School nursing in North Carolina 1911-1940

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School Nursing in NC
            School nursing programs were introduced in New York City in 1902. So after, several municipal school and health districts, particularly in the Northeast and the West, began their own school nursing services (Rogers, 1917). In other areas of the country, particularly the Southeast, school nursing remained an under-developed area of nursing practice. In each location, it developed uniquely, responding to local personalities, political considerations and community needs. By the early 1930’s the Great Depression and the Federal response known as the New Deal began to change the provincial nature of school nursing services.
 
            At the turn of the 20th century formal education in North Carolina was a meager affair at best. For the most part, one and two room school houses were opened for four months out of the year at public expense. Some of the early teachers had considerable education while the ability of others was severely limited. Support services such as transportation, food service and school health were unknown in NC (Whiteaner. 1949).
 
In 1900, the movement to improve public education in NC got an inadvertent boost from the move to disenfranchise African American voters. In that year, the electorate approved an amendment to the state constitution to restrict voting to men who would be required to pay a poll tax and pass a literacy test.
 
            As late as 1900, one fifth of the white male population in NC was illiterate (Gilmore, 1996). An unexpected consequence of this legislation was an increased interest in public schooling by white working and middle class families. By the end of the first decade of the 20th century, public education facilities, quality of teachers, length of the school term and school support services had improved.
 
            Concurrently, a new era in public health was beginning. The role that nutrition, sanitation, hygiene and lifestyle choice played in health and disease was being recognized. Scientific breakthroughs in medicine and surgery offered new hope to many people. These convergent advances in education and public health were the catalysts for the emergence of school nursing.
 
            The first school nurse in the Tar Heel state was Percy Powers of Salem. In 1911, the Wayside Workers of the Home Moravian Church, a charitable service organization of Moravian women, hired Powers to do health inspection and follow-up work among the school children of East and West Salem schools. She measured height and weight, and screened for vision, dental problems, swollen tonsils and adenoids, and malnutrition. She also taught students and parents basic sanitation, nutrition and hygiene to prevent and control the spread of disease. Powers remained in this position until 1917, when Winston-Salem established a city health department, and she accepted the position of supervising nurse. The Wayside Workers continued to fund a school nurse who worked closely with Powers at the health department for four and a half years until the city assumed responsibility for school nursing (Wyche, 1938).
 
On May 1, 1915, the NC State Board of Health organized the Bureau of Rural Sanitation. The aim of this new department was to interest local governments in funding public health work. One demonstration project was Medical Inspection of School Units (NC Board of Health, 1966). Doctors and dentists made a thorough survey of several thousand children enrolled in schools in six widely scattered counties to determine the physical conditions of children of all ages, races and socioeconomic classes. The results were appalling. Eighty percent of the children needed dental treatment, more than 10% had diseased throats, more than 5% had defective vision and/or hearing, and numerous others suffered from tuberculosis, malaria, hookworm, and malnutrition (Health Bulletin, 1919).
 
The resulting publicity served as a catalyst at the state legislature meeting in 1917 to enact measures expanding the work of the State Board of Health. These measures included a provision “to provide for the physical examination of the school children of the state at regular intervals…” However well-intentioned, the legislature made no money available for the staff to carry out this mission. This omission was remedied in the next session of the legislature. In 1919, enough money was allocated to hire six full-time nurses to travel across the state and provide screening and follow-up services at three year intervals for all students under the seventh grade, regardless of race (NC Board of Health, 1966).
 
NC’s state-supported school nursing program was restrictive in nature in the racial makeup of the nurses. By law and custom, white nurses could travel anywhere in the state and treat any child, but this was not the case for African American nurses. In many rural white communities, lodging and hospitality were not available to them. The State Board of Health did not hire an African American nurse for school work until 1938 (NC State Board of Health, 1939). The first six registered nurses to serve the state as school nurses and who all remained in their jobs for over 18 years were Birdie Dunn, Cleone Hobbs, Mrs. HP Guffy, Flora Ray, Cora Beam and Katherine Livingston (State School Nurses, 1933). Other registered nurses were employed by city and county health units to provide school nursing services. Some of the other early school nurses in NC were Emily Pickard of Durham, Blanche Lambe of Greensboro, Sallie Cook and Girlie Strickland of Winston Salem. Strickland appears to be the first African American registered nurse to work in NC (Wyche, 1938). 
 
The ninetieth biennial report of the NC Board of Health issued in 1922 contained a summary of the work of the Bureau of Medical Inspection of Schools branch. The objectives of the Branch were: (1) to arouse the teachers of the elementary schools of NC to the necessity of making the same efforts to teach the children things they should know for the development of their bodies and for the protection of their health that they make for their intellectual advancement; (2) to discover the children who have remedial defects, and to have them treated while curable and before the condition becomes chronic.
 
In order to carry out these mandates, the nurses lectured directly to groups of teachers as well as in their classrooms on various health topics, and demonstrated to teachers simple screening techniques that they could use when they suspected physical problems. During the biennium, 1919-1921, the six nurses also coordinated clinics for immunizations, tonsil and adenoid removal, and dental treatments; and inspected 92, 566 students (NC Board of Health, 1922).
 
According to Dr. George Cooper (1935), the supervising physician of the Medical Inspection of Schools program, the six nurses “have caught the benefits of good health to the people of every community in NC. They have traveled on foot, horseback, on rafts, by boat, tram, on cart, anyway to reach the “forgotten child”.
 
A report submitted to Dr. Cooper by Cleone Hobbs, one of the six state supported school nurses, describes a situation she found in Wilkes County in 1919. She wrote the following about a patient seen in the tonsil and adenoid clinic:
 
“The last one who came in before 1 p.m. was a pitiful looking woman and child dusty and travel stained… The child was a boy nine years old. His mouth was open. I looked at this throat. I don’t think I have ever seen a worse throat. It was almost closed. The tonsils met at one point. The other part throat so they bulged and looked taut and shiny like a balloon. I asked the mother how far they came and she said eight miles. I asked her how she came and was amazed when she replied “we walked”.
 
The child was lying on a bench. I questioned her and found out she had four children. That her husband worked at sawmill for $1.50 a day and they owned 40 acres of land. She said her husband was not well, had dropsy in his feet sometimes. She had been telling her husband for some time that something would have to be done for the child. He cannot talk plain and chokes when he is asleep. His pillow is always wet with salvia…Before I knew all this I asked her if they could afford to pay and she said yes. They would manage it some way. After I found out I told her I would do him free. I have shed the first tears in this county over this incident. That is saying a lot”.
 
There is an editorial postscript to this report and it is unclear if Dr. Cooper or Nurse Hobbs wrote it. It seems to reflect the values of all the early pioneers in school health in NC. It says “We suppose an investigation would be in order in this case, or at least a committee appointed to place a value on the forty acres and to inquire about the whereabouts of the mule before arranging for a lifesaving operation for that boy. But we will cheerfully leave all that to the coroner or somebody. Our business is to get the child treated before it is too late.” (Hobbs, 1919).
 
Complementing the work of the nurses from the State Board of Health was the effort of hundreds of nurses employed by church and civic groups to provide public health services to their communities. Their work usually included school health. The American Red Cross employed some 50 nurses between 1912 and 1935 to work in community health programs in NC (Kernodle, 1949). Goldie Allen, RN was a Red Cross Nurse assigned to Avery County in health related topics for the local paper, the Avery Advocate. In one, she described the relationship between poor health and poor academic progress. Her sentiments are as relevant today as the day she wrote them. “Children with impaired vision, deaf ears, diseased tonsils, adenoids, undernourished bodies or fatigued nervous systems cannot do the work of normal children” (Avery Country Red Cross, 1928),
 
Allen inaugurated a “Progressive Program for Better Health” for the school children of Avery County. In this program, the school with the highest number of children following eight health habits over a period of time received a silver loving cup. The eight health habits, most still advised today, included: a full bath more than once a week; brushing teeth at least once a day; sleeping long hours with the windows open; drinking as much milk as possible, but no coffee or tea; eating green vegetables or fruit every day; drinking at least four glasses of water a day; playing a part of each day outdoors; and, a bowel movement every morning. The program was endorsed by local doctors, dentists, and school board representatives and appears to have helped impress upon the children better health habits (Avery County Red Cross, 1928). In other counties, nurses started “Modern Health Crusader” clubs in the schools. These clubs shared the same objectives and many of the same methods as Allen’s Progressive Program for Better Health (Erhenfeld, 1921).
 
Allen’s report in 1930 details the number of people participating in the clinics she coordinated. Each clinic with its corresponding number of patients is as follows: removal of tonsils and adenoids (95), orthopedics (41 treated), dental problems (503 treated), tuberculosis (180 screened) and typhoid and diphtheria immunizations (2896 given). Additionally, she worked on a county-wide fly eradication campaign, worked to get new water supplies for Newland and Cranberry schools, sent three children to the tuberculosis sanatorium, one to an epileptic colony, two to the school for the blind and five to the school for the deaf and dumb (Report made 1930).
 
Allen’s work was repeated in essence by Red Cross and locally hired nurses in many counties in the state from 1911 to 1930. Community groups often expressed gratitude for their school nurses. For example, the Watauga County Chamber of Commerce publicly thanked Stella McCarthy, the Red Cross nurse assigned to their county in 1921 by declaring she”…makes it a point to discover the most needful conditions in the county and to give these things her first attention…We are fortunate in having secured the service of one of the most capable public health nurses to be found anywhere (Watauga Democrat, 1921).
 
Between nurses employed by the State Board of Health, county health departments and church and civic organizations, many schools in NC were receiving at least the rudiments of school nursing services by the late 1920s. However, the Great Depression quickly diminished years of progress. Donations to church and civic groups dried up since approximately one fourth of American citizens lost their jobs (Leuchenberg, 1963). At the same time, tax revenues dropped dramatically and public services were sharply curtailed or totally eliminated. School nurses and school nursing programs suffered in both public and private areas for most the 1930s.
 
In 1933, President Roosevelt initiated The New Deal, a series of programs to respond to the economic Depression. These programs provided jobs and services using federal funds to supplement or replace local monies. In NC, several counties decided to use some of their New Deal funds to school nursing services. For example, in Catawba County, the school nurse was hired through a New Deal agency, known as the Emergency Relief Administration, to direct the Catawba County Preventorium for undernourished and underprivileged children. The Preventorium was a cooperative effort to provide medical care, proper nutrition and health education to indigent children. The country government, county hospital, American Legion, American Red Cross and a variety of civic clubs including the Kiwanas Club, Rotary Club, Women’s Club, and the Business and Professional Women’s Club also contributed to this four month summer program. During the summer of 1935, 73 children were helped at the Preventorium. Of these children, 39 had tonsillectomies, 6 received glasses, 16 had dental work and 20 received other medical treatments. The group ate 3 meals a day, gained a total of 273 pounds, and consumed 5640 quarts of milk. Without the assistance of the federal government it is unlikely these children would have received needed health care or an adequate diet (McKay, 1935).
 
Another New Deal program involving school nursing in NC was the Special Child Welfare Project conducted under the Civil Works Administration in the spring of 1934. Sixty five registered nurses were employed by the Department of Child Health Work under the State Board of Health for 15 weeks. Of these nurses, 35 were assigned to county health departments and 30 others worked directly for the State Board of Health in counties without a county health department. They worked in 55 out of the 100 counties in NC. During the 15 weeks, the CWA nurses visited 781 nursery schools and 3086 public schools. They examined 115,771 children and made home visits to 17,618 families. In addition, they assisted in 39 dental clinics, gave thousands of immunizations and held 115 health education meetings for teachers and parents (Special Child, 1934).
 
Health education was another major focus of school nursing work in the 1930s. The NC state legislature, in 1935, passed a law stating the effects of alcohol and narcotics on the human system would be taught in public schools. School nurses frequently helped with this instruction. In 1936, May 1 was declared National Child Health Day by President Roosevelt. The NC state superintendent of public schools urged local school systems to cooperate with other local agencies to make National Child Health Day activities successful. School nurses also helped organized activities in February 1938 for the Second National Social Hygiene Day. The State Department of Public Instruction endorsed a program composed of pamphlets, exhibits and films aimed at the slogan “stamp out syphilis-enemy of youth.” School nurses across the state helped direct and implement these activities.
 
School nursing in NC has continued to grow and make an impact on the children and communities across the state. The commitment and dedication of those pioneers in school nursing have made an indelible mark in the history of nursing in NC. Their vision of NC continues to provide a firm foundation for contemporary school nurses as they strive to make a difference today as well as to meet the challenges of the 21st century.