Public Health Nursing in Early 20th Century Canada

an cities for at least three decades by the time the Canadian Public Health Association was founded in 1910.1 Journals such as the American Journal of Nursing, the Visiting Nursing Quarterly, and the Canadian Nurse provided the profession with compelling accounts of nurses working in a variety of roles to prevent illness and promote the health of vulnerable populations such as: immigrants; the urban poor; infants and children; and isolated families living in rural and northern Canada. The terms “visiting nurse” and “district nurse” were used interchangeably in the journals and textbooks of the time, and in all cases, these nurses were defined as public health nurses (PHNs). Lillian Wald, a registered nurse and social reformer who founded the Henry Street Settlement in New York City in 1895, coined the term PHN in 1893 to describe the nurses who worked in poor and middle-class communities rather than in hospitals or in the homes of wealthy employers.2 Little is known about the earliest Canadian PHNs, but most were likely employed singly or in pairs by charitable or religious organizations who established small community-based outreach programs in many parts of Canada. For example, it is known that a diet dispensary in Montreal employed a district nurse as early as 1885.1 Toronto’s Nursing-at-Home Mission was established in 1889 to support two nurses who worked with poor families living near the Children’s Hospital.1 In 1897, the Victorian Order of Nurses (VON), a national district nursing association modelled on the British Institute of Queen’s Nurses in Britain, was founded in Ottawa.3 In many communities, the VON contracted with local governments or charities to provide PHN programs, and they have continued to do so throughout their history. As well, many voluntary PHN programs were founded by local organizations during this era, including the Margaret Scott Nursing Mission (Winnipeg, 1905),4 the Lethbridge Nursing Mission (1909),5 and the St. Elizabeth Visiting Nurses’ Association (c.1910).6 School health programs, sponsored by local school boards, emerged early in the 20th century. In 1907, the Montreal school board inaugurated the first medical inspection program in Canada.7 Mandated to identify and seek treatment for school-aged children with preventable health problems or communicable conditions, school boards initially hired physicians to work in the schools. However, they soon discovered that the effectiveness of school health programs was significantly enhanced when nurses made home visits to the families of children identified in the school setting as being ill or at risk of developing illness. In 1909, school boards in Winnipeg and Hamilton employed nurses to work with school-aged children and their families.7,8 In addition to the physical inspection of children, school-based PHNs also provided health education programs to children and their families.7-9 In response to the high mortality rates associated with tuberculosis (TB) and preventable childhood illness, early PHNs also worked in communicable disease control and child health programs. However, unlike school nurses, their first employers were voluntary organizations. Between 1901 and 1910, milk depots and child health programs organized by local charities were established in Toronto, Montreal, and Winnipeg.3,6,8 In 1905, a private donor enabled the Toronto General Hospital to employ a nurse, Christina Mitchell, to work with TB patients in their homes.6 However, the magnitude of the public health problems associated with poverty, communicable disease and lack of knowledge about prevention of illness overwhelmed the fiscal and organizational resources of charitable organizations. By the early 20th century, most were seeking public funding to maintain their programs. So, for example, in 1910, Winnipeg’s civic health department provided annual grants to the local district nursing association and the milk depot to support their child health programs.10 In the long term, however, transfer of voluntary PHN programs to civic governments became the solution of choice. TB control programs were often the first to be integrated into the public sector. TB control PHNs were transferred to health departments in Ottawa in 1905, and in Toronto in 1907.6,10 In 1914, both the Toronto and Winnipeg health departments took over voluntary child health programs and created Child Hygiene Departments to continue this work.6,8 In most jurisdictions, PHNs worked in specific programs within health departments. The early exception was Toronto, where the health department amalgamated its communicable disease control and child hygiene programs in 1914.6 This decision, according to Eunice Dyke, Superintendent of Toronto’s PHNs, reflected the department’s desire to “specialize in homes rather than diseases.”11 The scope of their practice was enlarged in 1917 when the board of education’s nurses were transferred to the health department and their responsibilities were integrated into the practice of the department’s generalist PHNs.6 In rural areas, development of PHN services proceeded at a much slower pace. Hampered by sparse populations and the general belief that the costs associated with PHN services should be paid by municipal (county) authorities, funding to employ PHNs was difficult to sustain. In some instances, local women’s groups such as the Women’s Institute or the United Farm Women employed physicians or nurses to conduct child health clinics or school inspections because no other organization was willing to provide the service.7,12 In 1916, after years of lobbying from farm women’s groups and social reformers, Manitoba became the first province