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Elizabeth Gardiner, Director, Division of Maternity, Infancy, and
Child Hygiene, Department of Health, Albany

Rural hygiene in all its phases has for a long time occupied the attention of the greatest authorities in public health practice in this country and abroad.

When we visualize the various types of rural communities, as we can without any great stretch of the imagination, we come to the conclusion that the problem resolves itself into questions of the provision of more public health nurses specially trained in rural hygiene, and the provision of measures to meet the difficulties of transportation and communication.

While this seems a very simple solution on paper, in actual practice we find ourselves confronted by almost insurmountable obstacles. Let us recognize some of these difficulties and then consider the possible achievement of an effectual local maternity and infancy program from the angle of the state department of health's functions, and of the local community itself.

Difficulties. While not familiar with all types of rural community in our country, I know that in some sections swamp lands and, in others, deserts present obstacles to efficient and equalized service, and surely the mountainous districts must increase travel problems enormously. Again, the absence of roads or the ruinous condition of those that do exist in some places must render travel even by the bumptious Ford a questionable procedure. In New York State vast areas of the rural districts are cut off for weeks at a time by snow in the winter and by mud in the spring. These difficulties, coupled with the separation of family units, must necessarily retard the promotion of any health program and increase the expense greatly.

How about the rural people themselves? Not to mention the problems arising in connection with the education of non-English-speaking groups, the native rural families offer certain difficulties. Widely separated as they are, they lack that cohesion of community interest, more often displayed in well-populated areas, which is so necessary and so valuable if work is to be carried forward consistently. Then, too, just at the most favorable seasons of the year, from the health worker's standpoint, rural families are plowing and planting or harvesting, with all of the extra arduous labor involved; and during such seasonal increased activity in the mere business of earning a livelihood, they are not apt to be as appreciative of the educational efforts of the nurse as one could wish. Last, and perhaps it should have been mentioned first, comes the economic factor. It must be remembered that the valuation of property in the country district is low in comparison with that of the urban; the wage scale is lower, and more must be expended in order to get less service than in the urban community. Even the same amount of tax revenue received by the country district as in the urban community will not buy the same amount of facilities and service. Actual cash in the hand of the farmer is limited, and he views with alarm any and all

innovations that may translate themselves into increased taxes. These are not by any means all the hampering difficulties contended with in rural health work; but in our experience at least, they are the most lively ones.

Program. The elements of an adequate maternity and infancy program are constant, whether for the rural, semi-rural, or urban community, i.e., education and proper care of the expectant mother; proper and safe facilities for delivery; provision of medical assistance; skilled and aseptic after-care of the new mother; instruction in infant hygiene, with emphasis on breast-feeding technique; well-baby visitation at frequent enough intervals to insure survival and control of illness; centers for group instruction in health protection, and where the preschool child may receive nursing supervision and medical oversight; all carried out methodically and applied to a large enough proportion of the mother and child population to have a lowering effect on mortality and morbidity rates. Let us consider these elements and see whether the rural nurse can carry them all on, and how she could go about it. We ask her to instruct and supervise the health of expectant mothers. First, how is she going to find them? This will tax to the utmost her resourcefulness; it is obvious that pregnant women will not report themselves. In the rural districts they are not, as a rule, under medical care early in pregnancy, therefore the doctors cannot be expected to report them; so that the nurse must be very alert, as she is visiting her families for other purposes, to seek out the expectant mothers. She must utilize fully every exist- ́ ing social agency in her search, make her desires known by talks to rural groups, home and farm bureaus, granges, W.C.T.U. meetings, clubs, ministers, and priests. The local papers will help by stating that, among other services, she is prepared to visit them and give real help. Birth registration should never be overlooked as a source of information, not only as to new-born babies, but, in the records of a year or a year and a half back, for prospective subsequent pregnancies. It is her duty, too, to see that medical assistance is assured to prospective mothers, and if delivery is expected during a season of the year when roads are impassable, arrange to have them brought within reach of the doctor two weeks in advance; or, if this is not possible because of financial considerations or family cares, then she must instruct carefully, over and over again, the neighbors or relatives who are to be with the mother at the time of delivery.

The earnest rural nurse will be eager to give delivery service in special cases where trouble is expected, or where there is no one to assist the mother, and there is no surer way to the hearts of the rural family than help at such a time; but such service is not always practicable; the education for the event is practicable, however, and even a father may be instructed for possible emergencies. After-care should be done as far as possible by the nurse herself during the first few days, instructing each time the family helper in aseptic principles. She should not relinquish this part of the work until breast feeding is actually established and breast-feeding technique fully understood by the mother.

The new baby should be seen as often as once a week during the first month of life, then every month for the next three months, and then alternate months

until a year old. During this important period much can be taught; habits, for one thing, and regularity; the value of weighing frequently; preparation for weaning; introduction of new foods; value of fruit juices, cod liver oil, and sunlight for all babies; and finally, the value and economy of medical supervision even if the baby seems well. The year-old baby can now be placed on a quarterly visit schedule, but in the meantime the nurse has probably found other health problems in that family. If so, these quarterly visits of the preschool child can be coordinated with the regular family visit.

Now, one may say that all this is assuming that the nurse has an area of such size to cover that she can reach all the families in her district. What about the nurse having altogether too large an area to cover decently? I think the answer to that is for her to zone her district into four sections, and plan to work out of four centers a week at a time. This means a sort of nomadic existence for the nurse, but if she has the pioneer and missionary spirit, and it is certainly needed in rural work, she will adapt herself to this as well as to other inconveniences. She can easily educate her community to expect her in their vicinity a certain week of the month. As for communication, a drug store in the center from which she works will gladly take messages for the nurse in anticipation of her week in that district. Even undertakers' offices have been used for this purpose.

It is too much to expect that the rural nurse will be a special maternity and infancy nurse, so it is inevitable that she will be a very busy person, with diverse duties and responsibilities. What do we, as a state department, do for her and for the community in order to make her presence a greater asset in that locality? State assistance. We have said that group instruction is to be included in her program of maternity and infancy work. Besides the value of the educational matter itself great benefit is to be derived from the mere assembling of the group of women, and here we step in, whenever requested, with the so-called mothers' health clubs. The nurse organizes the group, or perhaps several groups in the different villages, and requests a state nurse to conduct the course. Two hundred and twenty-two of these groups were taught in 1923-25, varying in attendance from ten to fifty, and 921 took written examinations and received their certificates.

It may be that the nurse would like to do this herself, but has not had the opportunity to fit herself for teaching, in which event she attempts to interest other nurses in the formation of a group for an extension course in maternity and child hygiene to be given by one of our consultant nurses. In the past three years 52 of these courses have been given, and 325 certificates awarded to public health nurses.

While we advocate the provision of mother-and-child health stations, not many of the rural nurses covering large territory have them, so that independent local clinics for mothers and children are not feasible. In such case the rural nurse is only too eager to request that the state child health consultation unit visit her district covering several villages and towns. Thus she is able to bring expert medical attention to her preschool children, whose parents ordinarily

would not consult a physician concerning an apparently healthy child; it gives her the opportunity in the follow-up to secure correction of defects at the hands of the family doctor, as neither treatment nor prescribing is done at the consultations. She may call on us too for a like service for her expectant mothers, by requesting the state prenatal consultations.

With the many duties and the wide expanses to cover that confront the rural nurse, she begins to realize the great need for an orderly plan of work; she realizes that to work intelligently events should be recorded; that to learn how to cover her work without loss of motion she needs the assistance and guidance of someone more experienced than herself. Here again, on request, we come to her aid with our consultant nursing service. By the consultant nurse she is supplied with proper recording and reporting forms and shown how to use them with the least possible outlay of clerical time; she is taught to file her cases in such way as to be able to reach them at regular intervals; she is taught the best distribution of her time; in what directions or for what types of work she needs to expand. The consultant nurse may accompany her to visit one of the town fathers in order to secure funds for necessary equipment. She may find it necessary to approach the committee in order to convince them that they are expecting the impossible of their nurse. If it is the proper time to establish a child health station, the consultant nurse helps with this also, as to equipment, location, and activities, and if the time is ripe for prenatal or child health consultations, the state again assists by paying the doctor for examinations.

Now as to provision of more public health nurses: the division of Maternity, Infancy, and Child Hygiene, since the acquisition of federal funds, has tried in every way possible to bring this about, by nursing demonstrations for varying periods, and by giving actual financial assistance to local communities in their efforts to secure a nurse. These demonstrations have varied in character according to the needs and capacities of the community, but they have always carried along a more or less complete maternity and hygiene program; in one county, a breast feeding campaign; in another, a rural maternity nursing demonstration; in a third, a demonstration and teaching center combined. Thirty or more of these demonstrations are being carried on at the present time, all with good prospect of becoming permanent when we withdraw. Maternity and infancy projects are being carried according to standard in rural localities where no child hygiene work whatever was ever done before, and is being expanded toward completeness and excellence where it was already under way.

If it is true, as is often stated, that one reason for state levy of taxes is to equalize facilities, and if, as we have tried to show, every factor peculiar to rural public health work tends to make it a slow and expensive process in the face of limited sources of wealth, then is it not the function of the state, through its department of health, to share its larger opportunity for expert knowledge and actually set to work shoulder to shoulder in the planning and execution of the local program? We have so interpreted our function, and as long as funds are available, state or federal, shall continue in this policy.



Bertha C. Reynolds, Associate Director, Smith College School
for Social Work, Northampton

It is time that we tried to answer the question so often asked by our patients: "Just what is it that you do for people?" even though we show, not what has been developed, but what may or might be. To this discussion many social workers have already contributed, and many more must do so by their openminded experimentation before a clear outline of treatment processes can emerge. If the statements which follow sound dogmatic, they are so only because they are today's cross-section of the growing convictions of the writer, and because only as they are clear and definite can they challenge your thought and provoke the discussion which results in closer approach to truth.

However far we are from having a professional body of knowledge, social case workers have come to be looked to for certain techniques which no other profession develops as a part of its training. Social workers, it is said, know how to arrive at an understanding of a total situation where individuals are involved and to adjust the difficulties between individuals and their whole environment. How do they do it?

The answer leads us to processes of great complexity. Perhaps the best we can do is to pick out, for clearness' sake, three techniques which, interwoven though they are in practice, lead to understanding. They are the interview, observation of social phenomena, and the application of a background of social knowledge to the interpretation of what is seen and heard. Similarly, let us consider the techniques of adjustment as three: the application of knowledge of community and personal resources, the coordination and organization of resources, and the education of the individual through his own experience.

Why do we include the techniques of understanding as a part of the processes of treatment? First, because treatment begins in the first interview. By this I mean something more than the useful catharsis one usually gets from telling one's troubles, even, as in our early youth, to as self-centeredly unsympathetic an object as a kitten. I mean that the way in which a worker obta as information indicates already her skill in treatment-nay, is treatment. Se may think that she is out for information only and that the diagnosis forma y made is the temple bell which must ring before the ceremonial of treatment begins, but the

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