair Lady, exchanged ­between Professor Henry Higgins and Colonel Pickering. Colonel Pickering is congratulating Higgins on his success in training the flower girl, Eliza Dolittle, to speak proper English. The scene occurs right after Eliza’s stunning performance at the Grand Ball where everyone thought her to be a royal duchess. The two men stand at Center Stage congratulating themselves while Eliza looks on from the wings. Later, discovering in my research that in his original grant application to ­establish a coronary unit, Meltzer proposed to determine “whether or not nurses could be trained” to interpret ECGs and “initiate a planned treatment program,” the analogy was locked. Like Higgins, Meltzer was conducting an experiment, predicting that with specialized education, he could influence the nurses’ status within the profession (like Eliza’s status was raised in society). After reading the medical histories about coronary care, I could easily imagine that the nurses who were involved in the CCU movement might feel much like Eliza. They too, have stood unobserved in the shadows of the stage, whereas cardiologists and technology have taken center stage. And, here is my point: it takes nurse historians, with a unique lens focusing on nursing, to challenge the conventional medical histories, bringing to light the many contributions of a large segment of health care providers.



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That unique perspective includes more than “making visible the invisible,” however, and from Joan I learned this early on. From the history of nursing, we can examine professional choices in context: analyzing for ­example—as Joan noted in another editorial—“how nurses chose to become employees during the 1930s instead of independent practitioners, how clinical ­innovations actually infiltrated nursing practice, or how unanticipated conflicts arise between professional ideals and the delivery of needed health services.” Context, like timing, is everything. The postdoctoral fellowship under Joan’s mentorship also introduced me to the cadre of nurse historians at Penn—the group of scholars with whom I feel most connected as I navigate the world of nursing history. We critique each other’s work, share resources and ideas, coauthor books and articles, and consult on each other’s projects. From that group has grown an ever-widening circle of international scholars of health care history—most of whom are connected in some way to Joan’s mentorship. Connected not only by Joan but also by AAHN and the two Centers for nursing history that she influenced, these scholars have presented nursing history papers in conferences here in the United States as well as in countries around the world. Apparently, “going global” was a goal Joan and others had from the beginning of the formation of the AAHN, when the organization was called “The International History of Nursing Society.” That goal has been achieved. So also has been the goal of uniting the group through the Review. As Joan noted in the 1993 issue: This first volume reflects our intent: to help all those interested in health care history to keep in touch with new and ongoing work, gain ready access to related historiography, and analyze the historical perspective on contemporary health care concerns.

The connections we have made between the Bates Center for the Study of the History of Nursing and University of Virginia’s (UVA) Bjoring Center for ­Nursing Historical Inquiry should not be left unnoticed. Together, the two ­Center’s ­research grants mechanisms, particularly the Brunner and Brodie Fellowships, have funded thousands of dollars in historical scholarship. My own recent funding from the Brunner Fellowship serves as only one example. That funding supported my work on the history of nursing in the 1918 influenza epidemic in Philadelphia: part of a larger study on the role nurses played during the 1918 pandemic in cities and towns across the United States. That research has resulted in several publications and presentations detailing the scope of the work Philadelphia nurses performed in large teaching hospitals, in makeshift emergency hospitals, and in homes throughout the neighborhoods of the city during the epidemic.

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Although many authors have written about medicine and public health ­ uring the Great Flu, far fewer have documented or analyzed the nurses’ story. d Once again, the unique perspective from the lens of nursing history challenges the conventional medical histories. There is no doubt that physicians and public health officials were instrumental in the nation’s response to the epidemic; nurses also played a significant part, dealing with patients and families on a day-to-day basis through the critical months of September, October, and November of 1918. In a recent paper on the topic that I gave recently at a conference on World War I medicine, I argued that because medicine had little to offer flu victims in 1918, and because Philadelphia civic and public health leaders had made no plans to deal with such a widespread flu disaster, it would be the nurses, aided by the spontaneous cooperation from medical and nursing ­students, religious groups, social agencies, society women, and local Red Cross ­volunteers, who provided the bulk of necessary care. That response blurred social boundaries and job descriptions, and challenged society norms. An ­excerpt from that paper follows: With the flu on a rampage, the city’s hospitals were soon over-flowing and emergency hospitals had to be established. Churches, synagogues, ware houses, country clubs, motion picture halls, and schools were all utilized.3 Emergency hospital #1 was set up at Holmesburg while the old Medico-Chirurgical Hospital was refitted with 200 beds and opened under the direction of Dr. George Meeker, dean of the Graduate School of Medicine at the University of Pennsylvania.4 The local Red Cross, under orders from Washington, also appealed to “Every healthy woman in the city” to help, and women of all social classes responded to this patriotic duty. Society women from the Main Line volunteered their private automobiles and set up soup kitchens in churches; Bryn Mawr College girls scrubbed floors and washed windows at the emergency hospitals; members of the Junior League assisted the Visiting nurses as they went house to house. Class boundaries blurred as people throughout the city tried to help in any way they could.5

The point is this story has not been told—or analyzed from the unique lens of nursing history using a social history perspective. From our unique ­perspective “as we study and interpret the history of nursing and health care”— once again quoting Joan Lynaugh—“we [can] realize fully the ­opportunity to shape the past.”6 The latter quote is from Joan’s last editorial in the Nursing History Review in 2002, when she turned the journal over to Patricia D’Antonio and her capable editorial skills. Her words, however, continue to guide us all as we investigate and reinterpret health care history and analyze its significance in shaping health policies today. That, in addition to her continued presence in



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the field of nursing history, reaffirms the fact that Barbara Brodie and I made a wise decision in naming Joan Lynaugh the first recipient of our Center’s prestigious Agnes Dillon Randolph award for “significant and sustained contributions” to scholarship in nursing history. The honor was well deserved! Notes 1. Mark Hilberman, “The Evolution of Intensive Care Units,” Critical Care Medicine 3, no. 4 (1975): 159–65. See also Bruce Fye, American Cardiology: The History of a Specialty and its College (Baltimore, MD: The Johns Hopkins University Press, 1996); E. Grey ­Dimond, “The First CCU: One Man’s Effort,” The View from the Hill, (December 1990; column repr., Public Relations Department, Bethany Medical Center); Richard Bing, ed., Cardiology: The Evolution of the Science and the Art (Philadelphia: Harwood Academic Publishers, 1992). 2. Joanne Ashtyn, “Interviews regarding original coronary care unit at Bethany Medical Center, Kansas City—with Dr. Hughes Day, Natalia Gill RN, Penny Rietfors RN and Judy Stuart RN” (Videotape. Original tape in the Public Relations Department, Bethany Hospital, Copy in the Keeling Collection, Center for Nursing Historical Inquiry, The University of Virginia [hereafter KC, CNHI], 1987). 3. Charlton Yarnall, “Report of the Vice-Director, Dept of Medicine, Sanitation, and Hospitals,” Emergency Service of the Pennsylvania Council of National Defense in the Influenza Crisis. Pamphlet 173: 6. Archives, The College of Physicians, Philadelphia. 4. Southeastern Pennsylvania Chapter of the ARC, “Repost in the Influenza ­Epidemic, Sept–October 1918,” NARA-CP, box 689, 803.11 influenza, p. 3. 5. No author: “Rich Women as Maids Serve in War on Grip,” Newspaper Clipping, VNS Scrapbook. VNS papers, BBCSHN, UPENN. 6. Joan Lynaugh, Editorial, Nursing History Review, 10 (2002): n.p.

Arlene Keeling, PhD, RN, FAAN Centennial Professor of Nursing Director, Eleonor Crowder Bjoring Center for Nursing Historical Inquiry 1410 Gate Post Lane Charlottesville, VA 22901-9587

PANEL 3: A NEW GENERATION OF SCHOLARS

A Graduate’s Gratitude Keith C. Mages Robert L. Brown History of Medicine Collection, University at Buffalo

I was a bit nervous on that Saturday morning, April 14, 2012. In the lobby of the University of Pennsylvania’s School of Nursing, a diverse group of ­scholars, students, and supporters had assembled to take part in an international ­symposium, an event meant to mark both the 25th Anniversary of the Barbara Bates Center for the Study of the History of Nursing as well as the life and accomplishments of Dr. Joan Lynaugh, the Center’s founding ­director (and resident Living Legend!). Had I been there simply to partake in the ­festivities, my nerves might have rested. However, I was to speak that ­afternoon. It was a great honor to be sure, but as a recent doctoral ­graduate, I was also ­intimidated. I had only just embarked on my scholarly path, yet there was my name in the program, published alongside a cohort of very ­accomplished, seasoned ­speakers. When the moment came, I consciously slowed my speech, took the time to pause at pertinent moments and delivered my paper. Today, my memories of the event are fond ones. The insecure ­moments have mostly faded from mind. Instead, I recall interesting conversation with other attendees, encouraging comments regarding my scholarship, and of course, the uplifting anecdotes that provided a more nuanced view of Joan’s life and work. Up until that day, I had known Joan for 5 years, from the perspective of a Penn graduate student. Afterward, I was able to add several decades’ worth of memories to my own, many from distinctly different points of view. Of all the insights gained, I was particularly struck by the notion of the generous scholar, that rare individual who freely ­imparts her insightful intellect so that another’s scholarship might more fully develop. Everyone it seemed, regardless of their vantage point, appreciated Joan for such remarkable generosity. I was not alone in my gratitude. Nursing History Review 22 (2014): 132–136. A Publication of the American Association for the History of Nursing. Copyright © 2014 Springer Publishing Company. http://dx.doi.org/10.1891/1062-8061.22.132



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If I pull the frame back though, I begin to realize that Joan’s intellectual openhandedness extends further than her individual connections. Joan’s viewpoint has been translated into an institutional mission. With a thriving archival repository, a cadre of internationally recognized historians, and a ­diverse assortment of historical activities, the Bates Center is a nexus of nursing ­history, perfectly suited to inspire, inform, and nurture the study of health care’s past. Quite reminiscent of Joan herself, wouldn’t you say? In an editorial written for the Journal of Professional Nursing’s reoccurring feature Inquiry, Insights, and History, Joan highlighted the Bates Center, as it was in 1991.1 Today, this piece is a time capsule. As I read her perspective on the Center as it stood two decades ago, I found myself actively comparing them to my own, more recent recollections. It made for an intriguing intellectual exercise, juxtaposing Joan’s past interpretation of the Center’s intentions against my recent experiences as a graduate student whom benefited from the Center’s accomplishments. In her piece, Joan noted the Center focused its resources on three goals: the establishment and growth of a repository, the production of historical research, and the dissemination of historical nursing knowledge. Galvanized by a “dearth of collected, usable nursing history material and the lack of curatorial services . . ., ” the first goal of the Center was to solve this problem. In 1991, Joan mentions the steps made toward that end. Through the support of generous individuals, the Center built a secured, ­climate ­controlled archival space. They joined the Research Libraries Information Network (RLIN), which allowed the Center to broadcast its holdings through an ­early-federated catalog. Furthermore, curator David Weinberg joined the Center to ensure proper management and preservation of the ­growing ­collection. When I came to Penn in 2006, it was to the same space Joan described those 15 years earlier. Betsy Weiss welcomed visitors as the Center’s archival and administrative assistant, working closely with curator Gail Farr. The reading room stood at the heart of the Center, with a small meeting room, the Director’s office, the controlled stacks, and a collections processing room radiating off of this central space. It was a pleasant space, one that I had only just settled into when word came that extensive renovations were slated to begin in spring of 2007. The Center was moving, transitioning into a new home. As I had a background in special collections librarianship, Center Director Dr. Julie Fairman asked if I would assist Gail, Betsy, and Center volunteer Ira Joel Sartorius with the move. Together, we calculated linear feet, took ­inventory, and prepared holdings for their temporary home in the ­University Records Center. Mary Clymer’s diary, records from the Philadelphia General

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Hospital, and Starr Center photographs were carefully counted and loaded into special boxes for transport. In these behind the scenes moments, I stumbled upon early 20th century mementos of a cruise ship nurse, an Auzoux anatomical uterus complete with papier-mâché fetus, and even a student nurse’s basketball uniform. Each record, photograph, and object was another corridor of nursing history. For a year, Center faculty and staff continued administrative operations from a temporary home in the LIFE building, further afield in Philadelphia’s west side. Faculty offices in the LIFE building featured shared bathrooms. Despite such luxuries, the distance between school and offices necessitated the use of shuttles. I tended to miss these convenient modes of transport and often ended up briskly walking the 15 blocks. When the Bates Center returned to Fagin Hall in August of 2008, the beautiful new space promised new ­beginnings, and the hope that I would once again be on time for meetings. The modern Center boasts a reception area complete with lockers for researchers, the Dr. Ellen D. Baer Reading Room, two temperature controlled archival spaces, a meeting room, workroom, and multiple offices for faculty and staff. After the retirement of Betsy Weiss, Tiffany Collier was brought on board as administrative coordinator. The work of the Center is now supported by Gail Farr and fellow archivists Sandra Chaff and Jessica Clark. Today, the  Center’s unique historical resources combine with a staff of remarkable talent. Joan’s vision of a world-class repository for nursing history has been actualized. Of course, the Bates Center is not only a repository; it is also a major center for the production of historical nursing research. In the Center’s first newsletter, published in Fall of 1986, Joan noted the Center’s faculty—consisting at that time of herself, Dr. Karen Buhler Wilkerson, and Dr. Ellen Baer—­ focused their research on the “evolution of the professional ideal in nursing, changes in American health care and educational institutions, and history of community/home care nursing.”2 In her Inquiry, Insights, and History piece, Joan mentioned that the Center had been established to foster historical ­methodology, but conceded that such endeavors were “. . . in some ways, a risky decision since financial support for historical research is limited.”3 In addition to their own lines of research, the Center’s faculty actively encouraged all graduate students to explore and seek funding opportunities. As with many research intensive universities, grant writing was an ­expected activity of doctoral students. To articulate my research endeavors as concisely and cogently as possible, I worked closely with my advisors Drs.  ­Patricia D’Antonio and Julie Fairman. Drafts went through several iterations ­before any were submitted. Although not all of my proposals were successfully



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funded, Pat and Julie helped me understand that every decision was ultimately a learning opportunity. If unfunded, reviewer’s critiques could help to sharpen my questions and voice. Funded grants provided access to repositories and enhanced my knowledge base. Each grant written was a mentoring opportunity, a task my advisors ­always seemed willing to undertake. The Center’s faculty have developed a deep commitment to such activities. Looking back to Joan’s Inquiry, ­Insights, and ­History editorial, this same dedication to mentoring was evidenced then, “[t] hrough seminars, preceptorships, advising and committee work . . .” Pat and Julie guided my research and pushed my questions further, ­always helping to uncover deeper insights. Dr. Barbra Mann Wall guided me in teaching methodology. For 3 years, I had the pleasure of working as her teaching assistant in one of our school’s upper-level history of nursing classes. Through her guidance, I became more comfortable (and capable) as a lecturer. Drs. Karen Buhler-Wilkerson, Jean Whelan, and Cynthia Connolly always had their doors open, I would often drop in to say hello and leave with a fresh perspective. And Joan herself, although always moving from one meeting to another, would frequently take a moment to chat before leaving me with much and more to think about. Together, these mentors introduced me to wider opportunities, to the ­individuals, and to resources available in Penn’s Department of the ­History and Sociology of Science, the American Association for the History of ­Nursing, and the American Association for the History of Medicine. ­During weekly seminars, they offered generously of their expertise and time. At these meetings, my intellectual curiosity was piqued by the presentations of ­invited speakers, or by the developing research of Center faculty and students. ­Post-seminar discussions were lively, enriching events. Each faculty member also inspired through teaching history. Course instruction and guest lectureships were expected activities. It always seemed to me, these women understood the classroom as not only a place to educate but also as a space to inspire, ­understand, and even provoke. Certainly, these are the things I took away from their lectures. Revisiting all of this, whether in person, via an editorial written ­during the early 90s, or through my own more recent memories, brings forth a sense of gratitude. For 5 years, my daily life revolved around a world-class archive, ­supported by an equally eminent cohort of faculty and staff. I learned, ­researched, and challenged myself among some of the best resources, historians, and students. Joan, your Center has truly flourished over the decades, take pride! It has touched the lives of many individuals, on levels both professional and personal. Together, you and your Center have instilled within us

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the hope that we too may enrich the lives of others through nursing’s proud professional history. Thank you Joan, for all that you have created. We, who have had the chance to learn from you, are truly the lucky ones.

Notes 1. Joan E. Lynaugh, “Nursing History Along—at Penn,” Journal of Professional Nursing 7, no. 1 (1991): 9. 2. Karen Buhler-Wilkerson, “Gala Celebrates Past and Future,” The Chronicle, ­Center for the Study of the History of Nursing 7, no. 2 (Spring 1995): 1. 3. Ibid.

Keith C. Mages, PhD, MLS, MSN, RN Robert L. Brown History of Medicine Collection University of Buffalo, Health Sciences Library Abbott Hall, B5 3435 Main Street Buffalo, NY 14214

Joan Lynaugh Winifred C. Connerton Pace University School of Nursing

My research involves the work of American nurses in the U.S. occupied territories of Cuba, Puerto Rico, the Philippines, and Hawaii at the beginning of the 20th century. Specifically, I look at how U.S. Army, colonial, mission, and plantation nurses contributed to the American imperial mission. This is an extension of my dissertation research, which was an examination of the role of nurses in the colonial occupied Philippines and Puerto Rico. I came to this topic out of my own clinical background. I am a certified nurse-midwife, and I have spent most of my professional life working in the New York City hospital system. There, most of my nursing colleagues were from other countries, in fact in my first nursing unit, I was the one of only two nurses trained in the United States on all three shifts. I was curious about this movement of nurses around the world, and I came to University of Pennsylvania expecting to study nursing migration. That plan got derailed, partially because I found out that other people had already looked at that phenomenon (specifically Barbara Brush who looked at Filipino nursing migration) and because I was interested in an earlier historical era. So I ended up going through old American Journal of Nursing (AJN) issues looking for what sort of international content was in there. It turned out that there was quite a lot, and that American nurses were going all over the world for many different reasons. These nurses wrote to the AJN fan­tastic  stories about their adventures and hard work. They travelled abroad as part of the first group of nurses in the Army Nurse Corps (ANC), as Protestant ­missionaries, and as civil service workers in colonial health programs. The letters included details about nurses’ hard work, with brave stories of how they persevered against disease in remote clinics far from any medical support, as well as great stories about their adventures. Perhaps my favorite of these is this 1903 description from Egypt: In the opposite direction the electric tram runs from the bridge to the Pyramids, which are seven miles out, completely surrounded by desert, with the everlasting Sphinx. These are best seen by moonlight, and many trips and parties are made up to Nursing History Review 22 (2014): 137–139. A Publication of the American Association for the History of Nursing. Copyright © 2014 Springer Publishing Company. http://dx.doi.org/10.1891/1062-8061.22.137

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Winifred C. Connerton visit them in the full of the moon. I have been there while the Nile was high, when earth and sky blend into glorious shades and cast exquisite tints on the water.

So I started thinking more seriously about American nurses and what they were doing overseas. My dissertation committee wisely limited me to the Philippines and Puerto Rico (I had wanted to study the whole world), and I went on to study the Army, colonial, and missionary nurses in both colonies. I had two major findings from this project. First was that American nurses were essential to the colonial endeavor. The army, colonial, and mission administrators all sought out trained nursing to advance their colonial goals. For the Army, this meant keeping the soldiers healthy and providing an acceptable level of care for those who were sick or wounded. For the colonial government and missionaries, nurses as individuals were representatives of a particular American way of life, and as a profession were an avenue for social reform. In fact, in both the ­Philippines and Puerto Rico, the mission and colonial administrators established nursing training schools as a way to “improve” local society. My second finding was that the presence of nurses in the colonial setting changed the domestic profession. This begins with nurses in the Army: they had to meet specific standards for their education to enter the ANC, specifically that they had attended a training school of 50 or more beds, and that included operating room training. The civil service nurses also needed to meet specific training standards, and also had to pass the nursing Civil Service exam. These requirements were put into place in 1900, far earlier than any school accreditation or national exam for nursing practice. In addition, these nurses practiced their profession as employees of the federal government, some of the first professional women to do so. U.S. nurses who worked in the American colonial Philippines and Puerto Rico were important representatives of “America.” Since I completed the dissertation, I have been in a postdoctoral fellowship through the Center for Health Outcomes and Policy Research and the Barbara Bates Center for the Study of the History of Nursing. During these 2 years, I have reconceptualized my dissertation by adding the territories of Cuba and Hawaii (you can ask me why I have left out Guam later if you like), and I have started considering nursing within the American national mission of expansion and imperialism. This new approach has pushed me to reexamine some material from the dissertation, as well as offered me the opportunity to do more research including a month long trip to Hawaii this last January. I could not have done this research without the support of the ­faculty at the History Center. Even describing the impact the center had on me is



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­ ifficult because I do not quite know where to begin. The collections were d ­simply invaluable. I was able to use materials here that were otherwise ­unavailable or would have been very difficult to find. The people are equally important, of course. As a student, I received mentorship and guidance from everyone, whether or not they were on my committee, and I learned by ­example as I saw them all work on various projects. Finally, the regular seminars were a great opportunity to meet other scholars, see the way the work develops, and ­participate in group discussion. It is impossible, too, to think about the ­impact the History Center has had on me and my work without thinking about Joan because she was so formative in the place and the people in the Center. I would like to end by talking a little bit about how important Joan has been to my own development as a scholar. The first thing that I realized about Joan is that she knows everything and everyone. For example, when I started the dissertation research she suggested that I begin in 1890. Joan didn’t ­explain why 1890, but I followed her suggestion and it didn’t take long before I saw the beginnings of international nursing organizing in the pages of the Trained Nurse and Hospital Review. Even though I started my project with the Spanish-American War of 1898, it was Joan that got me started with ­important background material for my topic. I always enjoy how, no matter what the topic, she has some thoughtful insight and suggestion. This came in handy for me as she read drafts of my dissertation and saved me from sure embarrassment on small details and made the entire product better through simple questions and suggestions. It was in those drafts, too, that I got to ­appreciate her comments in the margins—her use of the happy/unhappy face was quite effective, and their appearance certainly had an effect on my mood. Finally, on a personal level, I’ve enjoyed getting to know Joan, and I consider her my go to person for advice on “cat ailments.” Winifred C. Connerton, PhD, CNM Assistant Professor Lienhard School of Nursing College of Health Professions Pace University 163 William St., Room 511 New York, NY 10038

Reflections on a Legacy of Mentorship Margo Brooks Carthon University of Pennsylvania School of Nursing

Despite their importance, our mentors and advisers rarely receive the high praise that they are most deserving of unless we are to count the acknowledgments that we are obliged to provide at the outset of dissertations or at the close of a published manuscript. So, having this opportunity to openly reflect on the indelible impression that an individual mentor has provided and the ways in which Joan has helped to inform my scholarship is indeed, for me, a happy occasion. For the past 8 years, I have spent a great deal of time and energy researching the social, historical, and cultural underpinnings of health disparities, particularly among racial minorities and individuals with low resources. Most of us here today are likely aware that those racial minorities and those with lower incomes suffer worse health outcomes. African Americans, for instance, suffer higher rates of mortality across most health indices, experience a higher prevalence of AIDS/HIV, are more likely to be uninsured or underinsured, have increased constraints on their access to health care, experience lower rates of satisfaction with their health care providers, and report higher rates of mistrust of their medical providers and lower use of health care resources. My research as a historian over the past 8 years has attempted to unravel some of the complex undercurrents driving these health disparities. And seeks to understand what nurses and communities can do to improve health outcomes in racial minority communities. That journey began in 2004 with a dissertation that would seek to capture the illness experience of Blacks living in Philadelphia at the turn of the 20th century. Using tuberculosis as a vehicle, I sought to discover how communities made sense of illness and created partnerships and networks of support to address the pressing health and social needs of Blacks living in the city. In the early months of my doctoral study, I had a deep interest in the Black church for I imagined that it was a site where the Black community had coalesced to gain information about the risk of infectious diseases such as tuberculosis. Nursing History Review 22 (2014): 140–143. A Publication of the American Association for the History of Nursing. Copyright © 2014 Springer Publishing Company. http://dx.doi.org/10.1891/1062-8061.22.140



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I was, in fact, convinced that the Black church had been on the front lines of a “tuberculosis health movement.” I had my reasons for my suspicions. The Black church, of course, has historically served as a central institution in the Black community—providing both moral and social consciousness. And there were of course precedents to support my suspicions particularly in Philadelphia. For instance, Richard Allen and Absalom Jones and the Free African Society provided essential medical and nursing aid during the Yellow Fever epidemic of the late 18th century. And the records of Frederick Douglas Hospital, a Black run hospital located here in Philadelphia at the turn of the 20th century, indicate that it received financial support from churches. So being the good fledgling historian that I was, I began to conduct some reconnaissance to see what archival resources remained to support my suspicions. After a trip or two down to Mother Bethel and to several other historic churches, you might imagine my surprise when there were no well-cataloged boxes with file folders waiting for me with information about church activities from 100 years ago. To be sure, Mother Bethel kept some records, but not of the sort that would necessarily have been helpful to someone conducting a dissertation (and one hoping to finish in the next decade). So I took my findings to my dissertation committee comprising the fabulous Dr. Julie Fairmain, the dynamic Dr. Barbara Savage, and of course the sage Dr. Joan Lynaugh—to lament. And this is where the magic would happen. Never one to dash a student’s hopes but ready to encourage and when necessary redirect, I recall Barbara Savage saying to me, “Well Margo, was there a black church health movement?” Hmm, well not that I can put my hands on. Then Joan added in that way that only she could, “Well you might want to check . . .” (so here it is friends, this is where you start feverishly scribbling notes to make sure that you catch precisely what she says next because you know that she knows just about everything). Well you know, she continued, “you might want to talk to Margaret ­Jerrido the archivist over at the Temple Urban Archives.” And yes, she was right! I would talk to ­Margaret Jerrido and although she was on her way into retirement, the Temple Urban Archives would be a second home to me for many months during my dissertation. It was here that I fell upon the records of the Whittier Center, a civic association established here in Philadelphia in 1912 under the helm of social progressive Susan Parrish Wharton. The Whittier Center was, of course, known to many historians as the benefactor association responsible for paying the salary for the first Black tuberculosis nurse to work here in Philadelphia for the Phipps Institute. My own work would expand on that understanding of

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the Whittier Center’s role in health care and trace its work with the Black community back many decades. So again, quite excited with this new road that I found myself travelling, I return to my dissertation committee to report that perhaps it was these social organizations in the communities that were most critical to the provision of health and social services to Black community members? Eureka! Well, says Joan “if you’re ­interested in those types of voluntary settlement type organizations you might want to check out the Starr Centre records. You know we have them here at the Bates Centre.” So that would begin yet another phase in my research, a phase that would take me back into the late 19th century, to the haunts of W.E.B. Du Bois and the 4th, 5th, and 7th wards of Philadelphia. And it was here that I would explore the Starr Centre and its gardens and penny lunch programs, and dispensaries and the Coal Club and the Rainy Day Society. This is where my dissertation started to speak to me. Both the Coal Club and the Rainy Day Society were mutual benefit societies composed of Black community residents and operated through the Starr Centre and later the Whittier Center. Each was purposed with the mission of providing sorely needed goods and services to their members. The Coal Club for one provided a cooperative opportunity for members to collectively purchase coal, whereas Rainy Day Society members pooled their resources to provide a sick fund for members. The inner workings of these cooperatives became the cornerstone of my thesis on understanding how community health promotion could be successful in minority communities. First, I would argue, it would be through creating partnerships and relational ties and second, by focusing attention on community building and meeting material needs. Then perhaps someone may be prepared to listen to lectures about health. And indeed they were. Since completing my dissertation, I have continued to maintain interest in minority health outcomes and policy and the provision of health care, particularly in safety net settings. And with that even now one of Joan’s comments continues to stay with me. In one of our discussion about Black hospital closure, Joan questioned “with the passage of Medicare majority hospitals had to begin to admit black patients to get paid, and not long after many black hospitals began to close. I wonder what happened to all of those ­patients?” Where, indeed, did they go? Did they go to our large medical centers? Or did they forego health care altogether unless absolutely urgently required. And 50 years since the passage of Medicare, where are minorities receiving care now? Are they going to local emergency rooms, retail clinics, or community health centers? And who is most capable of providing



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this much needed care—physicians, advanced practice registered nurses, or both? Well, indeed that is what the next phase of my research will uncover. Please stay tuned. So, I will stop here with a word of thanks to Joan, who has always been a strong supporter of my work. At times I think that she thought it was more interesting than I did. And at times that was exactly what I needed. So, I thank you today Joan as well as my other champions here in this room today—you know who you are! Margo Brooks Carthon, PhD 306 Sugar Bush Court Mullica Hill, NJ 08062

Notes and Documents

Edward L. Bernays and Nursing’s Code of Ethics: An Unexplored History Guy Philbin Notre Dame of Maryland University David M. Keepnews Hunter College and City University of New York Graduate Center

The Code of Ethics occupies a special place in the nursing profession. A code of ethical conduct, as Marsha Fowler notes, is of vital importance because it “stands as a central and necessary mark of a profession. It functions as a general guide for the profession’s members and as a social contract with the public that it serves.”1 The Canadian Nurses Association explains that the code is a “statement of the ethical values of nurses and of nurses’ commitments to persons with health-care needs and persons receiving care.”2 Harold Sox calls codes of ethics “the tangible expressions of professionalism” and “arguably the way a profession defines itself to the public.”3 Establishing a code was a priority for the American Nurses Association (ANA) at its founding in 1896.4 Although ANA considered a ­Proposed Code in 1926 and a Tentative Code in 1940, it was not until 1950 that it ultimately adopted the Code for Professional Nurses.5 Three years later, the International Council of Nurses adopted its code of ethics (most ­recently revised in 2012).6 Since that time, numerous national and regional ­nursing organizations and regulatory bodies have adopted similar codes. We ­submit that a significant but unexplored factor in the ANA’s adoption of the Code for Professional Nurses in 1950 was the role played by Edward L. ­Bernays, a widely known U.S. public relations expert who served as an ANA ­consultant from August 1947 to April 1949. As part of his efforts to achieve Nursing History Review 22 (2014): 144–158. A Publication of the American Association for the History of Nursing. Copyright © 2014 Springer Publishing Company. http://dx.doi.org/10.1891/1062-8061.22.144



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wider recognition for nursing as a profession, he pressed for the adoption of a code of ethics from the beginning of his brief tenure with ANA until his termination.

Edward L. Bernays: “U.S. Publicist No. 1” Bernays’s profound contributions to the field of public relations have been well documented by Stuart Ewen and Larry Tye among others.7 “To put it simply,” in the words of Ewen, “Bernays’ career—more than that of any other ­individual—roughed out what have become the strategies and practices of public relations in the United States and, increasingly, on a global scale.”8 ­Bernays was often called “the father of modern public relations”9 and “U.S. Publicist No. 1,” a title attributed to him by Time magazine. Bernays, a nephew of Sigmund Freud, focused his efforts on shaping public opinion in support of his clients. He defined his basic approach as follows: first, “To intensify the favorable attitudes of a public we already have”; second, “To convert a public we do not have to our point of view, and to get them to undertake actions on our behalf ”; and third, “To negate or blanket a public against us.”10 He called this approach, which was based on propaganda techniques developed during the First and Second World Wars, “the engineering of consent.”11 He prided himself on his ability to manipulate public opinion. His efforts went beyond merely seeking publicity for his clients. “I never visited newspapers,” he told a reporter in his later years, “I created circumstances.”12 He “created circumstances” for a wide variety of clients, ranging from presidents and entertainers to major corporations and civic organizations. His campaign for the American Tobacco Company, which made smoking in public acceptable for women in the 1920s, tied smoking to women’s social status and independence; it included a march of women holding lit cigarettes, ­described as “Torches of Liberty.”13 To promote soap use among ­schoolchildren (on ­behalf of his client, Procter and Gamble, who hired him to boost sales of its Ivory Soap brand), he developed a National Soap Sculpture Contest with a noteworthy panel of judges.14 He helped increase flagging sales of hairnets by devising a campaign to link their use to workplace safety.15 Bernays worked on behalf of the Committee on the Cost of ­Medical Care, a high-profile, foundation-supported initiative whose 1932 report ­included recommendations to reorganize health care services to make them more widely accessible. These recommendations included encouraging group medical practices and voluntary or tax-supported medical insurance.16 ­Bernays conducted

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a widescale public relations campaign to urge the implementation of these ­recommendations. The American Medical Association (AMA), however, which strongly opposed the Committee’s recommendations, derailed them through a public relations campaign of its own, likening the proposals to socialism and Communism in a widely cited editorial in the Journal of the American Medical Association (JAMA). Editor Morris Fishbein declared that the report and its recommendations posed the question of “Americanism versus sovietism for the American people.”17 Bernays reportedly remained openly resentful of the AMA for decades afterward.18 Some of Bernays’s services were more controversial. In 1954, while working for the United Fruit Company, he helped lay the groundwork for the overthrow of Guatemala’s elected government, which had initiated agrarian reforms that threatened some of the company’s land holdings.19 As biographer Tye put it, Bernays “realized that controversy breeds coverage, which ­almost ­always was good for his client.”20 Bernays pioneered the use of opinion ­surveys as a ­marketing tool, not only for collecting data to help formulate his campaigns but also by surveying experts and reporting his findings in a ­manner that would most effectively bolster the image of a client or product. For ­example, based on his survey results showing that physicians favored eating a “hearty breakfast,” he devised a successful campaign in behalf of Beech-Nut Packing Company promoting a “bacon and eggs breakfast.”21 In like manner, his work for ANA was founded on a series of articles themselves largely based on opinion polls. The endgame for these articles was the same: to bolster the image of nurses and present the nursing profession in the most positive light possible.

Bernays and Nursing Bernays’s work on behalf of nursing began in 1945 when Mary M. Roberts, longtime editor of the American Journal of Nursing (AJN), commissioned him to write a series of articles. At the time, the nursing profession suffered from a severe workforce shortage, low pay, growing dissatisfaction, and a low level of understanding of the nurses’ functions and responsibilities by the public (and often by nurses themselves). Bernays’s articles detailed the status of nurses and how they could improve their position in postwar America.22 The editors first introduced Bernays to AJN readers in the May 1945 issue, publishing a talk he had given to the New York City affiliate of the National League of ­Nursing Education.23 The Editor’s Note to this piece identified Bernays as “a very well-known public relations specialist, described by Time magazine as



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U.S. Publicist No. 1, who has solved public relations problems for corporations, philanthropists, institutions, industrial organizations, and individuals,” and cited his work on behalf of the Committee on the Cost of Medical Care. Bernays called on nurses to adopt a realistic approach to image building that depended on two factors: “One is that you and the public understand each other; and the other is that you definitely meet the real needs of the public for nursing service.”24 In his AJN series of 16 short articles written between 1945 and 1946, Bernays outlined how nurses were viewed by physicians, hospitals, patients, educators, and the general public, grounded by what the editors called “factfinding and public opinion measurement [techniques] which have been used successfully to meet comparable problems in other fields.”25 The series began with a foundational piece focusing on nursing’s contribution to the American victory in World War II. An editors’ note outlining the content of the series reads in part: The articles that follow will attempt to appraise . . . the existing relationships between the nursing profession and the great social forces that make up America— the relationships of nursing with medicine, public health, government, community services, hospitals, public opinion and other important fields of our society. They will attempt to interpret these relationships and will make recommendations, that [sic] individual nurses or nursing societies may use to produce better adjustment.26

A list of Bernays’s AJN articles is included in Table 1. Bernays reprised the main points of his series in an article entitled “­America Looks at Nursing: A Summation,” in which he asserted that the nurse would not gain “true professional status until she raises her prestige.”27 Not surprisingly, he concluded that a robust public relations program was absolutely necessary for the profession: Leaders themselves admit they do not know as much as they should about nursing, and believe the people lack information. A public relations program, planned to educate Americans about the types of nursing service available and the goals and standards of the profession, should help the nurse to achieve professional status.28

He explained that this program “can and should publicize [nursing’s] standards and aims so that [the American people] will know them and be sympathetic with them.”29 In his memoirs, Bernays wrote that his AJN series “created a stir in the profession, whereupon the American Nurses Association, as Miss Roberts had

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TABLE 1. Edward L. Bernays’s Articles for the American Journal of Nursing “The Nursing Profession: A Public Relations Viewpoint,” AJN 45, no. 5 (1945): 351–53. “The Nurses’ Contribution to American Victory: Facts and Figures from Pearl Harbor to V-J Day,” AJN 45, no. 9 (1945): 683. “The Medical Profession and Nursing,” AJN 45, no. 11 (1945): 907. “Opinion Molders Appraise Nursing,” AJN 45, no. 12 (1945): 1005–11. “What Government Officials Think About Nursing,” AJN 46, no. 1 (1946): 22–25. “Hospitals and the Nursing Profession,” AJN 46, no. 2 (1946): 110–13. “The Armed Services and the Nursing Profession,” AJN 46, no. 3 (1946): 166–69. “Nurses and Their Professional Organizations,” AJN, 46, no. 4 (1946): 229–33. “Nursing and Community Groups,” AJN 46, no. 5 (1946): 297–99. “Educators Appraise Nursing,” AJN 46, no. 6 (1946): 372–74. “Nurses and Business,” AJN 46, no. 7 (1946): 475–77. “Social Scientists Look at the Nursing Profession,” AJN 46, no. 8 (1946): 518–19. “America Looks at Nursing: A Summation,” AJN 46, no. 9 (1946): 590–92. “What Patients Say About Nurses,” AJN 47, no. 2 (1947): 93–96. “A Better Deal for Nurses,” AJN 47, no. 11 (1947): 721–22. “Nursing and Its Public,” AJN 48, no. 12 (1948): 744–47.

anticipated, engaged us to advise them on public relations to improve their ­position.”30 While ANA’s decision to hire Bernays and his organization may thus have not been surprising, it is no exaggeration to say that if any group sought to launch a major public relations effort in 1947, it could not have ­chosen a better-known, more high-profile consultant. ANA initially contracted with Bernays as a public relations counsel for a period of 1 year. It convened a Committee on Public Relations, to be staffed by Bernays’s organization, which held its first meeting in July 1947. Based on the initial work of this ­committee, Bernays made an animated presentation before ANA’s ­leadership at a meeting of its Advisory Council on January 17, 1948. On a cold and blustery Saturday, the council, comprising the Board of Directors and representatives of each state affiliate, met at New York’s Henry Hudson Hotel. Snow had fallen outside while a killer blizzard was gripping the U.S. Midwest. After handling ­several routine items in the opening business meeting, ANA President Katharine J. Densford introduced the topic of public relations by exclaiming: “I have pleasure now in presenting the outstanding public relations counsel in the United States of America—Mr. Bernays!”31 Bernays took the podium and laid out a detailed plan of work based on resolutions adopted by ANA at its 1947 House of Delegates meeting. In a slide accompanying his speech entitled “The Six Planks of Our Platform,” Bernays listed these areas of focus: economic security, legal control (i.e., mandatory nursing licensure, which had



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not yet been achieved in all states), placement and counseling, recruitment, quality nursing service, and public recognition. In regard to quality nursing service, Bernays’s presentation stated that, “The nursing profession is proud of its standard and seeks constantly to give the public the best possible nursing service.”32 He told his audience that they had embarked on a program using “the engineering of consent” to better the status of nurses by forming positive public opinion. .

Raising Nursing’s Visibility During his relationship with ANA, Bernays worked to raise the visibility of nursing in America with a barrage of press releases, radio spots, and public relations events designed to dramatize and humanize nursing. His staff also conducted a series of public relations workshops for nurses around the country.33 His largest scale project for ANA focused on nursing’s ­Diamond ­Jubilee, which celebrated 75 years since the founding of the first nursing schools in the United States. For this event, Bernays used opinion leaders to dramatize the ANA’s priorities—telegramming President Harry ­Truman to urge him to declare a nursing crisis, telephoning the governors of every state to elicit support for nursing’s agenda, and drawing numerous ­luminaries to endorse and attend a highly publicized banquet to commemorate the ­Jubilee.34 The ­Diamond Jubilee Banquet was sponsored by a committee that included, among others, Truman (who served as chair), former ­President Herbert Hoover, the surgeons general of the army and navy, University of Pennsylvania President and former Minnesota Governor Harold E. ­Stassen, University of Chicago Chancellor Robert M. Hutchins, writer Walter Lippmann, author Fannie Hurst, and the presidents of the American College of Surgeons, the American Hospital Association, and the American Medical Women’s Association.35 In addition to these efforts, Bernays also played a key role in reviving ANA’s efforts to adopt a code of ethics, which had been a longstanding but elusive goal for ANA. As Mary Roberts later explained: The uncertainties of the mid-century indicated imperative need for a code of ethics. The preparation and publication of a code had been one of the initial purposes of the association, but action had been deferred until the organization should have a body of experience on which to build. Tentative codes had been published, for discussion preliminary to formal action, in 1926 and 1940, but neither was completed.36

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ANA leaders were well aware of the importance of having a code of ethics. Even before it adopted its code in 1950, ANA used the previously ­proposed but unadopted codes in support of elevating the professional status of nurses. A successful 1946 brief filed by ANA with the U.S. Civil Service ­Commission  requesting reclassification of federally employed registered nurses from the ­Subprofessional Service to the Professional and Scientific Service cited the 1926 and 1940 proposed codes as evidence of nursing ­professionalism.37 Although Bernays advocated adopting a code of ethics, his advocacy was not necessarily motivated by a commitment to ethics or professionalism per  se, but rather was part of his approach to the effective promotion of a profession. He suggested a four-part formula for status and recognition for every profession. The first three steps were to define the profession, mark the educational requirements, and specify required experience. The final step was to “determine standards of ethical conduct.”38 His belief that adopting a code of ethics would help boost nursing’s image was not made explicit in his articles or other public pronouncements, but it was clearly on his agenda. In his first report to the newly formed ANA ­Committee on Public Relations in July 1947, he included ethical standards as one of the external themes aimed at the general public to help establish “the  place of nursing in the U.S.A.”39 Minutes from that initial meeting ­indicate that one of his staff members was to be appointed to execute plans previously outlined by ANA’s Committee on Ethical Standards, which had remained ­inactive after the unsuccessful 1940 effort to adopt a code. At that meeting, Bernays proposed staging a dramatic event to crystalize the complex issues of nursing ethics in the minds of Americans. He suggested hosting a meeting of experts, with ANA having the ethical standards already prepared and calling for them to be codified in the interest of the public and of nurses. “This would immediately develop into a news story,” he argued, “which might say, ‘leading social scientists confer at Hotel Plaza with nurses committee to set up ethical standards for nursing profession, etc.’” The public relations splash Bernays proposed never came to pass. But after some delay, the committee’s temporary chair, Sister Mary Berenice Beck of Marquette University, sent a questionnaire to state nurses’ association presidents and executive secretaries, asking whether ANA should have an ethics committee, what its functions should be, what it should attend to, and what it should omit.40 Of the 44 responses obtained, 38 indicated that such a committee was needed and that a professional code with guiding principles should be developed. The results of this survey formed the basis of a lively discussion on the need for a code of ethics at the January 1949 meeting of the ANA



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­ dvisory Council. A tentative report from Beck’s committee outlined what A had not been done as of that time and suggested that the ­Committee on Ethical Standards provide advice on ethical issues to the ANA Board of ­Directors, state nurses associations, and individual members. The report also proposed that the Tentative Code put forward in September of 1940 be ­revised, ­adopted, continuously studied, and modified to respond to changing needs and conditions of the profession.41

Delay and Mark Time As work on the code moved forward, Bernays’s brief tenure with ANA was nearing its end. In July 1948, ANA had renewed his 1-year contract for an ­additional year. But a November 30, 1948 memorandum from Janet M. ­Geister, chair of ANA’s Public Relations Committee, proposed that “current [public relations] activities should mark time, and present projects be brought to a conclusion.” Insisting more reflection was needed before further action was taken, she advocated intense discussion of policies and practices before deciding on a public relations program for 1949.42 At an ANA Board meeting 9 days later, she was more blunt, questioning the effectiveness of Bernays’s ­services and asserting that they had been “planned by people who know nothing about nursing.”43 Geister, who had been appointed chair of the Committee on Public Relations just a month earlier, came to that position with considerable authority in ANA and the profession. She had been ANA’s executive director from 1927 to 1933. A prodigious author and researcher, she served as editor of Trained Nurse and Hospital Review. Her appointment as public relations chair signaled the beginning of the end of Bernays’s work for the association. In January 1949—on the heels of Geister’s memorandum wrapping up current public relations projects—newly elected ANA President Pearl S. ­McIver, citing drastic budget reductions, gave Bernays notice that his services would no longer be needed as of May 1. This was 3 months prior to his ­contract’s scheduled expiration.44 Based on a series of internal notes attached to various reports, it appears that Bernays and his staff continued their work on the code of ethics during the last months of his association with ANA, researching and presenting the work that had been done on the code to date, and suggesting courses of action to be followed. Through the Committee on Public Relations, which was staffed by ­Bernays’s organization, the Committee on Ethical Standards was asked

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to ­consider ­formulation of a philosophy to guide its ethical inquiry. A ­December 9, 1949 memorandum from David U. Snyder (one of Bernays’s staff members) to Alma H. Scott (a member of the Committee on Public Relations and a former longstanding member of the Board of ­Directors) suggested: In case the point comes up again, you might find of helpful reference these definitions of: philosophy, policy, principle. It would appear to me the policy directive governing the public relations program is laid down in the . . . [resolutions] adopted at the Bienniel [sic; referring to the 1947 ANA House of Delegates meeting]. The Committee can, of course, adopt a supplementary public relations policy directive, or more exactly, a definition of public relations principles, which would establish a settled rule of action or frame of reference under which the work-a-day mechanics of the public relations program can go forward.45

However, when asked to explain this request at a January 1949 meeting of the Committee on Ethical Standards, Scott instead recommended delay— most likely reflecting the leadership’s new approach to public relations work and to Bernays, specifically.46 A note from Bernays’s staff member, accompanying materials from the prior Committee on Ethical Standards, stated: This exhibit brings the history of the committee up to 1933. You may wish to consult the Curriculum Guide [for Schools of Nursing] of 1937 for the outcomes regarding the course in ethics for schools of nursing. . . . Thereafter, though the [C]ommittee [on Ethical Standards] continued activities, neither a code, a pledge, nor a set of guiding principles were developed in final form, though, as you will note, a tentative code appeared in the A.J.N. [sic] in September 1940.47

Adopting the Code of Ethics After Bernays’s departure in May 1949, work on the code continued through ANA’s Committee on Ethical Standards, Advisory Council, Board of Direc­ tors, and chairs of its structural units, as well as leaders of other national nursing organizations. In September, AJN published a notice inviting nurses to “participate in formulating a code of ethics for nurses.” Interested readers were directed to send a request to ANA to receive a checklist of the proposed code statements. The notice further explained that “it is hoped to have the code ready for final consideration by the House of Delegates” in May 1950. In addition to soliciting responses from individual nurses, ANA distributed checklists to other national nursing organizations, state and district nurses



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a­ ssociations, employers, and schools of nursing. Upward of 375 responses were received. Because most of these were sent by groups, ANA officials subsequently estimated them to represent the opinions of 4,789 persons.48 This skillful use of survey results may itself suggest that Bernays’s influence survived his departure from ANA. In January 1950, Roberts coordinated and edited the proposed code that the Committee on Ethical Standards ultimately had produced, ­incorporating changes suggested by the Advisory Council and Board of ­Directors. The April 1950 AJN then featured the proposed Code for ­Professional Nurses.49 In May 1950—a year after Bernays’s departure—the Code was approved unanimously by the House of Delegates at its meeting in San Francisco. When the vote was confirmed, ANA President Pearl McIver announced: “I want to congratulate this house for adopting the professional code after the many years of consideration. I believe it is ­really something we should all be proud of. I particularly want to thank the committee for their work.”50

Appraising Bernays’s Role There should be no question that the development and adoption of nursing’s code of ethics was accomplished through the active leadership and commitment of ANA volunteer leaders and the participation of thousands of other nurses. The code fundamentally reflected nursing’s professional values, ­expressed in the context of nursing’s experience and documenting its contract with society. In the six decades since the code was adopted, it has continued to occupy a place of central importance for nursing and ANA. The code has been revised several times since 1950, most recently in 2001.51 At the same time, it appears that Bernays played a significant if rarely discussed role in the process of adopting a code. It was part of his public relations strategy for elevating the status of a profession by setting and ­disseminating clear standards, and it is clear he sought to move ANA ­toward adopting a code. During Bernays’s brief association with ANA, he restarted efforts to adopt a code following years of inactivity. Although his star had fallen at ANA by the time the Code for Professional Nurses was finally ­approved, it seems clear that he played a significant role in catalyzing and revitalizing ANA’s efforts to adopt a code of ethics—efforts that bore fruit at the House of Delegates in 1950. The role of Edward L. Bernays in reaching this historic moment was unacknowledged and has remained so since.

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If anything, as time has passed, his role in the code’s adoption has passed into further obscurity. There are a few likely reasons Bernays’s role in adopting the code remained largely unexplored. First, while he was in many ways a relentless ­self-promoter, he also recognized that an effective public relations effort often requires keeping its source invisible. His tactics frequently focused on staging “­spontaneous” events to popularize a cause or product. In fact, as noted earlier, his initial proposal for spurring adoption of a code of ethics had involved such an event. Second, this was precisely the kind of effort in which he would have sought a low-profile role—to do otherwise would have been poor public relations practice. Of course, Bernays was generally glad to take credit after a successful campaign, because this helped bolster his reputation and legacy. Third, in this instance of adopting a code of nursing ethics, ANA continued the effort to its successful conclusion after Bernays had been terminated. Thus, not only would it have been uncharacteristic for him to publicize his role before adoption of the code; it would not have been in his interest to do so afterward. Fourth, professional associations are often hesitant to give credit to “­outsiders,” defined as external consultants who are not members of the profession. In fact, the role of such a consultant is arguably to support an organization’s members and staff and to position the organization, not to take credit for his or her efforts. Bernays’s arrival at ANA had clearly been greeted with great enthusiasm by many. But his departure came soon after election of a new ANA leadership, one that—to judge by its actions—either failed to share that enthusiasm or perhaps decided Bernays had outlived his usefulness. Budget problems may, as claimed, indeed have played a role in his termination. But given such a high previous profile to his consultancy, and the criticisms that preceded the ­decision to terminate him, it seems unlikely the savings represented by ending the contract 3 months early was the decisive factor. The ANA may have also been particularly uncomfortable with the aggressive efforts of this public relations “outsider” to implement his vision for advancing nursing. It is worth recalling the words of ANA public relations Chair Janet ­Geister’s ­December 1948 memorandum that “any public relations program for nursing must begin within the profession.” Despite (or perhaps because of ) ­Bernays’s ­preeminence as a master of public relations, he also drew his share of criticism from those who viewed his tactics—his “manufacture of consent”—as manipulative and even amoral. Thus, there may have been particular reticence to speak of his role in something with as much special significance for nursing as its code of ethics—a document that expresses the moral center of the profession.



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The idea that the ANA’s ultimate success in adopting a code of ethics was caused, even in part, by the efforts of a public relations expert, especially one seen by many as amoral, should not diminish the significance of this success, or the continuing importance of the code. Bernays believed that a code of ethics was an essential element of professionalism and a crucial step in elevating the status of any profession. In this respect, his perspective did not differ significantly from those of many others, including nursing leaders. It should also be emphasized that he does not appear to have played—or even sought—a role in developing the substantive provisions of the code. That was the province of nursing leaders.

Conclusion In the 1940s, assigning an important role to public relations and marketing professionals in nursing and health care may well have seemed bold or even controversial. Today, such professionals are routinely employed by professional associations. Social marketing techniques are widely used to deliver health-related messages to the public. Projecting a realistic and positive image of nursing is widely viewed as a priority for the profession and, in fact, is currently cited by ANA as one of its purposes.52 The U.S. public perception of nursing as the most trusted profession—as regularly revealed in annual surveys by the Gallup Organization, most recently in 201253—is understandably a point of pride for the profession, and its ­organizations have not been hesitant to recognize the public relations value inherent in being trusted. Efforts to popularize nursing as a profession, such as Johnson & Johnson’s Campaign for Nursing’s Future,54 have continued to use professional public relations strategies and techniques in the United States. As was true for most of his professional career, Edward L. Bernays, the hand behind the curtain, was nowhere to be seen when the code was ­adopted. Bernays’s outré suggestion for how to go about obtaining the maximum public relations effect in the adoption of a professional code of ethics for nursing fell on deaf ears, and he was not successful in having the ANA adopt a code of ethics during his tenure. Yet by providing clear guidance about what had been done and what remained to be done, he gave the ­project renewed impetus and acted as a catalyst for its subsequent adoption. His role in activating the ethics committee, providing it with clear direction, and positioning the nursing profession to finally adopt its ethical standards

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adds to our understanding of the history and development of the code of ethics, and it should be acknowledged.

Notes 1. Marsha D. Fowler, Guide to the Code of Ethics for Nurses: Interpretation and ­Application (Silver Spring.: ANA, 2010), ix. 2. Canadian Nurses Association, “Code of Ethics for Registered Nurses,” http:// www2.cna-aiic.ca/cna/practice/ethics/code/default_e.aspx (accessed September 2, 2012). 3. Harold C. Sox, “The Ethical Foundations of Professionalism: A Sociologic ­History,” Chest 131, no. 5 (2007): 1532–40. 4. Fowler, Guide to the Code of Ethics, xiv. 5. “A Suggested Code: A Code of Ethics Presented for the Consideration of the American Nurses’ Association,” AJN 26, no. 8 (August 1926): 599–600; “A Tentative Code: For the Nursing Profession,” AJN 40, no. 9 (September 1940): 977–80; “A Code for Nurses,” AJN 50, no. 4 (April 1950): 196. 6. International Council of Nurses, “ICN Code of Ethics,” 2012, https://www.icn .ch/about-icn/code-of-ethics-for-nurses/ (accessed December 5, 2012). 7. Stuart Ewen, “Introduction,” in Crystallizing Public Opinion, ed. Edward L. ­Bernays (1923; repr., Brooklyn, NY: Ig Publishing, 2011); Stuart Ewen, PR! A Social ­History of Spin (New York: Basic Books, 1996); Larry Tye, The Father of Spin: Edward L. ­Bernays and the Birth of Public Relations (New York: Crown, 1998). 8. Ewen, “Introduction,” 10. 9. “Edward Bernays, ‘Father of Public Relations’ and Leader in Opinion ­Making, Dies at 103,” New York Times, March 10, 1995; “Propaganda Battle,” Time 31, no. 4 (­January 24, 1938): 28. (Time had actually dubbed him “the nation’s top publicist,” but the title has been almost universally cited as “U.S. Publicist No. 1.”) 10. Edward L. Bernays, Memorandum to ANA Committee on Public Relations, 1 December 1948, 5–6, in Edward L. Bernays Papers (LOC I:71), Manuscript Division, Library of Congress, Washington, DC (hereafter Bernays Papers). 11. Edward L. Bernays, “The Engineering of Consent,” Annals of the American ­Academy of Political and Social Science 250 (1947): 113–20. 12. Brett Barnes, “Public Relations Pioneer Edward L. Bernays Dies,” Washington Post, March 10, 1995, D4. 13. Jennifer Lee, “Big Tobacco’s Spin on Women’s Liberation,” New York Times, October 10, 2008. 14. “Edward Bernays, ‘Father of Public Relations,’” New York Times. 15. William E. Geist, “Selling Soap to Children and Hairnets to Women,” New York Times, March 27, 1985. 16. Arthur J. Viseltear, “Medical Care for the American People: The Final Report of the Committee on the Costs of Medical Care, Adopted October 31, 1932,” American Journal of Public Health 64, no. 1 (1972): 82. 17. “The Report of the Committee on the Costs of Medical Care,” editorial, JAMA 99 (December 10, 1932): 2034–2035.



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18. Tye, The Father of Spin, 100. 19. Ibid., 177. 20. Ibid., 26. 21. Ibid., 51–52. 22. Edward L. Bernays, Biography of an Idea: Memoirs of Public Relations Counsel Edward L. Bernays (New York: Simon and Schuster, 1965), 669. 23. Edward L. Bernays, “The Nursing Profession: A Public Relations Viewpoint.” AJN 45, no. 5 (1945): 351–53. 24. Ibid., 351. 25. Edward L. Bernays, “The Medical Profession and Nursing,” AJN 45, no. 11 (1945): 907. 26. Edward L. Bernays, “The Nurses’ Contribution to American Victory: Facts and Figures from Pearl Harbor to V-J Day,” AJN 45, no. 9 (1945): 683. 27. Edward L. Bernays, “America Looks at Nursing: A Summation,” AJN 46, no. 9 (1946): 590–92, 591. Although this article was the last in the series, Bernays authored three articles for AJN after this: “What Patients Say About Nurses,” AJN 47, no. 2 (1947): 93–96; “A Better Deal for Nurses,” 47, no. 11 (1947): 721–22; and “Nursing and Its ­Public,” 48, no. 12 (1948): 744–47. 28. Bernays, “America Looks at Nursing: A Summation,” 590. 29. Ibid., 592. 30. Bernays, Biography of an Idea, 669. 31. ANA Advisory Council minutes, 17 January 1948, 90, Advisory Council Reports of the American Nurses Association (1947–1953), Proceedings of the Advisory Council, Archives of the ANA, New York (hereafter ANA Archives) 32. Edward L. Bernays, 1948, Bernays Papers. 33. Edward L. Bernays, “Nursing and Its Public,” AJN 48, no. 12 (1948): 744–47. 34. “ANA Public Relations Program Promotes ‘Nursing Progress Week,’” AJN 48, no. 9 (1948): 556. 35. “News from National Headquarters,” AJN 48, no. 10 (1948): 668. 36. Mary M. Roberts, American Nursing: History and Interpretation (New York: Macmillan, 1961), 562. 37. ANA, Application for Reclassification of Graduate Registered Professional Nurses into the Professional and Scientific Service (Washington: U.S. Civil Service Commission, 1946). 38. Edward L. Bernays, The Later Years: Public Relations Insights 1956–1986 (­Rhinebeck: H&M Publishers, 1986), 100. 39. ANA Special Committee on Public Relations, first meeting, draft minutes, 16 July 1947, 3, ANA Archives. 40. Mary Berenice Beck, Memorandum to Presidents and Executive Secretaries, 16 December 1948, Bernays Papers. 41. ANA Committee on Ethical Standards Report, 17–18 January 1950, ANA ­Archives. 42. Janet Geister, Minutes, ANA Committee on Public Relations, 9 December 1948, ANA Archives. 43. Janet Geister, Excerpt from Proceedings of ANA Board of Directors Meeting, 30 January 1949, Bernays File, ANA archives. 44. Pearl McIver, Letter to E. L. Bernays, 31 January 1949, Bernays File, ANA Archives.

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45. David U. Snyder, Memorandum to Alma Scott, 9 December 1948, Bernays Papers (emphasis in original). 46. Alma H. Scott, Minutes, ANA Committee on Ethical Standards, 18–19 January 1949, Bernays Papers. 47. Internal note, ca. 18–19 January 1949, Code History, Bernays Papers. 48. “A Code for Nurses.” 49. Ibid. 50. ANA Advisory Council Reports, 31 May 1947–4 January 1953, Proceedings of the Advisory Council 1 (New York: ANA): 113. 51. ANA, 2001. 52. ANA, “Statement of Purpose,” http://www.nursingworld.org/FunctionalMenu Categories/AboutANA/ANAsStatementofPurpose.html (accessed July 31, 2012). 53. Gallup Organization, “Honesty/Ethics in Professions,” http://www.gallup.com /poll/1654/honesty-ethics-professions.aspx (accessed December 20, 2012). 54. Johnson & Johnson, “Campaign for Nursing’s Future,” http://www. discovernursing.com (accessed July 30, 2012).

Guy Philbin, DSc, MEd, CASE, MLA Notre Dame of Maryland University David M. Keepnews, PhD, JD, RN, NEA-BC, FAAN Hunter College and City University of New York Graduate Center 425 E. 25th Street, #967 New York, NY 10010

THE FUTURE OF HEALTH CARE’S PAST IN CLOSING

A Colleague’s Salute to Joan Lynaugh Barbara Brodie University of Virginia

Thank you for including me in this lovely salute to a trail blazing nurse historian, professional nurse, teacher, mentor, colleague, and friend. My only regret about this day is that two very important people to nursing history, to Joan, and to all of us—the incomparable Barbara Bates and Karen ­Buhler-Wilkerson— are not with us to enjoy it. They would have loved today and would have had words of wisdom and humor to share about Joan and her legacy. I first met Joan at the University of Rochester in 1973 when I visited Harriet Kitzman to learn about their Pediatric Nurse Practitioner program and research. Harriet suggested I meet Joan, the director of their Advance Nurse Practice program, because she too was creating a new practitioner role for nurses and was successfully dealing with some of the challenges inherent in placing nurses into an area traditionally considered the sole province of medicine. Together, we briefly spoke of the problems inherent in this new role and our admiration of the young nurses who were eagerly preparing themselves for clinical practice and leadership in the nurse practitioner movement. I believe (by now) enough time has passed for us to be able to claim that nurse practitioners forged a vital new role for nurses, and in doing so they significantly changed the role of nurses and the care they provided patients. I believe they truly reshaped nursing education and the health care system. Ten years later, I met Joan at an American Association for the History of Medicine (AAHM) conference at Duke University. I was teaching a history of nursing and medicine course in the University of Virginia’s new PhD ­Nursing program and I was at the conference to learn as much as possible about the history of medicine. I knew no one in the AAHM, so when I saw Joan I was elated. She graciously took me it tow and immediately introduced me to four medical historians whose names I recognized from their books that I had read. Nursing History Review 22 (2014): 159–162. A Publication of the American Association for the History of Nursing. Copyright © 2014 Springer Publishing Company. http://dx.doi.org/10.1891/1062-8061.22.159

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Through the rest of the conference, she introduced me to about 25 other historians and I began to wonder if she knew every medical and nursing historian in the country. I soon learned that Joan has a rich social network of names of medical historians in the United States and abroad and that through this network she was introducing young nurse historians to scholars who were most knowledgeable about their particular field of interest. So phenomenal is her grasp of the names of medical and nursing historians, their work, and their areas of interest that I soon began to encourage nurse historians to speak to Joan about their study and need for additional sources of information. Thus, I have long been treating Joan as the “Google” of nursing and health history . . . just ask her a question and she will direct you to the important historical studies pertinent to your subject and the historians who have or are working on this topic. From the 1970s onward, our paths crossed frequently at conferences, meetings, and workshops of the recently formed American Association for the History of Nursing (AAHN) organization. Many of the AAHN’s ­meetings were held in Philadelphia and Joan invited me to stay at her home that she shared with Barbara Bates. Over dinner, wine, and stimulating and funny conversations, I met many of their friends and learned that Joan was not only a well-trained medical historian but was also very insightful on what needed to be accomplished to create a cadre of educated nurses capable of historical studies that documented and analyzed the development of the nursing ­profession. During our frequent conversations, we explored what kinds of organizations were needed that would allow us to enhance the vitality and productivity of nurse historians. As I read more of her work and listened to her presentations and comments, I was impressed with Joan’s deep commitment to making nursing history a scholarly field of study and of her leadership skills. At this point I began to see Joan as an excellent evangelist for nursing history. In the tradition of John the Baptist (minus the beard and with her a head on her shoulders), Joan was preparing the way for a new generation of nurse historians capable of spreading the gospel of nursing history and its value to the nursing profession. As an evangelist she sometimes was in front leading people to move ­nursing history into the mainstream of nursing education, but most of her most effective work was done through her publications, presentations, or accomplished in small discussions. She consistently attracted intellectually bright and talented nurses and enticed them to become involved in nursing history projects and then mentored them into publishing their work. She, with others, convinced the AAHN that it was time for the organization to create the Nursing History Review, and then led the negotiations with first the



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University of Pennsylvania Press and later with Springer Publishing Company to publish the journal. More importantly, she assumed the role of editor of the Review and in doing so she developed its philosophy and style and set the standards for scholarly work. She sought the work of nurse and medical historians from around the world for the Review, thereby enlarging its readers’ understanding of the similarities and differences in health care in various countries. Her encouragement of all authors was visible even in the rejection letters she sent. I know the rejection letter I received about a manuscript was so warm, complementary, and supportive that I had to read it twice before I understood that I had to revise many things before it could be published. Today, we are also acknowledging one of her most lasting contributions to the advancement of nursing history, the creation of the University of Pennsylvania Barbara Bates Center for the Study of Nursing History. She, in collaboration with Karen Buhler-Wilkerson and Ellen Baer, an exciting and productive team, created the first nursing history center in the county. From its beginning, it quickly became the flagship of nursing history and helped bring scholarship and intellectual prestige to the field. But what has not been spoken of today is that creating a Center is easy compared to ­acquiring the financial, intellectual, and political capital necessary to make it a permanent part of a major research-intensive school of nursing. In a discipline that primarily ­receives research funds that focus on patient’s clinical problems, ­acquiring long time support is difficult. For many, nursing historical research appears far too abstract for most agencies and donors to support. The impressive accomplishment achieved by Joan, Karen, and Ellen is that they accepted this challenge and proved exceptionally successful in implementing a plan to acquire private and public monies to endow the center and make it a highly productive entity. They also accepted the challenge to prepare future nurse historians who would add to nursing historical scholarship around the world. Today the Barbara Bates Center for the Study of Nursing serves as an excellent example of how gifted and talented nurse historians can create and operate a premier entity recognized throughout the globe. Another attribute of Joan I wish to highlight is her ability and willingness to mentor students and colleagues interested in creating nursing research centers. When the University of Virginia School of Nursing opened its Center for Nursing Historical Inquiry in 1991, I sought advice from Joan about how to assure its academic credentials, financial and political support, and to develop strategies to acquire and preserve nursing documents while at the same time educating nurse historians and generating scholarship. I found Joan extraordinarily open and generous in sharing information about how their Center operated and acquired the resources, including personal, needed to allow it

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to grow and flourish. Her support and belief of the value of nursing history centers is further documented by the number of other Centers in the world who have benefited from the support and encouragement of the Barbara Bates Center for the Study on Nursing History as they created their own. Over the years, I have found Joan not only open and responsive to our multiple professional and personal requests for guidance but also remains a stalwart friend and supporter of the University of Virginia Center for Nursing Historical Inquiry. For this we are grateful. In conclusion, when one views the field of nursing history today, it is easy to see Joan’s contributions to the productivity and sophistication of nursing scholarship. Indeed, Joan has served as the architect of modern nursing history that illuminates the contributions of professional nurses to the advancement of medical and health care and offers opportunities to use critical knowledge from the past in planning for the future. Barbara Brodie University of Virginia 103 Surrey Road Charlottesville, VA 22901-2223

THE FUTURE OF HEALTH CARE’S PAST IN SUMMATION

Transnational Feminist Practices and the History of Nursing Susan Reverby Wellesley College

Joan Lynaugh, and the institutions, ways of thinking, and practicing nursing history she was so masterful at creating are forms of “transnational feminist practices.” That is what Women’s Studies’ scholars Inderpal Grewal and Caren ­Kaplan have defined as “forms of alliances, subversion and complicity within which asymmetries and inequalities can be critiqued.”1 For no one was better at alliances and subversions—and even complicities with both leadership and rebels— across boundaries of practice fields and nation than Joan Lynaugh, I would argue that Joan created transnational feminist practices within nursing history. What then do I mean by this? It starts with the complexities that Joan and her colleagues were attempting to explore. Much of the new Women’s Studies scholarship over the last decades has sought to understand in concrete terms what “intersectionality”—the infelicitous term used to describe analyses that link race, gender, class, sexuality, ethnicity, and religion together—means.2 The new nursing history that Joan was so instrumental in writing, encouraging, and supporting was always about intersectionality. Coming of age in conversation with Women’s Studies and History scholars at the same time, this new nursing history could hardly have avoided such linkages. However, whether Women’s Studies scholars were always able to create this with all the categories together, and mostly we failed, the effort to think in these terms was very much there. This failure was also one of theoretical concepts. We just did not have the terms yet to explore women’s relationships to one another across time, space, nation, and institutions, and the very “murkiness” of the term made it hard to use.3 In many ways, Women’s Studies itself would have gained from reading the nursing history being developed in the 1980s. For it was within this field that the tensions not just between nurses and doctors, but between differing groups Nursing History Review 22 (2014): 163–165. A Publication of the American Association for the History of Nursing. Copyright © 2014 Springer Publishing Company. http://dx.doi.org/10.1891/1062-8061.22.163

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of nurses, was becoming central to the historical analysis. Nursing historians also began to understand that nurses as seeming subaltern subjects could be ­oppressed and powerful at the same moments in time. The very concreteness of the studies in nursing history would actually been helpful then to Women’s Studies scholars if there had been more reading from Women’s ­Studies in the nursing history literature.4 Joan certainly tried to make this possible as her warmth, institutional building skills, and knowledge made those of us who “not now nor have never been nurses” welcomed into the historical tent she was spreading. Secondly, Joan saw beyond the borders: of what nursing could do when she began her work in developing nurse practitioners and then in what nursing history could make possible. She did this through her own form of transnational feminist practices. She made alliances across academic borders and “traveled” back and forth bringing ideas, articles, and individuals with her. The new nursing history was always cognizant of power relations between women and what was politically possible or not. It analyzed wrong turns that would have consequences for years, and the small and large victories that would transform nursing’s work and identity. Third, this was never to be only about Western nursing. From the work on the International Council of Nurses to her support to others writing on the ­migrations of nurses across the globe and nursing in multiple other countries, she understood that nursing always made “travel” possible. Nursing was a “get a job” card that women exercised across the world, bringing their practices, ideas, and nationalisms with them. As Julie Fairman and Patricia D’Antonio have noted, it was nurses who put the global in global health. Thus it was this new nursing history that became a transnational feminist practice of ­historical scholarship that always realized power differences, imperial power, and ­colonial and postcolonial struggles. In 1986, Joan and I wrote an essay for Nursing Research entitled “Thoughts on the Nature of History” in which we laid out the myths of what history is supposed to be and the “truths” we thought it could tell.5 We wrote then that there was still much “left to do and explain.” Nearly three decades later, there is still much left to do and explain. The path of how to do this, however, and the interconnections needed to make this possible, are ever stronger now. The terms of the historical practice much more evolved.

Notes 1. Inderpal Grewal and Caren Kaplan, “Postcolonial Studies and Transnational Feminist Practices,” Jouvert: A Journal of Postcolonial Studies 5 (Autumn 2000), http://­ english.chass.ncsu.edu/jouvert/v5i1/grewal.htm (accessed February 21, 2013).



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2. Jennifer C. Nash, “Re-thinking Intersectionality,” Feminist Review 89 (2008): 1–15. 3. Ibid., 1. 4. I will always be grateful that my education came in nursing history first, before Women’s Studies, and it certainly shaped by scholarship and my women’s studies teaching. I do not think this direction, however, was common and the tensions between nursing and feminism has been documented elsewhere, see Ellen Baer, “The Feminist Disdain for Nursing,” New York Times, February 19, 1991, p. 25 and Susan Gelfand Malka, Daring to Care: American Nursing and Second Wave Feminism (Champaign-Urbana: University of Illinois Press, 2007). 5. Joan Lynaugh and Susan Reverby, “Thoughts on the Nature of History,” Nursing Research 36 (January–February 1987): 4, 69.

Susan M. Reverby, PhD Marion Butler McLean Professor in the History of Ideas Professor of Women’s and Gender Studies Department Wellesley College 106 Central Street Wellesley, MA 02481

In Memoriam

A Salute to Rosemary Theresa McCarthy, RN, PhD, FAAN, Colonel U.S. Army (Retired) On June 7, 2012, a dear friend and fellow nursing historian Rosemary ­McCarthy quietly died at the Sacred Heart Home in Hyattsville, Maryland, 19 days shy of her 86th birthday. The only child of Mary and Thomas ­McCarthy, Rosemary was born in Dorchester, Massachusetts, in 1926. A bright, talented, energetic, and serious young woman, she graduated from the Arlington High School on D-day, June 6, 1944. This was an important date for Rosemary because Allied troops were landing in France that day to begin the liberation of Europe from German occupation. Such a coincidence may have foretold her future. Unsure of what she wanted to do with her life, she considered being a physical therapist, artist, or nurse. Because her family was of modest ­financial circumstances, she selected nursing. At the time, hospital diploma schools of nursing charged little if any tuition. She first applied to the ­famous ­Massachusetts General Hospital School of Nursing but was rejected because they had already “accepted their quota of Irish Catholic Students.”1 She was not upset about this decision because the school also used quotas for ­Jewish and African American students. Encouraged by a family friend who was a nurse, she ­applied to the McLean Hospital School of Nursing in nearby ­Waverly. Admitted in 1945, she joined the school’s U.S. Cadet Nurse Corps Program because it provided her tuition, uniforms, and books, plus a stipend. In return, upon graduation she was required to serve as a military nurse if needed. Her serving as a cadet nurse during World War II, made Rosemary feel that she was, as other fellow Americans, answering the needs of her county. As part of her training at McLean, she managed to enjoy some of the educational benefits of “Mass. General” because some of McLean’s course work was “done on the medical and surgical floors of Massachusetts General Nursing History Review 22 (2014): 166–178. A Publication of the American Association for the History of Nursing. Copyright © 2014 Springer Publishing Company. http://dx.doi.org/10.1891/1062-8061.22.166



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Hospital and at the top ranked Children’s Hospital of Boston.” Rosemary finished her program in 1948, and because the war had ended in 1945, she wasn’t required to serve in the military. She liked the idea of being an army nurse because she believed service to one’s country was a duty and honor. Her father, however, was opposed to her joining the army because he did not think that the army was a place for a woman. He made her promise she would not become an army nurse for at least 4 years.2 As a new graduate nurse, she remained at McLean Hospital employed as a staff nurse until she was enticed by her classmates to work with them at the Colorado Springs Psychopathic Hospital. The sudden death of her dad in 1952 freed her from her promise, and with the Korean War in progress, she joined the Army Nurse Corps in 1953 and was commissioned a First ­Lieutenant. This decision would provide Rosemary with a highly satisfying and interesting 30-year military career that took her to many distant lands. She retired in 1983 as a full colonel. During her Army service, she was posted at hospital facilities in Texas, Japan, Korea, California, and Hawaii. In 1956, she was sent to Korea to serve a tour of duty in the 44th Mobile Army Surgical Hospital, one of the ­renowned MASH units. The experience of caring for injured soldiers in a war zone impressed Rosemary and shaped her attitude about the kind of care all military personnel should be provided. After this assignment, she was granted permission to enter the University of Minnesota School of Nursing where she earned a bachelor’s degree in 1957. Her postings for the next dozen years moved her between Army educational and administrative positions in bases across the country and while in these positions she managed to earn a Master’s Degree in Nursing at Boston University. She also attended military educational programs at Walter Reed Army Hospital and Institute and the U.S. Army Academy of Health Science at Fort Sam Houston, Texas. In the early 1970s, she began a doctoral program at the Catholic University of America where she earned a Doctor of Nursing Science in 1974. That degree was later changed to a PhD in 1995. In 1974, Rosemary was also honored by her nursing colleagues when she was inducted as a fellow in the American Academy of Nursing. Next sent to Washington, DC, she was appointed the Nursing ­Consultant and Directorate of Professional Services in the Office of the Surgeon General, a position she held from 1974 to 1977. Considered by the Army as an excellent educational advisor, Rosemary traveled for 2 years to army bases around the globe to work with their nursing staffs to upgrade their educational programs.

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Always interested in the history of military medicine, she wrote ­numerous papers on the role of nurses during wars. These writings were noted by the army’s commanders and they appointed her to the post of the Army Nurse Corps Historian at the Center for Military History in ­Washington, serving from 1978 to 1982. During her tenure as army nurse historian, ­Rosemary joined with civilian nurse historians to establish the new International History of Nursing Society in 1980. In 1982, the Society was renamed the ­American Association for the History of Nursing (AAHN), the organization that ­Rosemary would be an active member in until age and ­illness denied her the ability to participate. After retiring from the service, Rosemary began her second career. She joined the nursing faculty of Catholic University and then at Georgetown University School of Nursing where she taught undergraduate students ­research and the principles of administration. She also mentored doctoral students during their dissertations. Over the years, many nurse historians were befriended and helped by Rosemary as she opened her home to them when they visited Washington to attend conferences, meetings, or to do research in various archives. Dr. Olga Church, working on the history of the early days of psychiatric nursing, spoke of Rosemary’s generosity and friendship in providing her food, lodging, and stimulating historical discussions on the early days of the profession. Olga noted that her support and friendship lasted for many years and included her two sons. Eleanor Bjoring was another recipient of her warm hospitality and friendship when she attended a two-week archival course at the National Archives. Rosemary’s deep-seated desire to have her country acknowledge and honor the sacrifices of thousands of military and civilian men and women who served in the Korean War was met when she was appointed by ­President Reagan to the Advisory Board Planning Committee of the Korean War ­Memorial in 1983. She steadfastly attended hundreds of committee meetings and sessions with the designers of the memorial to make sure that the efforts of women were acknowledged as crucial members of the U.S. military forces during that war. She provided the designers with many personal war photos and stories. Some of these photos are etched into a wall that is part of the memorial, including one of Rosemary’s dressed in army fatigues at her Korean MASH unit.3 She told a friend that for all the time and effort she expended working on that Committee, she deserved to have her likeness etched there!4 She and her fellow committee members were personally honored and thanked by President Bill Clinton when the memorial was dedicated in 1994.



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Rosemary McCarthy with President Ronald Regan. Reprinted with the permission of the Center for Nursing Historical Inquiry at the University of Virginia.

As noted, Rosemary was one of the early founders of the AAHN. She did this because she believed that the organization, through its efforts to develop the field of nursing history and nurse scholars, was vital to the legitimacy of the profession. She believed that nurse historians possessed a special ability to illuminate and analyze the roles that nurses played in health care over the centuries. She thought that in documenting nurses’ responses to the needs of society, the profession’s values were recognized and enhanced. Rosemary served on numerous AAHN committees and was elected to several offices on the Executive Board culminating in her election as its ­president in 1986. One of her lesser known contributions to the organization ­occurred in 1987 when she joined Joan Lynaugh and Barbara Brodie to initiate and fund the Lavinia L. Dock Award for Exemplary Scholarship and Writing, the first scholarship award given by AAHN. In 1988, she assumed the responsibilities of being the organization’s first Executive Director, a part-time position she held for almost 10 years. In 2003, in recognition of her many years of exceptional service to the organization, she was awarded its highest honor, the AAHN’s President’s Award. Rosemary was a multitalented woman who enjoyed many things in life. These included traveling to distant lands, creating unique paintings

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and drawings, collecting diverse pieces of art that filled her home from top to bottom, good books, and enjoying fine food, drinks, and conversation with friends. One of the highlights of her week occurred every Saturday morning. She and her good friend Doris Lee had breakfast at the same little restaurant near her Capitol Hill home and then visited every yard sale in the vicinity of her home to search for interesting things to add to her collection or to share with friends. Visitors to her home on Saturdays were included in this fun experience and many found it difficult not to get caught up in the fun of collecting. These excursions always ended with a visit to the city’s Eastern Market that was filled with interesting things to eat and do. Among those things was visiting the studio of the famed artist Simmy Knox, known for his official portraits of Thurgood Marshall, William Clinton, and many others. Rosemary had a formal portrait of herself done by Knox garbed in her mess dress uniform. This portrait was proudly displayed in her home.5 Rosemary was a devoted Christian who honored God, the nursing profession, her family/friends, and her country. Throughout her life, she generously shared her time, talents, and resources to make the world a better place for all.

Notes 1. Rosemary Teresa McCarthy, “Memories of my Life” (circa 2011). Rosemary ­Teresa McCarthy Collection, Eleanor Crowder Bjoring Center for Nursing Historical Inquiry, The University of Virginia School of Nursing (hereafter RTM Collection, ECBCNHI, UVA). 2. Ibid., 2. 3. Rosemary Teresa McCarthy, Correspondence with the Korean Wall Memorial Committee, RTM Collection, ECBCNHI, UVA. 4. Eleanor Crowder Bjoring, Oral Interview, 2 February 2013. 5. Olga Church to Barbara Brodie, Oral Interview, 4 January 2013.

Barbara Brodie, PhD, RN, FAAN Professor Emerita, University of Virginia Eleanor Bjoring, PhD



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Eleanor Krohn Herrmann, February 1, 1935–July 31, 2012: Excerpts from a Eulogy by Lawrence Herrmann You may wonder why this old Marine with the symbol of the fallen soldier on his lapel is officiating at this relatively informal service. Like her dear departed brother-in-law, John Gates, an apple farmer from Nova Scotia who earned a PhD, Dr. Eleanor Krohn Herrmann, RN, MeD, EdD, and a Fellow of the American Academy of Nursing, was basically a farm girl from Great ­Barrington, Massachusetts, where she will repose next to the graves of her father, Martin, and her mother, Ellen, both immigrants from rural Sweden. With all her honors, degrees, awards, and her enduring legacy of students who became ­leaders in nursing education and nursing history, her two loves, ­Eleanor never lost the simplicity, the modesty, the humility, or the selfless sharing of that little barefoot farm girl who at age 13 years—with her mother in the hospital with her fifth child and fourth daughter, a 2-day-old ­Kristina—went to call her father to lunch on the family farm on the Housatonic and found that a hill had given way and a John Deere tractor had rolled over and crushed him to death. In typical Scandinavian fashion, he left no bills but no insurance. Mrs. Krohn went to work cooking, washing, and cleaning, and then became a house instructor at Northfield School for girls, ­devoting the sparse funds available to educating her son Frank, a University of ­Massachusetts- and Cornell-trained ­veterinarian. Mrs.  Krohn eventually was decorated by then Governor John Volpe as ­Massachusetts’ Mother of the Year for helping five kids through college and graduate school on a salary that never exceeded $7,500 a year. Who should be telling Eleanor’s story, a clergyperson who rarely or never knew Eleanor, sermonizing truisms about life or truths from the scriptures about death and heaven, or the friend she put up with for 43.5 years of ­marriage? A Congregationalist who once belonged to two synagogues, one in Cheshire and another across the street in Meriden out of respect for my faith, Eleanor was a deeply spiritual, ecumenical thinker whose experience with the continuity of life beyond death, actual experience, and confirmation, not mere faith or belief, made her unafraid of passing over. When my Marine brother Ron Perry was taking care of her in an emergency last spring, she told him she was not afraid of dying, she just hoped it wouldn’t be painful. In the late 1960s and 1970s, we studied privately with two advanced souls Alice Borchard Greene and her sister Gertrude. In the words of Alice’s

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Eleanor Krohn Herrmann. Reprinted courtesy of the University of Connecticut School of Nursing.

teacher, a student of Karl Jung, Eleanor’s passing was, I am sure, a glad release from physical limitations. We were taught that the soul is an entity which, like the seed, has gone down into the earth only to rise up above it again and be stronger for so doing. That process is the subject matter of all great religious teaching. It is the mystical allegory that led to the writing of the Book of Exodus for its inclusion in the Alexandrian Library in Athens. Eleanor shared much of her experience with the continuity of life beyond death with the classes she taught in “Alternative Nursing.” After high school, where she played center on the basketball team, Eleanor went on to study nursing at Adelphi, buying only one new pair of shoes in 4 years and cooking hamburgers in the snack bar to supplement her full scholarship. Years later, she was awarded Adelphi’s Distinguished Alumna Award. After working in an emergency room, she went on to get one of two master’s degrees at the University of Colorado and eventually a master’s and her doctorate at Teachers College Columbia University. Eleanor taught medical-surgical nursing, nursing ethics, alternative nursing, and her first love, the history of nursing at the Universities of Wyoming, Syracuse, Colorado, Cornell, and Yale for nine years and finally for 10 more fulfilling years at the University of Connecticut (UConn). I teased her that she couldn’t hold a job. The students at Yale gave her the Annie Goodrich Award as their best teacher. At UConn, she was the curator of the Josephine Dolan Collection of Nursing History, sharing the counsel and friendship of



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then Dean Anne Bavier, of professors and fellow historians Carol Daisy and Jennifer Telford, and that of her beloved last doctoral student Dr. Mary Ann Cordeau (now a Professor at Quinnipiac), who together with her childhood sweetheart and husband, Bob, endowed the Eleanor Krohn Herrmann Reading Room in the newly constructed Widmer Hall at the UConn School of Nursing. The Reading Room will house the Dolan Collection and Eleanor’s collection of historical treasures. It will be inaugurated in November and a Memorial Service in UConn Chapel will follow some weeks later. Eleanor was an avid reader and an innovative thinker and writer, but her research was not only in libraries. She was an expert at seeking out sources and conducting oral history interviews. A certified archivist, her office at home reminds one of the stacks and storerooms of an old museum with her World Wars I and II nursing posters, her old Red Cross pins, pins from every Connecticut school of nursing (except Norwich), her medical lead soldiers, her books, her files, and her World War I nursing related sheet music. Eleanor didn’t just learn alternative nursing from books. When her back went out at Cornell, she lay in bed until a colleague studying therapeutic touch in her doctoral program at New York University healed her in one session without even touching her hands to Eleanor’s back. When I lay paralyzed at the Neurological Institute at Columbia Presbyterian facing almost certain laminectomies, she observed while my Korean 8th Degree Black Belt brother Tom Choi, in an hour of acupressure, had me walking with ease, healing and strengthening me weekly at home thereafter as he did for the wounded on the battlefields of Vietnam. When Mother Rosa, a Santeria priestess in the Bronx, met Eleanor for the first time, she instantly told her a powerful tall spirit with piercing eyes was protecting her, one she had lost in her adolescence. It was a perfect picture of Eleanor’s father. We then went on to the initiation of Mother’s niece into the Santeria Cult of Ayemaya, garbed in light blue for the Goddess of the surface waters and in six continuous hours of Congo drumming, chanting, and gourd rasping, Mother, Eleanor, our friend Dario, and I were the only four persons present not possessed and speaking in other tongues. She was indeed a researcher. We were never blessed with children but we were blessed with young people, both related, and the children of friends, who have become like our own children as they enriched our lives. Dr. Brad, Jeff, and Frank W. Krohn are the powerfully dynamic sons of her brother Frank and his magnificent wife ­Carole. Dr. Jonathan (Jay) and Sander Gates are the sons of Eleanor’s ­departed sister Jane and her departed husband John. The loss of both left ­Eleanor  ­desolate. Both Jane and Eleanor sincerely believed Jay and Sander walked on water. Victoria Herrmann, my brother and Violet’s beautiful

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youngest daughter, is a treasure whose singing voice seems to come from the Heavens. And the Gomez children of Cali, Colombia whom we mentored in school and who have been so attentive to Eleanor, calling from Colombia every week and in the final stages and thereafter every day. I met Eleanor in Ecuador when she was spending the summer working for Project Hope setting up the country’s first university-level nursing school at Catholic University. When people asked how we met, I would tell them I was in the public square in Quito looking out over some 5,000 heads with black hair, few more than 5 ft tall and silhouetted against the Quito Cathedral was a 5911 Swedish blond with blue eyes. Our eyes met and I fell in love. ­Eleanor let me tell that story for the first 17 years of our marriage, and one night at dinner with friends, she told me I had to stop telling it. I asked why. She ­replied, “Larry, I have brown eyes.” Eleanor served as the World Health Organization’s (WHO) advisor to the nursing school in Belize and did her doctoral dissertation on its nursing history from the first British Matron, to local Creole control in 1977, and into the late 1980s, conducting oral history interviews and preserving crumbling records. It was published by WHO as a model for all developing countries. The Belizean nurses accepted this Caucasian Yankee with her respect for their traditions and autonomy and preferred her over advisors from Jamaica and other Caribbean islands who they believed often gave off a sense of superiority. We moved to Cheshire in 1977 into a house built in 1750 which she filled with rustic early American antiques. She preferred Native American silver and turquoise jewelry over diamonds. Her favorite dresses were those sewn by her mother with her talented arthritic fingers. She served on the Cheshire Historical Commission with her childhood friend Jeanne Chesanow whose husband, Bob (a childhood sweetheart), is funnier than a barrel of drunken monkeys. Eleanor assisted the Standardbred Retirement Foundation, which ­adopted three of our retired racehorses, two pacers, and one trotter. She joined the ­Marine Corps League Silver City Mamas because she so valued my Marine Corps brethren and their wives and women of the auxiliary. Although her series of strokes in the final years affected her participation, it did not lessen her admiration of the military service of her husband and his Marine brotherhood and the brotherhood of the Jewish War Veterans. Eleanor was one heck of a loving nurse. When I had a serious back ­accident in Guatemala, she slept in the clinic with me, transported me on a stretcher to Columbia Presbyterian, and helped bring me back to health. She paired gentleness with strength, skill with sensitivity, courage with modesty,



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and a sense of humor with dignity, her heart is a furnace warming those who were chilled of life, never beguiled by the outer shell of beauty. She saw facts as mere husks as she sought Truth, the holy foundation of all things. Eleanor also presided over the American Association for the History of Nursing, a collection of the world’s most eminent nursing historians and served as the Victorian Mistress of ceremonies with me in costume at our traditional auction for nursing history scholarships. She and I also endowed six portraits of African American nursing pioneers to hang in the School of Nursing at Medical University of South Carolina, something done purely on principle as a tribute to our historian friend Dr. Sarah Johnson. Eleanor authored or coauthored four books, editing the last edition of Nursing in Society with Josephine Dolan and Dean Louise Fitzpatrick of ­Villanova. She also wrote Origins of Tomorrow: The History of Belizean ­Nursing, Signature for Nursing, a collection of vignettes of remembrance of the life of our friend, Virginia Henderson, and Capturing Nursing History with the former Associate Dean and current Professor of Nursing at Pace University, Dr. Sandra Lewenson, who at our auctions makes Bob Hope look like a straight man. When Eleanor retired from teaching because of her bouts with cancer, she kept so busy she wondered when she had had time to work. She took great pride in supporting the induction of her mentor and friend Jo Dolan of UConn into the American Nurses Association Hall of Fame, citing her as an internationally esteemed nurse and author. Now I want to share Eleanor’s final year and days with you. A survivor of five cancer surgeries—colon, cervix, and bladder; with a final bladder removal, she was hospitalized July 2011 from a broken femur and in December for a shattered wrist and fractured forearm. Three months in demeaning subacute rehab followed. The year 2012 brought three more hospitalizations for infections, muscle paralysis, and renal failure. Nine days before her passing, ­Eleanor had her last stroke, and she could fight no more. Unable to move, chew, or finally to swallow, she tried to speak, murmuring a sound to friends and family whose loving care she so appreciated. Unable to take fluids, our beloved family physician advised that dehydration was a painless way of passing and to avoid futile emergency revival efforts. Two psychic hospice nurses advised she was already spending most of her time on the other side. It was now about 10:45 in the morning of July 31st. With me on the porch were Phoebe, our loving Lab, and Paul Shappy, a fellow Marine from a brotherhood only we Marines can understand. The hospice nurses came out to the porch and told us Eleanor was failing. I went to her side, she was still breathing slowly. I pat my hand on her forehead, gave her a kiss and told her

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I loved her. I called her Zelda, the nickname her mother had given her, and told her that her mother and father and sister Jane were waiting for her. As her sister had advised, I told her it was okay to let go and I told her Phoebe and I would be okay. With my hand on her forehead, she took one more breath and passed on. I know she had heard me. The hearse arrived from the Ferry Funeral home, with a group of meticulous, sensitive, and compassionate people. They could not get the gurney into our antique house to roll Eleanor out of bed. Paul told me to stay on the porch, that I didn’t want to look, and this Purple Heart Marine veteran, as he did all too often in Vietnam with all or parts of his fellow comrades, lifted Eleanor’s still form into a body bag and she left her beloved home for the last time. In ancient Chinese and Native American traditions, the body is accompanied by images and objects for the journey to the afterlife. Accompanying Eleanor in the coffin are two red roses (one for Claudia Gomez, one for my mother Rose), a yellow and a blue flower (the colors of Sweden for her parents), flowers from Mary Ann Cordeau, cat treats for her cat Spats, dog biscuits for her three departed Labs, pictures of friends, a rosary from Colombia, an “I Love Nursing” pin, a gold replica of a nursing stamp with a Red Cross, a little Guatemalan stuffed burro I always used to hide in her suitcase when she was traveling, two gold pre-Colombian frog pins, a Navajo silver roadrunner pin with a turquoise eye, and the pin of the fallen soldier as she lies in state in her blue and black doctoral robes. Clasped in her right hand is a coin stamped with the Marine Corps globe and anchor and the Legend Marine Wife. If challenged by the U.S. Marine guards that the Marine Corps hymn assures us are guarding the gates to Heaven, she will never have to buy them drinks when she slaps her coin down on a celestial bar. In Scandinavia, traditionally, God was pictured as Thor with a hammer and a forge, a seemingly warlike image for a daughter of Sweden with such a gentle, loving soul. So with some help from Kahlil Gibran, I write: Two souls Two light sparks Struck from the same forge Who cross paths in life From time to time But just like the columns Of an ancient temple Derive their strength From the space between them



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Eleanor and I respected each other’s space but we helped each other in our respective careers, counseling and guiding each other when asked. She shared in my sense of fulfillment when I was able to help another as an attorney and counselor and as a Marine veteran. I took great pride in my proofreading of her writings and in my fundraising masquerades at the yearly fundraising auctions at the AAHN conferences. We were privileged during the time we lived in Guatemala and ­Manhattan to study with Alice Borchard Greene, a PhD in Psychology and the wife of my Community Development Mentor Sam Greene, and with her sister Gertrude. Disciples of May Benzenberg Mayer, a student of the psychoanalyst Karl Jung, they taught us that Freud, in his understanding of the transliminal (never using the word subconscious), mistook the Atlantic coastline for the North American continent, as we decoded dreams, Greek myths, and the Old Testament, studying the evolution of the human soul and the continuity of life beyond the body’s death. Eleanor knew that bodily death was not the end of life for the soul and the spirit. In ancient Greece, a by word was athanatos eh psuche (phonetic) meaning the soul is immortal. Eleanor is an old soul, a noble, quiet, sensitive woman with a robust sense of humor for one of Scandinavian descent, with a sense of selfless devotion to others and to her mission in life as a nurse, as a teacher, and as a historian. We learned that you cannot be your brother’s keeper until you become your own keeper. Eleanor was her own keeper. Her legacy lives on in the compassionate and wise care of her students, many of them leaders of their profession as caregivers, as teachers, as researchers, and as historians. As she traveled through this training school of the soul we call earth, the radiance of the light from this beautiful child of God allowed many to bask in its rays and illumined the journeys of many others. Her path allowed others to follow her light, calling to their own strengths across the stillness of the earth. As Eleanor wrote in the preface to her book on Virginia Henderson, Henderson sought not applause or fame but joyed in the recognition she was able to bring to her profession. How applicable these words are to our Eleanor who has thus spoken at her own funeral. I now ask God to enfold her soul and her spirit and to give Eleanor a hug as she journeys from this lifetime to join with her parents and with her sister Jane and brother in law John and with my mother Rose. I ask that she be guided to Rainbow Bridge to greet her departed Labs and her feral house cat as they bound over the clouds to greet her and lick her radiant countenance. Please rest for a while, beautiful lady, enjoy the welcome of your loved ones and regain your strength for soon you will also be teaching on the other side.

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Love is the force which sustains all living. You have been the source of boundless love for humanity and for nursing. May God bless you always. I know you are here today with our friends and you will always be with us in remembrance. Although we may weep, we also rejoice in your meaningful life and the end of your suffering. I miss you so much, my best friend, but your journey continues to a more beautiful and kinder place than this troubled earth. Pray for all those you have left with your enduring legacy and for those who need healing of body, mind, or soul, and please pray for a world to be at peace. We thank you O Lord for lending us your Eleanor who has brought so much meaning into our lives. I am so proud of the blessing of having shared life with you. I remember how, on that stormy, rainy day as you sped to Rhode Island upon hearing of the death of your mother, the darkened skies suddenly opened up, the sun shone through, and you heard your mother’s voice saying Jag älskar dig, Jag älskar dig (I love you). Bon voyage our Eleanor. Jag älskar dig, Eleanor. Amen and Omen!

MEDIA REVIEWS The Recipes Project: Food, Magic, Science and Medicine. 2012. Early Modern Recipes Online Collective, University of Saskatchewan, Saskatoon, SK, Canada. Editors: Lisa Smith and Elaine Leong. Regular Contributors: Michelle DiMeo, Rebecca Laroche, Laura Mitchell, Jennifer Munroe, Sally Osborn, and Alun Withey. Twitter account: @historecipes. http://recipes.hypotheses.org/

Explaining that “old recipes can tell us a lot about the past,” The Recipes ­Project: Food, Magic, Science and Medicine is a moderated blog focused on the history of medical, culinary, and household recipes. Launched in July 2012 by the Early Modern Recipes Online Collective, the project’s goal is to create an interdisciplinary community of scholars, graduate students, undergraduates, and those interested in recipe history. This interactive website features monthly articles by specialists of recipes from Britain, Europe, and early America who address recipe history from various perspectives, with a temporal focus loosely ­limited to the long early modern period (approximately 1500s– 1800s). Users are ­encouraged to participate in conversations with scholars via a twitter ­account or by posting comments. Recipe books have recently come to the attention of historians of health care and science as rich primary sources for early modern healing knowledge and practices. During the early modern period, domestic health care remedies and practices were intertwined with cooking, gardening, botany, alchemy, and veterinary medicine, and the lines between learned medicine and vernacular or “magical” healing were also blurred. Historian Alun Withey notes that ­women’s domestic recipe books provide a window into wide-ranging health care information networks that included kin, neighbors, lay healers, and physicians.1 Medicinal recipes demonstrate that these healers operated within a similar medical worldview based on modified Galenic humoral theories, which emphasized balancing the four bodily humors. In this framework, ­dietary therapies were as important as medicines. This is also evident in foodways historian Chef Stephen Schmidt’s analysis of an 18th century gingerbread recipe in his history of gingerbread reveals its use as both a confection and as a medicine to soothe gastrointestinal complaints including seasickness.2 Recipe research intersects with a wide variety of ­disciplines that include ­foodways Nursing History Review 22 (2014): 179–187. A Publication of the American Association for the History of Nursing. Copyright © 2014 Springer Publishing Company. http://dx.doi.org/10.1891/1062-8061.22.179

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history, women’s and gender studies, book history, and literary studies, in addition to the histories of nursing, medicine, pharmacy, and science. For historians of nursing, the website offers insights into women’s healing practices prior to the advent of professional nursing. Women chiefly compiled domestic recipe books and their remedies demonstrate the scope of their healing work in their homes and communities. The Recipes Project offers pragmatic information on how scholars interpret these recipe books. For example, in a two-part posting “On the Oil of Swallows,” literary scholar Rebecca Laroche and Michelle DiMeo, digital librarian at the Philadelphia College of Physicians, walk readers through comparative textual analyses that explain the evolution of recipes employing unusual ingredients like oil of swallows, hare’s urine, and earthworms.3 This website offers working examples of historical methodologies such as textual analysis, the process of transcription/annotation, and procedures for dating and identifying historical information. Elaine Leong’s discussion of recipe organization methods, for example, is an exploration of the historical interpretation of indexing in which she argues that Johanna St. John’s medical recipe index reveals St. John’s categorization of a “defined body of ­knowledge dealing with women’s health issues.”4 The website also provides engaging ­examples of how recipes can be used as tools for teaching many subjects, such as historian Lisa Smith’s description of her students’ collaborative transcription of Johanna St. John’s 17th century recipe book for a crowd-sourcing transcription platform while learning about XML and manuscript analysis.5 The home page offers monthly articles, an archive of past postings, and recent tweets. Users can access content through a search engine, preselected search categories, or a tag cloud with internal links to keywords. Individual articles include images and bibliographies. This site is unique in its assemblage of scholars from many disciplines, and in the analytic attention to recipes as documents. There is a page dedicated to “Further Reading” that includes links to related recipe sites such as Colonial Williamsburg’s “History is Served,” the University of Iowa’s Culinary Manuscripts transcription project, contributors’ academic websites, and the London’s Wellcome Library. When searching for the site, users should be aware that there are nonhistorical cooking sites with similar names. The Recipes Project provides a lively and diverse virtual community for nursing historians interested in pursuing research in early modern health care. Comments on articles are useful and discursive, but are generally limited to website contributors. The more active tweets are a mix of lighthearted and scholarly responses by more varied participants. Although some postings may not be of interest to historians of nursing, the search options allow users to find relevant



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topics. The website is well worth a visit, either to connect with like-minded scholars or simply to enjoy a journey into a surprising world of historical recipes. Notes 1. Alun Withey, “Social Networks and Sharing Medical Recipes: The Receipt Book of Amy Rowlands,” http://recipes.hypotheses.org/29. 2. Stephen Schmidt, “English Gingerbread Old and New,” http://recipes.­hypotheses .org/660. 3. Michael DiMeo with Rebecca Laroche, “On the ‘Oil of Swallows,’ Part 1: Did anyone actually use these outrageous remedies?” http://recipes.hypotheses.org/330­. “A Source for Young Bees: On the Oil of Swallows, Part 2,” http://recipes.hypotheses.org/308. 4. Elaine Leong. “Recipe Organization: It’s not as easy as A, B, C.” http://recipes .hypotheses.org/370, para. 8. 5. Lisa Smith, “An Experiment in Teaching Recipe Transcription,” http://recipes .hypotheses.org/500.

Susan Hanket Brandt, RN PhD Candidate Department of History Temple University Binding Wounds, Pushing Boundaries: African Americans in Civil War Medicine Exhibit. University of Virginia, Charlottesville, Virginia, October–December, 2012. Curated by Jill L. Newmark. Exhibit and website organized by the National Library of Medicine, National Institutes of Health. http://www.nlm .nih.gov/exhibition/bindingwounds/exhibition.html

Binding Wounds, Pushing Boundaries: African Americans in Civil War ­Medicine is a six-banner traveling exhibition with an associated educational website designed to explore the stories of African American men and women who served as surgeons and nurses during the American Civil War. This exhibit was ­developed and produced by the National Library of Medicine (NLM) and ­National Institutes of Health (NIH), with research assistance from the Historical Society of Washington, DC and curated by Jill L. ­Newmark. The exhibit is divided thematically into six banners entitled Binding Wounds, Pushing Boundaries; In Uniform; Catalyst for Change; Nursing the Wounded; Working Toward Freedom; and Within These Walls. The experiences of numerous African Americans are explored through a series of

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­ istorical images, brief discussions, and quotes. The exhibition features Black h surgeons in the Union Army, medicine during the 1860’s, antislavery movements of the era, African Americans fighting for freedom, and Black nurses. Although the bulk of the exhibition addresses African Americans who served in the Union Army, a portion of the exposition concerns free and enslaved Blacks at Chimborazo Hospital, a large Confederate medical complex outside of Richmond, Virginia during the war. Nursing is the central focus of the fourth banner entitled “Nursing the Wounded,” although nursing is mentioned on the other banners as well. This banner features brief summaries describing how fugitive slaves, known as “contraband” worked for the Union Army as cooks, laundresses, laborers, and nurses. Among photographs on the fourth banner are Black health care ­workers in a Nashville hospital; ex-slaves who served with the 13th  ­Massachusetts ­Infantry c. 1863–1865; the Union hospital ship Red Rover; and a large image of nurse Susie King Taylor. Taylor is arguably the most well-known Black nurse during the civil war largely because of her 1902 memoir, Reminiscences of My Life in Camp with the 33rd United States Colored Troops Late 1st S.C. Volunteers. Taylor’s account is the only known published diary of a Black nurse during the war. She is quoted or referenced on several of the six banners. One of Taylor’s featured quotes is, “There were loyal women, as well as men, in those days who did not fear the shell or shot, who cared for the sick and dying.” In a reference to Taylor on another banner, soldier James H. Payne of the 27th United States Colored Troops, 1865, wrote, “the cause, which nerved the soldiers to pour out their life-blood, was her cause and that of her race.” Many histories have been written about medical care during the civil war, but the participation and contributions of African Americans as nurses, surgeons, and hospital workers has often been overlooked. Binding Wounds, Pushing Boundaries: African Americans in Civil War Medicine examines how a unique intersection of events during the civil war shaped the experiences of all Black health care providers, including nurses. Through historical images and copies of period documents, the exhibit gives a glimpse of the lives of surgeons and nurses like Susie King Taylor as they provided medical care to soldiers and civilians. It also explores how they, along with other African Americans, gave care while also participating in a quest for freedom. Students and educators as well as researchers will find this exhibition thought-provoking and informative. It challenges the prescribed notions of race and gender by highlighting the roles of African Americans during a ­tempestuous time in U.S. history. The website connected with the ­traveling exhibition offers even more resources for the educator and historical researcher.



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It includes lesson plans for grade school and high school students, specific documents such as hospital rosters, and references for further reading and ­investigation. Both the exhibition and the website will undoubtedly stimulate some to further investigate topics found within it and others to contextualize a larger picture of medical and nursing care during the civil war. Kudos to the NLM, NIH, the Historical Society of Washington, DC, and other contributors for bringing this rarely explored part of our ­American history to light. Varying levels of students, educators, and historians will appreciate this exhibition as well as the website connected to it. The banner exhibition of ­Binding Wounds, Pushing Boundaries: African Americans in Civil War Medicine is currently touring the country. I highly recommend visiting this exhibition when it comes to an area near you. In addition, it is possible to reserve the exhibition for viewing at your local organization or educational institution. Locations of future displays and instructions for obtaining the exhibition on loan can be found at http://www.nlm.nih.gov/exhibition/bindingwounds/nursing.html. Barbara Maling, RN, PhD, ACNP-BC Assistant Professor School of Nursing The University of Virginia Farmville, VA 23901-1862 Controlling Heredity: The American Eugenics Crusade 1870–1940. University of Missouri Libraries, Special Collections and Rare Books, Columbia, MO. Curated by Michael Holland. http://mulibraries.missouri.edu/specialcollections /exhibits/eugenics/index.htm

Controlling Heredity is a collaboration between the University of Missouri (Mizzou), Life Sciences and Society Program and the University Special Collections Department that describes the American eugenics movement from the 1870s to the 1940s; it also provides a glimpse into the role of the Mizzou during the movement using materials from the Mizzou archives. The purpose of the site is to explore the “intersections between ethics and the ­pseudo-science [sic] of eugenics in the late nineteenth and early twentieth centuries.”1 The site originated in March 2011, as part of the Mizzou Life Sciences and ­Society Seventh Annual Symposium, Ethics and the Brain, and is operated by the ­Mizzou Special Collections, Archives, and Rare Books department. Controlling Heredity is divided into three thematic sections: Origins, ­Eugenics in America, and Eugenics at Mizzou. Each section has a short main

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overview, with links to key figures and subtopics in a text box to the right of the screen. The subtopics include links to open access material (through Google Books) and items found among the Mizzou Special Collections ­holdings. Each subtopic page has a brief introduction, a short bibliography, and select “Exhibited Items,” which are illustrations and copies of pages from archival materials, and can be enlarged by clicking. At the bottom of each page is a link to the exhibit timeline, which puts the assembled materials in chronologic, rather than thematic, order. The introductory page also features a video from the symposium’s opening speaker Stefani Engelstein presenting her paper “Visions of Transparency: The Human Body and Social Order.” The site is not large, and the navigation controls remain fixed on each page, which makes it difficult to get lost within the site, but links to the MU Library and to Google Books do bring the user to outside sites, losing the original location. The “Origins” section provides background material for the development of eugenic thought in Britain, Europe, and the United States, with links to the leading works in this area. Well-known authors such as Charles Darwin and Francis Galton are covered more extensively in subsets of this section, as well as lesser known figures such as Karl Pearson and Cesare Lombroso. Although useful in a general form, this is the smallest section of the site, and most of the information can be found elsewhere in more detail. “Eugenics in America” is by far the strongest and most comprehensive section of this site because it illustrates the pervasive presence of eugenics in public policy, and the depth of support for these ideas among the intellectual and social elite in the early 20th century. Subsections here include “Early ­Eugenical Studies” focused on studies of “degenerate” families with links to four major published studies. The subsection “Charles Davenport and the ­Eugenics Record Office” details the dissemination of eugenics theories through International Congresses, textbooks on heredity, and studies of men drafted into the military. Charles Davenport cultivated relationships with wealthy donors to finance large studies of degeneracy and intellectual defects, and teamed with anthropologists and sociologists to establish the “scientific” arguments for eugenics. The third subsection “Harry Laughlin: Workhorse of the American Eugenics Movement” details Laughlin’s impact on forcible sterilization laws and immigration restrictions. The final section “Eugenics at Mizzou” highlights the University’s contributions to the eugenics movement and national policy. Subsections here include the “American Breeder’s Association,” which promoted incorporating Mendelian laws of heredity into plant, animal, and human propagation, and three individual Mizzou faculty who were prominent in the Eugenics movement: Charles Ellwood, Carl Terence Pihlblad, and Maurice Parmelee. These



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e­ ugenics proponents are less known than Darwin or Galton, but they each had influence both within the university and with a wider, national audience. Missing from this section is a deeper analysis of the role of eugenics within the larger university, and what became of these faculty after the decline in the popularity of eugenics after World War II (WWII; Ellwood, for instance, retired in 1971). Nursing History Review readers who are interested in the history and influence of the American eugenics movement on culture, science, and health policy will find this site useful for its exploration of the proponents of eugenics in the United States, and in the links to archival sources. The lack of a recommended reading list, or a comprehensive bibliography limit the use of the site, but it does present an easy to use introduction to the mechanics of the eugenics movement. Users may find this site helpful in conjunction with other online histories of American Eugenics including the Cold Spring Harbor Laboratory (www.eugenicsarchive.org), and Lutz Kaelber’s assessment of compulsory sterilization in the 50 states (http://www.uvm.edu/~lkaelber /eugenics/ through the University of Vermont).

Note 1. Curators of the University of Missouri, “About the Exhibit,” University of ­Missouri Special Collections and Rare Books, http://mulibraries.missouri.edu/specialcollections/exhibits /eugenics/about.htm (accessed 1 December 2012).

Bonnie Pope, PhD, ARNP Assistant Professor School of Nursing Brooks College of Health University of North Florida Nursing in America: A History of Social Reform. 1990. Insight Media, Producer and Director Tony Ely. Insight Media, 2162 Broadway, New York, NY 10024. www.insight-media.com

My review of Nursing in America: A History of Social Reform visual media for university and high school classrooms comes over 20 years after its creation by the National League for Nursing, and the nature of technologic advances ­creates a feeling of obsolescence around this film. Despite the ­technical

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c­ hallenges older media present, however, the film does present an engaging overview of the history of American nurses, which can be mastered very quickly by most secondary school students. The film unites the story of American nurses under the oversimplified umbrella theme of social reform, and tags advances in nursing practice to major social and political events. The film begins with nursing’s origins in private care for the ill in their homes, and tracks the changes in nursing education and practice through the 20th century. The filmmakers present the developing nursing profession in relation to an assortment of U.S. social movements including women’s suffrage, the civil rights movement, immigration, and ­industrialization. Particular attention is paid to important figures such as ­Lavinia Dock, Isabelle Hampton Robb, Adelaide Nutting, Margaret Sanger, and Virginia Henderson, as well as institutions including Teacher’s College, Johns Hopkins, and the Frontier Nursing Service. The filmmakers have used these social movements to explain particular areas of change in nursing practice such as the rise of critical care units, the beginnings of nursing research, the desegregation of nursing, as well as the changes brought about by military action including the Spanish–American War, both World Wars, and the ­Vietnam War. The film ends with the development of the Nurse Practitioner role. Transitions between periods is as smooth as possible given the time span of more than a century, and some important areas are omitted entirely, including any discussion of men in nursing. This narrated DVD features some of the leaders of the history of nursing, namely Virginia Henderson, Ellen Baer, Joan Lynaugh, and Elizabeth Carnegie. Although video clips and photographs of leading nursing figures and historic events illustrate and bring the stories of nurses to life, these giants of nursing history eloquently articulate the trials, triumphs, and tribulations of our founding mothers and carry the story of nurses to nearly present day. Although the information contained in the video is historic and, one could argue, does not change with time, the digital media (DVD) on which this film is recorded is quickly becoming outdated. To watch this film, I needed to use a laptop that is still equipped with an optical drive for DVDs because my new desktop computer does not include that technology. When the film loads, a menu appears at the top left of the screen that list the film’s chapters, but because there is no way to select a particular section for viewing, this appears to only be a topical outline. This film also lacks the common feature in today’s multimedia: the ability to search by theme or object. It would be very useful for future versions of this film to include a selectable delineation of chapters and a way for the viewer to search the film for particular historic details. Designed to be used by educators of a generation of students so ­heavily



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armed with an arsenal of the latest, fastest, and most sophisticated gadgets, the outdated graphics of the opening menu are not a very inviting way to be introduced to the body of the history of nursing. In this age of nursing education, where more and more schools are steering away from undergraduate-level semester-long classes in the history of nursing, it is likely that schools of nursing will seek out media, like this DVD, to provide their students with an overview of the history of their profession; and at 30 min duration, it is a shorter alternative to the other Insight Media’s more recent offerings on nursing history. In order for this film to remain a relevant and valuable contribution to educators, the wave of the present and the future desperately call for this video to be updated, both in content and in the media chosen. Some relevant topics that might help to modernize this film would be to use the tools used by those well versed in the ever-evolving digital humanities field. By doing so, contemporary students of nursing would find it helpful to be able to search this tool as a database and learn the basics of the field of the history of nursing. Jennifer Casavant Telford, PhD, ACNP-BC Assistant Professor University of Connecticut School of Nursing and Department of History Storrs Hall, UNIT 2026 231 Glenbrook Road Storrs, CT 06269

BOOK REVIEWS

Racial Innocence: Performing American Childhood from Slavery to Civil Rights By Robin Bernstein (New York, NY: NYU Press, 2011) (318 pages, 54 illustrations, $24.00 paper)

For many historians, analysis of children in history provides a unique way of examining larger social and cultural concepts that may not be evident when considering adult populations. Robin Bernstein demonstrates the necessity for such a nuanced lens of analysis in her work Racial Innocence: Performing American Childhood from Slavery to Civil Rights. Using items of material culture as a data source, she shows how childhood played key roles in many large scale racial projects in the United States including slavery and abolition, anti-Black violence, and the early Civil Rights movement to name a few. What makes her work innovative is her analysis not of children themselves but of the idea of childhood as a racially charged entity as she traces it from slavery through the Civil Rights movement. By analyzing what she calls childhood in performance, Bernstein masterfully illustrates how adults with divergent political ideologies have used the same idea of childhood to justify their positions, both sides seeming “natural, inevitable, and therefore justified” (p. 4). By using dolls as well as literature such as Uncle Tom’s Cabin, Bernstein reveals how these aspects of material culture scripted certain behaviors in children in a dynamic relationship between the child and the object. She begins by arguing that childhood was a racially charged ideal: childhood was white and the ideologies held by society were hidden in its seemingly perfect alibi of innocence. Her analysis lies in the ability to interpret how objects “scripted” particular behaviors. The importance of this approach aims to “discover not what any individual actually did but rather what a [sic] things invited its users to do” (p. 11). The act of scripting is a historical event labeled as a culturally specific invitation. She examines the ways in which dolls, such as Raggedy Ann and the Topsy-Turvy, invited their users to physically respond in ways that might help historians determine social meaning from such invitations of use; both in construction and in material make-up, these dolls invited ­specific Nursing History Review 22 (2014): 188–207. A Publication of the American Association for the History of Nursing. Copyright © 2014 Springer Publishing Company. http://dx.doi.org/10.1891/1062-8061.22.188



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actions and thus give historians a “script” to interpret. Bernstein also examines what she calls the “repertoire” of Uncle Tom’s Cabin as it played out in interactions between people and the creation of objects that reflected the story and scripted responses; she reveals how the ideas of race specified in the presentation of the books themselves such as how the pictures were drawn and arranged by early illustrators and publishers. Bernstein’s consideration of race as it manifests in the idea of childhood is profound, but it is limited by its binary nature. Childhood, as she admits, is broader than racial ­categories of Black and White, but her analysis fails to address the possibility of what broader considerations of race—including other racial categories beyond the Black and White binary—might imply in her argument. Since her sources assume a binary approach, does her conceptualization of race as it is evidenced in dolls and literature of other non-White groups play out the same way? This heavily conceptual work challenges the audience to think about childhood in a broader sense than simply as a category of age. Bernstein supports the broader historical practice that shows how “living children, as well as historically located representations of children, have unique abilities to recapitulate adult culture while seeming to deflect it” (p. 7). She suggests a much broader conceptualization of childhood—it is not only a way of understanding a portion of a population demographic but is also a way of understanding how adults perceive themselves and the world around them. Childhood is not a state of being but a performance that is not limited to a measure of age. Her work, although it does not pertain to health care, should be mandatory for any historian interested in ­thinking about how the study of the history of children might illuminate historical analysis. Historians of nursing might find this book valuable for its contribution to how we consider age as an analytic category as well as how we implement assumptions about the dynamic relationship between material culture as a data source and the ways we use it in our own work as historians. Her analysis gives rich contextualization and demonstrates a thorough understanding of the issues and period of interest. Not only does she add to and challenge the scholarship regarding the consideration of childhood as an analytical category, but she also leaves the historian thinking critically about how we might consider material data in new and innovative ways in our own work. Briana Ralston, MS, RN Doctoral Student Barbara Bates Center for the Study of the History of Nursing University of Pennsylvania School of Nursing 501 Woodland Terrace, Apt 3R Philadelphia, PA 19104

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Gender and the Making of Modern Medicine in Colonial Egypt By Hibba Abugideiri (Farnham, Surrey, England: Ashgate Publishing Limited; and Burlington, VT, Ashgate Publishing Company, 2010) (268 pages, $124.95 cloth or eBook)

The process of modernization in former colonial states has received increasing interest, including a focus on women and nationalism. This book enhances understanding of the long process of modernization, economic growth, and state formation in Egypt during the Muhammad Ali dynasty and under British colonial rule. Medical education is used to detail the synergy between nation-building and the emergence of a modern medical profession with strong ties to the state. Gender is central to this inquiry, as demonstrated through development of female medical practitioners and midwives, and their subordination concomitant with the advance of anglicized Egyptian medicine, even as male medical influence grew over gendered domestic spaces including childbirth, breastfeeding, and child rearing. Medicine functions as an analytic lens to view the modern Egyptian state as shaping gender inequalities in citizenship, a view that critiques modernization theory as applied to the Middle East region. The framework emphasizes gender history, but also employs political history, history of medicine, and history of nursing. Book chapters flow very well to address the central ­thesis, with introductory materials sequenced skillfully to provide background and evidence for the reader’s analysis. Chapter organization is generally chronologic, but a ­chapter’s focus may require reaching back in time to introduce new themes. The modernization policies of Muhammad Ali, the Ottoman viceroy of Egypt (1805–1845), were tied to state-building for which the medical school of Qasr al-‘Aini (founded 1827) was instrumental. Building centralized economic activity and a national bureaucracy required an effective military, in turn supported by a strong medical corps. A healthy population was essential to Ali’s mercantilist goals; military medicine formed the basis for mass medicine and public health organization, which symbolically tied doctors to state-building because they became an intermediary between the state and society. Beginning in the 1830s, Egyptian midwives, known as hakimas or doctresses, were systemically trained in the government School of Midwifery to provide a female corps to reduce epidemic disease and improve the health of women and children—mass medicine as a critical step in Egyptian ­economic



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modernization and state formation. Difficulty in ­recruiting adolescent females and the frequent need to begin their education with ­learning to read, vastly limited total graduates. Midwifery skills similar to the ­Parisian schools ­included vaccination, bloodletting, bandaging, basic materia medica, and dispensing. The teaching method was indigenous, with the brightest student coaching the others. As under Ali, medical care and treatment of disease and epidemics under British rule became a means to consolidate state power. The first decade of British rule (1883–1892) emphasized financial and agricultural reform but delayed mass education and public health development, all toward creating an oversupply of cheap labor that was directed ­toward agricultural growth, particularly cotton for export. Restrictions on educational ­access and social mobility created a limited number of civil servants and professionals that served colonial goals. Anglicization of the medical school countered previous French ­influences and shifted curricular emphasis from theoretical to clinical learning. Restricted access to education at all levels limited the privilege of becoming a doctor to the urban elite; the framework of colonial medicine changed the focus of medical practice, even as it constrained the lives and work of doctors to serve colonial goals. The role of the hakima constricted under Victorian British reforms and transformed into nurse, becoming secondary to the authority of medicine. In the early 20th century, most women were delivered at home by nurse-midwives (muwallidas) or the lay midwives (dayas) they supervised, both responsible to physicians who took charge during complex labor. By the 1920s, doctors disdained traditional medical practitioners of both genders. Egyptian medical practice changed in response to emerging precepts of modern scientific medicine, including disease specificity, causation, and laboratory analysis. ­Egyptian doctors addressed epidemics through public health campaigns; colonial medicine itself supported the emergence of a modern, independent medical profession in Egypt that rapidly gained political power and extensive social influence. Medicine emphasized Republican motherhood, “a scientific discourse that sought to nurture the maternal and domestic ­instinct in women for the political purpose of modern nation-building” (pp. 1–2) that ­exposed relationships “among gender, medicine, class, and nationalism” (p. xi). As a medical discourse, Republican motherhood was key to forging an Egyptian national identity, but it applied colonial gender biases to enforce Victorian ideals of limited womanly roles for Egyptian women of all classes. The author relies on a broad range of significant primary sources (1881– 1930) written in French or English, and deposited in Cairo archives. Medical texts and reports (primarily 1840–1935) provide a rich source for interpretation of Egyptian medical ­professionalization. Primary works in Arabic,

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French, or English establish the background of political, educational, and ­sociocultural transitions. Extensive secondary sources are diverse; their strategic use in the book demonstrates the author’s abilities to synthesize across disciplines, languages, and traditions, as well as across time. Citations in text are specific and helpful. Counterevidence is presented and weighed. The author demonstrates the power of her step-by-step analysis through clear prose that incorporates diverse sources to find common themes that, once argued, are reliably established. Gender and the Making of Modern Medicine in Colonial Egypt provides a unique window into health care, medicine, and nursing in a colonial system as Great Britain restructured Egyptian institutions of education and health care to achieve its own political and economic goals. Because this book assumes some understanding of Egyptian and regional history, it may be initially a challenge to absorb, but it is a considerable pleasure to read and understand. It opens health professions and care system development in an Islamic country, leading to a deeply textured understanding of its construction through colonial/political influences. Yet this analysis resonates with past and present to suggest new questions about the American health system and its professions: Did professionalization of American medicine also benefit physicians through strengthening hierarchal relationships with female professions and with women patients? Academics interested in comparative health care systems will find lessons about divergent systems and professions, and particularly how colonial health systems may converge with that of the colonial power. This book suggests barriers for health system intervention proposals in less developed countries because outsiders may fail to foresee outcomes. For gender studies, the political construction of motherhood is again raised, relative to socially influential male physicians. Historians of medicine, and of nursing and midwifery, will likely identify new questions related to interprofessional development as well as to the power of a profession to shape everyday social interactions in the home. Janna L. Dieckmann, PhD, RN Clinical Associate Professor School of Nursing The University of North Carolina at Chapel Hill CB # 7460 Chapel Hill, NC 27599-7460



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Florence Nightingale on Wars and the War Office: Collected Works of Florence Nightingale, Volume 15 Edited by Lynn McDonald (Waterloo, Ontario, Canada: Wilfrid Laurier University Press, 2011) (1056 pages, $150.00 hardcover)

Florence Nightingale on Wars and the War Office is Volume 15 in the extensive series The  ­Collected Works of Florence Nightingale. This series aims “to make available Nightingale’s major published books, articles and pamphlets (many long out of print) and a vast amount of heretofore unpublished correspondence and notes.”1 As with the other volumes in this series, the book contains as much of Nightingale’s correspondence, official reports, and other extant written materials uncovered by the editorial team for this extensive project. A major goal of the project is to provide one accessible venue through which to publish Nightingale’s wide-ranging written works thus removing the burden for scholars of traveling from archive to archive to retrieve Nightingale material. The iconic status of Nightingale, her considerable influence on health care, and the extensive scope of her work and research is cited as a compelling rationale for compiling her writings in one far-reaching series.2 Volume 15 covers Nightingale’s writings that deal with the provision of military medical and nursing care before, during, and after wars. Conflicts covered in this volume include the numerous wars occurring around the world during the late 19th century, some in which Britain was involved and some not engaged in by the British. This volume follows The Crimean War (­Volume 14) and continues documentation of Nightingale’s prodigious efforts to influence and reform medical and nursing care to the military; efforts to which she devoted much of her post-Crimean War career. As with the other volumes in the series, the book begins with a short précis of ­Nightingale’s life. An introduction to the volume and key to editing follows. The main content of the volume contain sections entitled “Army Nursing in Peace and in War,” “War Office Reform in Peacetime,” and “Wars from the Geneva Convention to the Boer War.” Throughout each of the sections, brief editors’ comments are presented, which provide the reader with some background context for the topics discussed. A short appendix of biographical sketches of individuals highlighted in Nightingale’s correspondence completes the volume. Most of Nightingale’s works included in this volume are letters and other correspondence written over the period of her life from the time she returned to England after the Crimean War to the early years of the 20th century. This is a very large amount of material. The letters are presented within each

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section in chronological order, an organization that enhances the reader’s orientation to the issues discussed and allows the reader to obtain a richer idea of how Nightingale dealt with advancing her positions and solutions intended to ­reform health care. Of particular interest to this reviewer was the initial section of the volume which contains Nightingale’s Subsidiary Notes as to the Introduction of Female Nursing into Military Hospitals in Peace and in War. McDonald astutely notes that this work has received little attention by nurse historians but is worthy of notice for several reasons. Subsidiary Notes preceded Nightingale’s more famous Notes on Nursing and provides a clearer understanding of Nightingale’s controversial theories on contagion. It contains reviews and comparison of different systems of nursing care delivery, such as the Russian, Roman Catholic, and Anglican system during the Crimean War. Furthermore, although its focus is on military hospitals, Subsidiary Notes lays out a very detailed, thoughtful, and comprehensive plan for mid-19th century hospital administration. Some recent and well-received works on 19th century institutional delivery of nursing care, such as Carol Helmstadter and Judith Godden’s award winning Nursing before Nightingale, 1815–1899,3 has greatly broadened our understanding of this period and the complexities of organizing nursing services care delivery and Nightingale’s own words on how to deliver institutional nursing care is a welcome adjunct to this literature. This volume is rich with insight into Nightingale’s work, her thoughts on reform, and her dedication to British soldiers, a group with which she identified strongly and loyally admired. Her lifelong concern for their wellbeing permeates her writings. Sadly, as her correspondence testifies, improving the British military medical delivery system was neither easy nor permanent. The volume also reveals Nightingale’s conflicted attitude toward war. Not surprisingly, given her experience in the Crimea, she disliked war greatly but advocated strongly that if a nation went to war, they should do so prepared to deliver health care to the participants. Consistent with this belief, she expressed reservations about the emergence of the International Red Cross, arguing that care of the wounded in battle was the responsibility of the combatant nation. The sheer size of this volume provides scholars with a plethora of material from which to garner further comprehension of Nightingale as a transformative leader of health care reform. That is the major strength of both this book and the other volumes in the series. At the same time, scrutinizing such a ­massive work remains problematic without a more user-friendly search option. Breaking Nightingale’s writings down into specific sections is helpful as is the presence of an index, yet access to a more searchable form



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would be welcome. The website that describes the overall project states that a searchable format is on the horizon.4 Development of an electronic publication is to commence once the entire print series is completed. An easily searchable electronic version of this massive amount of material will be very welcome.

Notes 1. “The Collected Works of Florence Nightingale,” http://www.uoguelph.ca/~cwfn /Introduction/index.html (accessed December 9, 2012). 2. Ibid. 3. Carol Helmstadter and Judith Godden, Nursing before Nightingale (Surrey, ­England: Ashgate Publishing Limited, 2011). 4. “The Collected Works of Florence Nightingale”

Jean C. Whelan, PhD, RN Adjunct Associate Professor Barbara Bates Center for the Study of the History of Nursing University of Pennsylvania School of Nursing Claire M. Fagin Hall (2U) 418 Curie Blvd. Philadelphia, PA 19104

Australia’s Controversial Matron: Gwen Burbidge and Nursing Reform By Judith Godden (Burwood, NSW: The College of Nursing, 2011) (357 pages, $30.00 paper)

Matron, educationalist, reformer, and nursing advocate, Gwen Burbidge was one of ­Australia’s most prominent and influential nurses of the 20th century, ever present at the heart of nursing reform and its attendant challenges, controversies, and politics. Judith Godden has provided a comprehensive biographical study of Burbridge’s professional life. This compelling study should reassure those concerned for the future of the biography. The book achieves all  that the biography should: it narrates the life of an individual in some

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c­ onsiderable detail; it sets that life within the time, place, and context in which the subject lived; and it offers a lens through which wider historical developments and events may be viewed. Godden charts Burbidge’s early nursing career at the Melbourne Hospital, including her very traditional and typically harsh training under Jane Bell, her academic success, and her early rise to becoming a Sister Tutor under Bell in 1927. Burbidge’s efforts to introduce new teaching methods at Melbourne were frustrated by the very rigid structure and didactic methods of instruction on which the highly traditional and dogmatic Bell insisted. As we discover throughout the book, Bell was Burbidge’s nemesis in professional nursing. Early in the book, Godden introduces the reader to the politics of hospital nursing in Australia; the machinations surrounding the reception of Burbidge’s book, Lectures for Nurses, provides a case study of professional nursing’s less kind face and foretells the many future conflicts that Burbidge would later encounter in her various roles as administrator, educator, and reformer. Godden draws on Burbidge’s personal diary for much of the narrative concerning her time in England, where she completed a 2-year Diploma in Nursing at King’s ­College, ­London. In 1939, Burbidge was appointed ­Matron of the Fairfield Hospital, Melbourne, a position she held until her retirement in 1960. Godden describes the key stages in ­Burbidge’s professional life, including her work in modernizing the nursing and the infrastructure of Fairfield Hospital; her prominent role in addressing state and national nursing shortages during World War II; her personal achievements in obtaining a Rockefeller Scholarship to study nursing education in North America and in receiving the Order of the British Empire (OBE) in 1956 for outstanding ­services in the nursing profession; and her final 15 years at Fairfield from1945 to 1960. These years were marked with “frantic activity” in which Burbidge contributed to several state and national committees including the Royal ­Victoria College of Nursing (RCVN), the Nurses’ Board, the National Health and Medical Research Council, and the Nurses’ Guild. Godden describes the infighting and disunity that pervaded the nursing leadership in Australia in the postwar period, such as when as Burbidge and the International ­Florence Nightingale Committee went about founding a College of Nursing. In this period, ­Burbidge and Bell locked horns on several occasions. Ever the reformer, as the book’s subtitle suggests, Burbidge promoted the idea of education over training, rejecting the anti-intellectual narrative that was so pervasive in mid-20th century nursing and insisting that good nursing care arose from good nursing education.



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The book is beautifully presented in 13 chapters and is well organized around themes and related chronological periods. The jacket contains a somewhat untypical portrait of a hospital matron, with the broadly smiling ­Burbidge sitting in her car and “on the move,” and not suggestive of a woman burdened with endless disputes with her many antagonists. Godden’s book suggests several recurring themes, including the hospital as a complex social space, resistance to change, power brokerage, and nursing’s enduring capacity to be inward-looking. Godden shows how the hospital was populated by individuals and groups who competed for power and influence, resulting in personal squabbles, petty jealousies, and disruptive conflicts that delayed or halted progress. Vehement resistance to change, often it seemed for its own sake, is a constant theme in the book, with several instances of how ­Burbidge experienced opposition and opprobrium from traditionalists suspicious of academic achievement or fearful of losing their power and influence over nurses. Another recurring theme is power brokerage, illustrated in the almost absolute dominance of matrons over their subordinates and professional nursing organizations. The book also illustrates how collectively professional nursing could be inward-looking and isolationist, so effectively demonstrated in Godden’s accounts of the “endemic in-fighting” between the old guard and the new guard over attempts to address the abiding problem of the nursing shortage. Godden’s use of well-chosen evidence to illustrate key developments is a major strength of the book. The fact that one matron, Annie Sage of the Women’s Hospital, was effectively forced to resign in the same year that she was awarded the Commander of the Most Excellent Order of the ­British ­Empire (CBE) perfectly, if poignantly, illustrates the abiding power of the medical profession, the emerging managerial hegemony of the hospital ­secretary manager and declining power of the hospital matron. In this important book, Judith Godden has provided an exquisite, authoritative, and honest account of one of Australia’s most influential nursing leaders. Nursing historians engaged in or contemplating writing a biographical study would do well to read this ­exemplary biographical study, which is not merely a biography of “Australia’s ­controversial matron” but a scholarly and critical history of Australian nursing in the 20th century. Gerard M. Fealy, RGN, PhD Associate Professor, Associate Dean for Research and Innovation UCD School of Nursing, Midwifery and Health Systems University College Dublin, Ireland

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Das Tagebuch der jüdischen Kriegskrankenschwester Rosa Bendit, 1914 bis 1917 [The Diary of a Jewish War Nurse Rosa Bendit, 1914 until 1917] Edited by Susanne Rueb and Astrid Stölzle (Stuttgart, Germany: Fransz Steiner Verlag and the Robert Bosch Foundation, 2012) (175 pages, 6 black and white photos, €29.00 paper)

This is a printed edition of a rare find, the dairy of a Jewish nurse, Rosa Bendit, written while she was a voluntary Jewish war nurse in the German military medical service—a voluntary medical service of civilian medical personnel, in which thousands of nurses from all sectors of German society took part during the First World War. They staffed a large network of field hospitals for wounded German soldiers. The book provides a unique perspective on the experiences of German nurses during the war, written by a Jewish nurse who volunteered for service while being the head nurse of the Jewish Nurse Residence and Registry for home nursing in Stuttgart (Das Stuttgarter Jüdische Schwesternheim). The diary typically had about 8–12 entries per month. It is printed in full from a copy that most likely was left behind by Rosa Bendit at the nurse residence when she left her position in 1921. The attending physician of the home, Gustav Feldman, took this copy with him when he decided to immigrate with his family to Israel in 1935. The copy was among other documents Feldman brought with him about the Jewish nurse residence and other Jewish organizations in Stuttgart. The diary was deposited in the Central Archives for the History of Jewish People in Jerusalem. This printed version is published and prefaced with an introduction by Susanne Rueb and Astrid Stölzle. The book is enriched with six photographs from the nurses’ life and work during the war. From the introduction, we learn that Bendit worked closely with Feldman during the first year of her military service at the field hospital in Breisach at the border of ­Germany and France. Bendit, born in 1879, had obtained her nursing education in Berlin (1903–1906). Afterward, she began her career as a home care nurse (private duty) at the Stuttgart Jewish nurse residence and registry. After 16 years at the home, she left in 1921 to take care of her family after the death of her mother. Nothing is known about Bendit’s life after she left her position in Stuttgart, but her diary, kept during the war, provides a very personal glimpse into her profound war experiences, first in Breisach, then in Serbia, thereafter again in France, and during the last part of her war service in Romania. The introduction continues with the history of the Stuttgarter Jewish nurse residence. Interestingly, this nurse residence, founded in 1900, was among several Jewish nurses’ associations established in Germany in the late



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19th century by an American society of German–Jewish immigrants, who gathered funds for charitable causes and sought to enhance intercultural understanding. This society established several such associations for Jewish nurses in other German cities, modeled after similar ones founded by religious and civilian groups at that time internationally. After the First World War, these nurses’ associations experienced considerable economic hardship because of the general economic malaise in Germany at that time. During the 1930s, the Jewish nurses’ associations, including the one in Stuttgart, became tragically caught up in the overruling and eventual disbanding of the associations by national socialists, leading up to the killing of Jewish people in the Second World War and to the definite end of organized Jewish nursing in Germany. Susanne Rueb furthermore analyzes how the diary also provides insight in the particularity of the Jewish war nurses’ experiences. Similar to their counterparts in other nurse organizations and associations, the Jewish nurses’ work was a commitment to humanity in bringing good care and service to the sick and wounded. But their service also provided Jewish nurses with an opportunity to confirm their identity as rightful German citizens, seeking to counter the anti-Semitism they experienced nevertheless. Their bonds with other Jewish nurses formed a resource, providing trust and familiarity in the midst of sustaining themselves as a minority group. Astrid Stölzle completes the introduction with a thorough discussion of the way the voluntary German nursing war service was organized during the First World War. As an organization of voluntary civilian health professionals, nurses were merged into the state medical military service and, as such, became part of the army structure and hierarchy. As a result, many nurses spent long periods, sometimes years, away from home and family serving at the front, and experiencing the hardship and exhaustion the war brought for so many. Some nurses also died. The introduction gives depth and ­meaning to the diary that describes, in vivid detail, Bendit’s day-to-day work under the most challenging circumstances. But it also includes accounts of her leisure activities, a birthday they celebrated, or an evening spent at a local women’s association. A most interesting book on a much underexamined domain of nursing providing a unique perspective on Jewish war nursing in Germany during the First World War. Geertje Boschma, RN, PhD Associate Professor School of Nursing, University of British Columbia T201 – 2211 Wesbrook Mall Vancouver, BC V6T 2B5 Canada

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Come from Away: Nurses Who Immigrated to Newfoundland and Labrador By Jeanette Walsh and Marilyn Beston (St. John’s, Newfoundland: Breakwater Books Ltd, 2011) (285 pages, $18.95 CAN paper)

Using the traditions of oral history, the authors interviewed 41 nurses who came from foreign countries to Newfoundland and Labrador between the years 1953 and 2007 to ease the nursing shortage. Their stories add to our knowledge of nursing in the province, in rural areas as well as in St John’s, seen through the eyes of nurses trained in Europe (primarily the United Kingdom), the United States, Africa, Vietnam, and the Philippines. Previous books by these authors (reviewed in Nursing History Review, Volume 19) told the stories of nurses who were educated in Newfoundland. Although the authors acknowledge that oral history can be tainted by flawed recollections, the themes resonate. Frequently, these nurses had little idea of where Newfoundland was prior to agreeing to accept a position there. They found many differences in nursing practice, particularly in their scope of responsibility. Some expressed that nurses in ­Newfoundland lacked autonomy, especially in what they viewed as basic nursing care, such as providing hot water bottles and laxatives. The midwives also felt that they were not used to the full extent of their training. In contrast, in the rural areas, they practiced skills such as pulling teeth, which they had never envisioned. Situating their stories in the socioeconomic context of the province, with its strong connection to the sea and fishing as a livelihood, and the rural isolation, helps us to understand their experiences. Many of these nurses stayed in Newfoundland because they married local men. They described not only their nursing experience but also their integration into the community, especially their growing respect for their independent self sufficient neighbors. The book’s chapters are divided into regions, which loosely corresponds to whether the nurses worked in a rural or more urban setting. The experiences of the earliest nurses (1950s) describe working long hours in cottage hospitals in isolated outports, often ­beyond the scope of their training, such as administering anesthesia. The final chapter focuses on midwives, all of whom immigrated from 1990 to 2007 to St. Anthony on the ­Northern Peninsula. Although they were recruited because they were midwives, they describe ­working as staff nurses as well. The authors premise that foreign nurses made significant contributions to the health care of the province is clearly supported by these oral histories. Many



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Newfoundland trained nurses were not interested in relocating to the rural areas, so without foreign nurses many people would have lacked health care. Although the authors do not analyze the nurse’s experiences, they do provide some introductory information for each grouping. This information would be enhanced by the addition of references or footnotes for the material. The authors also assume that the reader is familiar with Newfoundland and Labrador. A map to help locate the nurses, and some information about the province, as well as definitions for words that might be unfamiliar would increase the appeal to people “from away.” These could be inserted as footnotes so as to not interrupt the story. In spite of these small issues, the book provides an interesting narrative of life in Newfoundland, and from a nursing perspective, a window into the experiences of these nurses who stayed after their initial contract ended. This book is especially useful today as we strive to promote nurses practicing to the full extent of their education. Understanding the practice setting from previous times and in other places adds to our knowledge of the evolution of nursing. Anyone interested in nurses’ stories of adventure and resilience will not be disappointed in this book. More likely after reading it, you may find yourself wishing that it was longer and that you could have a chat with these women (and one man) to learn more about their nursing careers. Susan A. LaRocco, PhD, RN, MBA Professor/Traditional Program Coordinator Curry College 1071 Blue Hill Avenue Milton, MA 022186

Downs: The History of a Disability By David Wright (Oxford, NY: Oxford University Press, 2010) (256 pages, $24.95 hardcover)

David Wright’s latest book Downs: The History of a Disability is the newest edition to ­Oxford University Press’s “Biographies of Diseases” series, coedited by William and Helen Bynum. The first book of its kind to chart the medical history of Down’s syndrome, Wright’s account spans the last 500 years of Western medicine and philosophy, taking its readers on a journey that begins with John Locke and ends with some of the thorny ethical issues that

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have long pitted disability rights activists against second-wave feminists. The narrative arc—and indeed the impetus for the research and writing of this book—arise from Wright’s own lived experience with Down’s syndrome. In an eloquently narrated prologue, Wright recounts his childhood of growing up with his younger sister Susan, who, born with Down’s syndrome, had become the poster child of the Canadian normalization movement of the 1970s and regularly appeared on billboards advertising the Special Olympics. Despite her celebrity status, Wright admits that he was an “­unwitting juvenile witness to some of the most contentious debates in the history of Down’s ­Syndrome of that era” (p. 3). The resultant book, it seems, is Wright’s attempt as a medical historian (and a brother) to grapple with what disability means in the 21st century and how we got to a point where society is driven by a seemingly contradictory impulse “to both integrate and eradicate” trisomy 21 (p. 185). The book is organized chronologically, with the intent to reveal the process by which this particular disability becomes named and renamed over time. Taking his cue from Charles Rosenberg, Wright contends that “naming disease . . . carries with it significant cultural baggage with no small amount of controversy” (p. 10). After a chapter devoted to a brief prehistory about “idiots” and their institutionalization in Enlightenment ­Europe (Wright has published more than a half-dozen books on the history of mental illness and institutionalization), he gets to the meat of the story in Chapter 2 with a history of Dr. John Langdon Down, the British physician who, in 1866, first described the condition we know today as Down’s syndrome. Down, however, did not name the condition after himself. Instead, he classified the asylum inmates with certain telltale facial features (flat-faced, small-nosed, oblique-eyed) as “Mongols.” Like many of his contemporaries in physical anthropology who were also coming to grips with Darwin’s 1859 On the ­Origins of Species, Down surmised that pathological “mongolism” was caused by atavism, “the spontaneous reversion of [Caucasian] individuals to more primitive races of humans” (p. 49). Subsequent chapters continue with the theme of how leading medical scientists—­always tethered to a specific set of highly contingent social, cultural, and political ­values—­reconceptualized mongolism over the next 150 years. John Langdon Down’s son, ­Reginald, continued his father’s tradition of “dermatoglyphics.” In 1905, Reginald argued that in addition to certain facial features, most so-called mongoloids had a “simian crease,” an anatomical fold running across the whole width of the palm that was also found on the hands of primates. With Reginald at the helm of the Eugenics Education Society from 1909–1936, mongolism became a frequent topic among eugenicists



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who worried about racial degeneration. Fears of racial decline were bolstered by the then new science of intelligence testing, which found that most adult mongoloids had “mental ages” of children, with IQs ranging from 20 to 70. The label mongolism would not fall into disrepute until 1961 when French geneticist Jérôme Lejeune, British psychiatrist Lionel Penrose, and Norman Langdon-Down (a grandson of John Langdon Down) penned a letter to The Lancet urging a nonracialized alternative. Some of the first medical scientists to be involved in the early science of genetics of the 1940s and 1950s, these men looked to chromosome maps rather than dermatoglyphics, and found that mongoloids had an extra copy of chromosome number 21. Going neither the way of genetics nor of custom, the editor of The Lancet chose to use the term “Down’s Syndrome” for the condition. Mongolism still held sway throughout the 1960s, however, as is evinced by the fact that in 1965, delegates from the People’s Republic of Mongolia objected to the World Health Organization’s continued use of mongolism in all of its publications (p. 118). Wright ends his account with a chapter on the normalization movement, deinstitutionalization, and the establishment of the Special Olympics, claiming that, from the 1970s onward, Down’s syndrome became “mainstream.” Both the rise of genetic testing (which threatens to eradicate) as well as the 1990s ABC hit series Life Goes On (starring Chris Burke, an actor with Downs) raised awareness of the disability, albeit with drastically different outcomes. Even though Down’s syndrome has become the face of intellectual disability in the last several decades, Wright admits that the “very label of a disorder threatens to obscure our view of the individual. . . . Individuals disappear in the powerful shadow of the medical ­syndrome” (p. 15). The same could be said of Wright’s book, for the only person with Down’s syndrome who has any kind of agency is the author’s sister Susan. To this reader’s mind, her story is the highlight of the narrative, but it also points to one of the book’s shortcomings: Downs is a disease history told almost exclusively from the perspective of those who name (medical experts), rather than a disability history (as the subtitle promises) told from or including the viewpoint of those who are named. Scholars in disability studies have long contended with the problem of naming (often assumed to be the ­purview of medical experts, but actually often the product of contestation among numerous actors)— and with how to shape their own identity.1 Attention to this literature, and to individuals with Down’s syndrome as historical agents of change, would have helped to round out the narrative. Misgivings aside, this is a truly ambitious and path breaking ­historical account that will undoubtedly set the agenda for more disability histories to come.

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Note 1. For an early example, see Irving K. Zola, “Self, Identity, and the Naming ­ uestion: Reflections on the Language of Disability” Social Science of Medicine 36, no. 2 Q (1993): 167–73.

Beth Linker, PhD Associate Professor University of Pennsylvania 365 Claudia Cohen Hall

Body and Soul: The Black Panther Party and The Fight Against Medical Discrimination By Alondra Nelson (Minneapolis, MN: University of Minnesota Press, 2011) (289 pages, $27.94 hardcover)

When one hears the term “Black Panther,” the visual imagery invoked is typically that of an angry Black man in a violent confrontation with the police. As a group, The Black Panthers are most often remembered for their revolutionary rhetoric and militant action. Their story and their legacy, however, should not be reduced to a media inspired one-dimensional interpretation. A full understanding of the group’s justice inspired activism is not complete without moving beyond stereotypical imagery and digging deeper into the full spectrum of Black Panther activism. Bobby Seale and Huey Newton established the Black Panther organization in October 1966 to deliver protection for poor Blacks from police brutality and to offer varied other services to these same communities. The organization was born in Oakland, California and quickly spread to a wide geographic representation of cities across the United States. The leadership of the organization espoused socialist and Marxist doctrines; however, the Party’s Black Nationalist reputation attracted a diverse membership. Party headquarters instituted guidelines for new chapters and members that specified, among other procedures and practices, the establishment of no-cost communitybased medical clinics. Mandated by the Party leadership but not funded by it, the operation of the clinics depended on the ingenuity of the Panther rank and file and members’ abilities to mobilize local resources. The full pursuit of health was conceptualized as a crucial component of full citizenship along with other components of the civil rights struggle.



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Alondra Nelson’s work speaks to the Black Panther pursuit of their community’s health as one particular and go unrecognized component of the Black Panther Party’s ­activism. Through the history of race and medicine, Nelson effectively argues that health and medicine can be vectors of power, political and otherwise. Through the historical cascade of medical discrimination, abuse, neglect, and racialization of medical services, Nelson reminds the reader that some Blacks are still reticent about seeking health care or participating in medical research. Nelson’s research uncovers how the Black Panther Party used the momentum of their time to provide a crucial bridge for poor Blacks to obtain some type of equitable health care and education from sources they could conceivably trust. Body and Soul illustrates circumstances in which African Americans confronted medical discrimination in the health care system, biomedical theories, and in research design. Nelson reveals how, in doing so, these communities did not assert a blanket rejection of medicine. In fact, they laid claim to a critical conception of healthfulness: a right to health equality and freedom from medical discrimination. Situating her work at the intersection of science and race, Nelson narrows her focus to whether and how African ­Americans responded to the stakes of racial formation and subjugation through this ­powerful i­ntersection. In Chapter 1, Nelson argues that the Panthers were heirs to a mostly uncharted tradition of African American health politics. She places this tradition within the long civil rights movement. Health advocacy, Nelson maintains, has been a deep-rooted concern of Black political culture, across the range of institutions, community organizations, and social movements within the protest tradition. Chapter 2 focuses on a confluence of factors that precipitated the evolution of the Panthers’ health politics. Attention to community service was an expression of Party founders’ initial commitment to the dual deployment of theory and practice. This commitment emanated in response to their frustration with what they deemed Black nationalists’ preoccupation with rhetoric and the imitations of the ­government’s War on Poverty Programs. The administration of the Party’s locally controlled, alternative health clinics, including how they were staffed, supplied, and operated is the focus of the third chapter. The Panthers’ health clinics were also bases of operation for its sickle cell anemia campaign. Chapter 4 details the efforts to highlight the problem of the disease. Its campaign, launched in 1971, was both practical and ideological. In response to what they perceived as deliberate and pernicious neglect of African American citizens by the health care state, the Panthers established their own genetic screening programs that included health education ­outreach.

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Nelson gathers her information from primary sources culled from government documents and official correspondence, state and library archives, ephemera, and personal ­papers. She also surveys press coverage of the Party on broadcast television, ­documentaries, magazines, and in mainstream and alternative newspapers, including the groups’ weekly newspaper, the Black Panther. Nelson effectively weaves her information together to ­explain how health offered a new moral terrain for a struggle that was no longer typified by “Whites only” signs and other Jim Crow artifacts. Nelson’s research sheds new light on Panthers’ health politics as an effort to provide resources to poor Blacks who formally held civil rights but who, by virtue of their degraded social status and social value, lacked social and economic citizenship and thus the privileges that accrue to these including access to medical care. In light of recent health care reform and its implications of social inclusion, the Black Panther’s struggle for health citizenship is an important chapter in the long health rights movement. Linda Maldonado, RN, MS Doctoral Candidate Barbara Bates Center for the Study of the History of Nursing University of Pennsylvania School of Nursing 1436 S 13th St. Philadelphia, PA 19147

North Carolina and the Problem of AIDS: Advocacy, Politics & Race in the South By Stephen J. Inrig (Chapel Hill, NC: University of North Carolina Press, 2011) (256 pages, $45.00 hardcover)

Stephen Inrig explores the history of AIDS in North Carolina in an attempt to explain the disparities that still exist in AIDS care and prevention in the Black community as recently as 2003. Inrig uses a social history framework to describe the challenges of AIDS care in North Carolina starting in the 1980s, comparing the responses of the White gay community with the ­delayed ­reaction of the Black community, and details his theories about why these ­responses unfolded as they did. Inrig’s research is based on a thorough ­review of relevant primary and secondary sources, including his own experiences



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mentoring Black gay college students at historically Black universities while a graduate student at Duke University. Inrig attempts to explain a disease that “acutely affects poor blacks in the American South” (p. 135) by pointing out that AIDS is not solely a problem of White gay men in San Francisco, or of children in Africa. The reality is that it remains a growing problem in the minority community that must be carefully examined. His obvious passion for the AIDS epidemic was caused by a mini-outbreak of AIDS among college students, most of whom were Black gay men at Historically Black Colleges and Universities (HBCUs), and his wanting to be able to understand and explain this trend to the at risk teenagers that he mentored in Durham, NC. He proposes that we cannot rely on a solution that favors individual behaviors over the social determinants of health. Inrig analyzes the initial approach to AIDS care in North Carolina based on a model of “tragic gay heroism,” an approach to care and prevention of AIDS outbreaks structured with education, volunteerism, and policy developed in large part by and for gay men. Unfortunately, the initiatives developed for the Black community failed to address the specific concerns of both Black gay men and intravenous drug users that were at highest risk for the disease. Ultimately, a culturally tailored response from within the Black community was both delayed and ineffective, resulting in a significantly higher incidence of death and disease in these at risk groups. Inrig suggests that part of the reason minorities were excluded from program and ­policy development was lack of time, staff, and resources. But he carefully details the ­long-term consequences of this exclusion showing that lack of culturally tailored interventions resulted in a continued prevalence of this epidemic in the Black community. Inrig concludes that “health systems must include primary target populations in the research, planning, and implementation of outreach efforts and buttress those with multiple levels of redundant prevention systems” (p. 131) to improve outreach and preventive efforts to sexual minorities. Vulnerable groups without a collective identity were ill equipped to face the emerging disease. Minority groups like Black gay men and intravenous drug users lacked “insider access to medical professionals and health care resources . . . to create an infrastructure of care for people with AIDS” (p. 25). Where the strength of the White gay community in facing AIDS was having a strong unified voice, leaders in the Black community failed to recognize the threat that AIDS posed. As a result, policies were made without substantial African American representation, assuming an affinity between White and Black gays resulting in outreach programs that were not culture tailored and therefore ineffective in high-risk minority communities. Inrig further poses

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that even as African American AIDS organizations developed, they were under resourced and unable to maintain a sustained presence. In the same way AIDS policy neglected the unique needs of sexual minorities and drug users, it also failed to address the significant challenges of rurality in the South. In fact, Inrig argues that rural residents suffering the effects of poverty faced a host of larger problems like teenage pregnancy, domestic violence, and drugs; and AIDS was only one problem on this list. Inrig’s story of the history of AIDS in North Carolina is a moving portrait of illness, activism, and policy development that is of particular interest to audiences concerned with either AIDS or health care disparities. This book has serious implications for AIDS care in the future, as well as approaches to addressing health care disparities. He not only looks at the history of this disease, he also snaps a candid portrait of the social determinants that fueled this epidemic. Inrig tackles the complicated overlay of the behaviors our society struggles to confront until times of crisis: sexuality, poverty, violence, drug abuse, politics, and religion, and how this intersection continues to contribute to the emergence of AIDS among minorities in North Carolina. LaShanda Brown, MSN, GNP, BC Doctoral Student University of Virginia, School of Nursing 4109 Oak Ridge Drive Winston-Salem, NC 27105

Pills, Power, and Policy: The Struggle for Drug Reform in Cold War America and Its Consequences By Dominique A. Tobbell (Berkeley, CA: University of California Press, 2012) (310 pages, $65.00 hardcover; $26.95 paper)

In the years after World War II, the American economy soared to heights previously unknown. At the same time, several industries forged partnerships with universities to support those schools that increasingly oriented themselves toward much more research-intensive missions. The pharmaceutical industry played a major role in both of these transformations, while at the same time helping to reconfigure definitions of health and disease and change the contours of American medical, nursing, and pharmacy practice. As a result of the pharmaceutical industry’s centrality to the postwar era, Pills,



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Power, and Policy provides essential content for anyone interested in the history of 20th century American health care. Despite the complexity of the topic, the book is a compelling read, well-­organized, and clearly and engagingly written. Tobbell begins with a ­thoughtful Introduction that is to be particularly commended for the section on “Why History Matters,” a well-argued, but not overdrawn, case for history’s importance to contemporary policy that serves as a map for anyone interested in thinking about history with an eye to current day events. Using a rich trove of industry, university, and governmental archival sources, the main body of the book is broken down into two main sections encompassing the period between the 1940s and the 1970s. Part I, “Forging ­Pharmaceutical ­Relations,” describes and analyzes the construction of networks between industry, ­scientists, ­physicians, and government and the many ways in which these relationships benefitted everyone involved. Part II, “Allied Against ­Reform,” explores the way in which these alliances—nested in Cold War politics, industry fears of new limits on free enterprise, the American medical establishment’s enduring antipathy toward anything perceived as “socialized” medicine, and medical schools’ and universities’ desire for infusions of funding to expand and compete with one another—stymied almost all attempts at regulation. In an Epilogue, Tobbell traces several legislative and political debates between the 1970s and today, showing how industry adapted to a shifting political culture and, where necessary, seeking out new alliances to avoid losing its influence or profits. Nurses and nurse historians should find one theme of the book particularly intriguing and thought-provoking: the postwar debates between physicians and pharmacists in terms of questions such as who owns certain knowledge, access to patients, and which group should be reimbursed for specific services—terrain, of course, that has also long been heavily contested between nurses and physicians. In a fascinating quote on page 189, for example, Tobbell includes a quote by William Apple, the president of the American Pharmaceutical Association (the leading professional organization for pharmacists) in which he worries that pharmacists have traditionally been viewed as doctors’ “handmaidens.” Given that as late as 1971, only 18% of pharmacy students were women, this gendered lament should be especially fascinating to clinicians as well as historians of nursing.1 Tobbell’s central thesis is that today’s debates about drug regulation and development are not new and cannot be understood without analyzing the perspective of many stakeholders beyond drug companies, among them the FDA, policymakers, physicians, researchers, medical schools, universities, and

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patient advocacy groups, all of whom are invested in pharmaceutical politics. She offers a compelling argument for why those who seek drug industry reform in the United States have found—and will probably continue to find— success elusive.

Note 1. Hedva Bareholtz Levy, “Women in Pharmacy: A Good Match,” Annals of ­Pharmacotherapy 40 (May 2006): 952.

Cynthia A. Connolly, PhD, RN, FAAN Associate Professor University of Pennsylvania School of Nursing 2017 Claire M. Fagin Hall 418 Curie Boulevard Philadelphia, PA 19104-6020

The Nursing Profession: Development, Challenges, and Opportunities Edited by Diana J. Mason, Stephen L. Isaacs, and David C. Colby (San Francisco, CA: Jossey Bass, 2011) (403 pages, $75.00 paper)

Published in 2011, this text is the fifth book in the Robert Wood Johnson Foundation (RWJF) Health Policy Series. The foreword by Risa LavizzoMourey, president and CEO of the RWJF suggests use of this book as a companion to the 2010 “Future of ­Nursing” report from the Institute of Medicine (IOM) and RWJF collaborative. Susan Hassmiller, RWJF Special Advisor on Nursing and Director of the Initiative on the Future of ­Nursing, states in the preface that the IOM committee working on the report was ­heavily influenced by the best thinkers of those who study and practice nursing, including authors of the articles reprinted in this book. The Nursing ­Profession: Development, Challenges, and ­Opportunities provides a comprehensive collection of 24 articles significant to the nursing profession. Readers will instantly recognize contributing authors’ names from nursing’s historical past such as Florence Nightingale and contemporary nurse scholars Peter Buerhaus and Linda Aiken. In addition, nurse historians Joan Lynaugh and



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Karen Buhler-Wilkerson are among the authors whose notable works were selected for this text. The text begins with an original article written by Diana Mason who provides a succinct review of the nursing field. She speaks to the rich history of nursing, its current issues and challenges, as well as a vision for nursing’s future. Mason sets the stage for the selected articles to follow organized into thematic categories of interest to the nursing profession today: (a) The History of Nursing and the Role of Nurses; (b) Nursing Education and Training; (c) Advanced Practice Nursing; (d) The Nursing Workforce/Nursing Shortages; (e) Quality, Safety, and Cost; and (f ) Specialty Practice in Nursing. Each section contains two to five articles, spanning time from 1860 to the present, selected by the editors for high quality content and influence to the field of nursing. Organized with a health policy framework, each article was reprinted as written by the original author. An “Editors’ Note” provides a brief introduction to each chapter which serves as a helpful preview for the first time reader and a quick reference for others. The editors highlight salient points of interest and how the content speaks to the development of nursing, its distinct challenges, and its many opportunities. As noted in the opening paragraph, this text is suggested for use as a companion to the RWJF and IOM “Future of Nursing” report which responds to the dramatic health policy changes found in the 2010 Affordable Care Act. This legislature represents the broadest health care overhaul since the 1965 creation of the Medicare and Medicaid programs. Transforming the health care system to provide safe, quality, patient-centered, accessible, and affordable care requires a comprehensive rethinking of the roles of many health care professionals, nurses chief among them. The editors of The Nursing Profession aligned the book contents with the four IOM primary objectives for nursing. Careful study of the articles provides the reader with a better understanding of the rationale for the IOM recommendations and the legislative changes to health policy. Indeed, the editors achieved their goal of creating a companion text. A natural criticism of the book could be found in the selection of articles by the editors. The editors reviewed more than 200 articles and book chapters for inclusion. In the final selection for the 24 articles, the editors captured pieces of historical importance (e.g., Notes on Nursing and the Goldmark Report), nursing influences (quality, safety, and cost), basic aspects of the profession (home care, hospital, and advanced practice nursing), and articles that well synthesized issues related to nursing (workforce and shortages). In support of the editors’ final article selection, more than 30 experts in nursing and health policy gave input into the recommended writings for consideration.

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An additional element of interest with this text is the artwork on the book cover, which incorporates a photograph of a colorful mural entitled “The Evolving Face of ­Nursing.” Found on the side of a building in Philadelphia, the 6,500 sq ft mural was designed by international muralist Meg Seligman and illustrates the many faces of nurses along with selected images and symbols to convey the “intellectual, creative, and emotional work of nursing” (p. i). The cover photograph invites perusal of diverse nurses caring for individuals, families, and communities over time and is apropos to the overall intent of the text. This book serves as a valuable resource for a broad audience. Historians and scholars will keep the text as a ready resource of classic articles. Educators teaching beginning nursing history or health care trends and issues courses will want to make the text required reading, particularly for students with limited knowledge of nursing’s history and evolution over time. Nurse leaders will find the content affirming and inspirational for innovation and transforming health care delivery. And finally, health policymakers will benefit from its contents because creative strategies are planned to address current health care concerns with special consideration given to the past, the distinct contributions of nurses over time, and a vision for nursing’s future. The editors achieved their purpose in creating a useful addition to health policy’s historical literature. Collectively, the text supports the argument that an examination of history often provides answers to challenging policy questions. Perhaps as never before in history, health policy recognizes the valuable contributions of the nursing profession and invites expanded roles for nurses for care delivery. Lisa M. Zerull, PhD, RN, FCN Academic Liaison Winchester Medical Center, Valley Health System 1840 Amherst Street Winchester, VA 22601

NEW DISSERTATIONS Compiled for the Nursing History Review by Jonathon Erlen, PhD, History of Medicine Librarian, Health Sciences Library System, and Assistant Professor, Graduate School of Public Health at the University of Pittsburgh, Pittsburgh, PA. These dissertations can be obtained through ProQuest Dissertations. Jia-Chen Fu. “Society’s Laboratories: Biomedical Nutrition and the Modern Chinese Body, 1910–1950.” PhD dissertation, Yale University, 2009. ProQuest (AAT 3392547). Elizabeth Cafer Du Plessis. “Meatless Days and Sleepless Nights: Food, Agriculture, and Environment in World War I America.” PhD dissertation, Indiana University, 2009. ­ProQuest (AAT 3390261). Sharleen Naomi Nakamoto Levine. “Meanings of Maternity and Medicine for Japanese and Filipino Women on Hawaii’s Sugar Plantations, 1919–1946.” PhD dissertation, University of California, Santa Barbara, 2009. ProQuest (AAT 3395241). Stacey Ingrum Randall. “With a Suspicious Mind and a Good Light: The History of Cervical Cancer Screening in the United States, 1920–1980.” PhD dissertation, Northern Illinois University, 2009. ProQuest (AAT 3390583). Michael Allen Randall. “Placing Civilization: Progressive Colonialism in Health & Education from America to the Philippines, 1899–1920.” PhD dissertation, University of California, Riverside, 2009. ProQuest (AAT 3389682). Tony King Yang. “The Needs of a Lifetime: The Search for Security, 1865–1914.” PhD dissertation, University of California, Riverside, 2009. ProQuest (AAT 3389694). Jennifer Elizabeth Clark. “Making ALS Matter: Disease Activism and Disease Identity in Amyotrophic Lateral Sclerosis, 1850–2000.” PhD dissertation, Harvard University, 2010. ProQuest (AAT 3395417). Nathan William Moon. “The Amphetamine Years: A Study of the Medical Applications and Extramedical Consumption of Psychostimulant Drugs in the Postwar United States 1945–1980.” PhD dissertation, Georgia Institute of Technology, 2009. ProQuest (AAT 3394433). Laurel Iverson Hitchcock. “The Creation of Federal Services for Crippled Children, 1890–1941.” PhD dissertation, The University of Alabama, 2009. ProQuest (AAT 3390556).

Nursing History Review 22 (2014): 213–4. A Publication of the American Association for the History of Nursing. Copyright © 2014 Springer Publishing Company. http://dx.doi.org/10.1891/1062-8061.22.213

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Natalia Chernyaeva. “Childcare Manuals and Construction of Motherhood in Russia, 1890–1990.” PhD dissertation, The University of Iowa, 2009. ProQuest (AAT 3390133). Lydia Lauritzen. “The Making of Bioethical History.” PhD dissertation, Case Western Reserve University, 2010. ProQuest (AAT 3394976). Suzanne Michelle Begeny. “Lobbying Strategies for Federal Appropriations: Nursing Versus Medical Education.” PhD dissertation, University of Michigan, 2009. ProQuest (AAT 3392992). Benjamin Mason Meier. “The Highest Attainable Standard: The World Health Organization, Global Health Governance, and the Contentious Politics of Human Rights.” PhD dissertation, Columbia University, 2009. ProQuest (AAT 3393608). Kelena Reid Maxwell. “Birth Behind the Veil: African American Midwives and Mothers in the Rural South, 1921–1962.” PhD dissertation, Rutgers The State University of New Jersey, 2009. ProQuest (AAT 3386804). A. Mackie Guerin. “‘Beneath the Muslim Peel”: Racial Science, French Native Policy, and the Question of Nationalism in Colonial Morocco, 1900–1939.” PhD dissertation, University of California, Irvine, 2009. ProQuest (AAT 3380424). Shane Elizabeth Minkin. “In Life as in Death: The Port, Foreign Charities, Hospitals and Cemeteries in Alexandria, Egypt, 1865–1914.” PhD dissertation, New York University, 2009. ProQuest (AAT 3380224). Gergely Baics. “Feeding Gotham: A Social History of Urban Provisioning, 1780–1860.” PhD dissertation, Northwestern University, 2009. ProQuest (AAT 3386365). Terri Lonier. “Alchemy in Eden: Entrepreneurialism, Branding, and Food Marketing in the United States, 1880–1920.” PhD dissertation, New York University, 2009. ProQuest (AAT 3380281). Lisa A. Rumiel. “‘Random Murder by Technology’: The Role of Scientific and Biomedical Experts in the Anti-Nuclear Movement, 1969–1992.” PhD dissertation, York University, Canada, 2009. ProQuest (AAT NR54104). Daniel B. Bouk. “The Science of Difference: Developing Tools for Discrimination in the American Life Insurance Industry, 1830–1930.” PhD dissertation, Princeton University, 2009. ProQuest (AAT 3388081). Nicholas Lawrence Parsons. “Methedrine, Ice, Crank, and Crystal: An Historical and Cultural Examination of Methamphetamine in the United States.” PhD dissertation, Washington State University, 2009. ProQuest (AAT 3388527). Richard Fry. “Fighting for Survival: Coal Miners and the Struggle Over Health and Safety in the United States, 1968–1988.” PhD dissertation, Wayne State University, 2010. ­ProQuest (250859289).



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Felicity Turner. “Narrating Infanticide: Constructing the Modern Gendered State in Nineteenth-Century America.” PhD dissertation, Duke University, 2010. ProQuest (250734448). Bonnie McKay Harmer. “Silenced in History: A Historical Study of Mary Seacole.” PhD dissertation, The University of Nebraska—Lincoln, 2010. ProQuest (193325872). Michiko Takeuchi. “Pan-Pan Girls and GIs: The Japan-U.S. Military Prostitution System in Occupied Japan (1945–1952).” PhD dissertation, University of California, Los Angeles, 2009. ProQuest (304852992). Lesley Lynn Broder. “Challenging Maternal Inevitability: Abortion, Careers, and Abandonment in the Nuclear Family, 1879–1939.” PhD dissertation, State University of New York at Stony Brook, 2009. ProQuest (305092648). William Wyatt Holland. “Who is My Neighbor?: Framing Atlanta’s Movement to End Homelessness, 1900–2005.” PhD dissertation, Georgia State University, 2009. ProQuest (250039236). Dea Hadley Boster. “Unfit for Bondage: Disability and African American Slavery in the United States, 1800–1860.” PhD dissertation, University of Michigan, 2010. ProQuest (305201531). David S. Brown. “Pathways to Power: Physicians in Charleston, South Carolina, 1790– 1860.” PhD dissertation, University of South Carolina, 2010. ProQuest (305201531). Fredric Mintz. “Hard Rock Miners’ Phthisis in 19th and Early 20th Century Britain: From Diagnosis to Compensation.” PhD dissertation, University of California, Berkeley, 2010. ProQuest (305184470). Michael Dennis Buckley. “Recipe for Reform: The Food Economy Movement in Britain During the First World War.” PhD dissertation, University of California, Berkeley, 2009. ProQuest (276092726). Stephanie Stegman. “Taking Control Fifty Years of Diabetes in the American Southwest 1940–1990.” PhD dissertation, Arizona State University, 2010. ProQuest (3410579). Kelli Ann McCoy. “Claiming Victims: The Mann Act, Gender, and Class in the American West, 1910–1930s.” PhD dissertation, University of California, San Diego, 2010. ­ProQuest (3407842). Angela I. Fritz. “Ten Cents a Dance: Taxi Dancers, a Living Wage, and the Sexual Politics of Women’s Work, 1912–1952.” PhD dissertation, Loyola University Chicago, 2010. ­ProQuest (3404143). Rebecca Sheehan. “American Sexual Culture: Women’s Liberation, Rock Music, and Evangelical Christianity, 1968–1976.” PhD dissertation, University of Southern California, 2010. ProQuest (3403642).

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New Dissertations

Stephen E. Randoll. “The Politics of Public Health in Chicago, 1850–1930.” PhD dissertation, Saint Louis University, 2010. ProQuest (3404329). Jennifer Johnson Onyedum. “Humanizing Warfare: The Politics of Medicine, Health Care, and International Humanitarian Intervention in Algeria, 1954–1962.” PhD dissertation, Princeton University, 2010. ProQuest (3410915). Alina B. Baciu. “Biopolitics and the Influenza Pandemics of 1918 and 2009 in the United States: Power, Immunity, and the Law.” PhD dissertation, The George Washington University, 2010. ProQuest (3404768). Nicholas Clarke. “Unwanted Warriors: The Rejected Volunteers of the Canadian ­Expeditionary Force.” PhD dissertation, University of Ottawa (Canada), 2009. ProQuest (NR61365). Kara Dawn Smith. “A Legacy of Care: Hesse and the Alice Frauenverein, 1867–1918.” PhD dissertation, University of Alabama, 2010. ProQuest (610183889). Winifred C. Connerton. “Have Cap, Will Travel; U.S. Nurses Abroad 1898–1917.” PhD dissertation, University of Pennsylvania, 2010. ProQuest (3414195). Kristine Ashton Gunnell. “Without Regard to Race or Creed: The Daughters of Charity and the Development of Social Welfare in Los Angeles, 1856–1927.” PhD dissertation, The Claremont Graduate University, 2010. ProQuest (3416903).