Although the county health officer is necessary for the administration of the technical aspects of public health administration, the most important gains in the health of the rural community will come through the personal education of its people on matters of hygiene and sanitation. This is the field of public health nurses, and I believe that the records of their work in rural communities will show that they have done more for health education than any other one agency. A decade ago trained visiting nurses were practically unknown in rural communities. In 1914 the American Red Cross first organized its Town and Country Nursing Service and coöperated with a few rural communities in supervising the work of trained public health nurses, but relatively few places employed rural nurses prior to the war. The county tuberculosis societies also employed visiting nurses who worked throughout a whole county and whose work inevitably created a demand for visiting nurses for a more general service. The shortage of physicians during the war and the influenza epidemic of 1918 revealed the need for rural nurses and since the war the local chapters of the American Red Cross, which is devoting much of its attention to public health work, have employed hundreds of rural public health nurses.
The success of school nurses in the cities has led to their employment in the smaller towns, and now county school nurses are being employed in individual counties in several states, and in other states school nurses are employed by townships or jointly by several rural school districts. Wisconsin and Ohio have recently enacted laws compelling every county to employ at least one public health nurse, and a dozen or more states have passed legislation making the employment of county or local nurses optional. Under whatever auspices they are employed, rural public health nurses have found that their most effective work may be done at first in connection with the schools. Medical examination of school children is now required in many states, but unless it is followed up by some one who will see the parents and encourage them to secure the necessary medical or dental treatment, the results of these examinations are often disappointing.
A most interesting and instructive account of the work done by a county school nurse during the first year of her work in typical Minnesota county has been given by Miss Amalia M. Bengtson, superintendent of schools of Renville County:
"Renville County is prosperous; there are few poor people, no child is underfed and no one wilfully neglected, yet our tabulated report shows an appalling amount of physical defectiveness. Out of our school population of six thousand we examined five thousand children, and found four thousand and ninety-five defective, testifying that 81 percent of the children were defective. This seems almost unbelievable, and yet it does not tell the whole story, for I could take you to school after school where there was 100 percent defectiveness, where we sent a notice to every parent in that school. Yet, as I said before, Renville County is a prosperous county, and we have every reason to believe that conditions in Renville County to-day are the same as in other counties where a health survey has been taken. The percentages of the defectiveness found were: teeth, 55 percent; nose, 40 percent; throat, 66 percent; eyes, 22 percent; ears, 17 percent; malnutrition, 16 percent; nervous disorder, 16 percent; neck glands, 14 percent; skin, 13 percent; and general appearance, 12 per cent."[57]
In reply to the question, "What of it? What good came of the health survey?" Miss Bengtson says: "Our records show that about one thousand of the children examined were taken to see either a doctor or a dentist, or both, the first year. Parents who at first opposed the work are fully convinced that a county nurse should be a permanent worker among us when they see how much their children have been benefited by a little medical help.
"Besides examining the children, the nurse has been a great factor in bringing about a general education for better health. In our county to-day you are behind the times if you do not know what adenoids are and the havoc bad tonsils can bring; why eye strain is so prevalent and how to prevent it; why teeth should be taken care of; why we should drink plenty of water and eat the proper kind of food; what kind of clothing is best to wear, and why we should not wear too heavy and too much clothing while indoors (we have induced some little boys to remove one coat and three sweaters while in school); why we need to be clean, etc.
"Another great service the nurse rendered us was to bring about a veritable epidemic of school-house improvement. She proved that the physical condition of the school-house was reflected in the physical condition of the children. For example, a poorly lighted and badly ventilated school-house always housed children with eye strain and nervous disorder, and in a school-house having ill-fitting desks were children of poor posture.
"During the summer of that first year the nurse was with us, we conducted so-called 'baby clinics' in the county, one in every township and one in each village. We urged the mothers to bring their children below school age to the clinics, and much the same kind of examination was given them as was given the children of school age. We found that 60 percent of the children of pre-school age were defective."
This is but a sample of the work and experience of hundreds of rural nurses and shows how the nurse is a health teacher in the most effective manner, for she gets into the homes and gives personal help in bringing about better health. She uses the demonstration method in health work just as the home demonstration agent does with food, clothing, and home management. Furthermore, when the nurse is devoted to her work—and most nurses are or they would not stick to so hard a job—she becomes endeared to the people just as does the family doctor, for the help she gives in cases of sickness, accident, and childbirth, when she is of invaluable service to isolated homes who can secure no other help. A slip of a girl—though a well-trained nurse—who commenced work in a nearby community was introduced to her new work with two confinement cases and an accident case the first day, for none of which was a physician obtainable. The Red Cross Nurse in my own county has spent many a night in a farm home in order to get sufficiently acquainted with parents to induce them to allow her to have needed treatment given to their children, and when the parents come to realize the benefit which their children have received from operations on tonsils or adenoids, the fitting of glasses, and similar services, and appreciate the handicap which such defects would have been to them through life, the nurse has a warm place in their hearts and they eagerly support her work.
One of the difficulties of the average country doctor is his lack of facilities for the expert diagnosis of disease and for the care of patients who need to be kept under observation and given supervised care. Medical science has become highly specialized. The human body is so complicated and wonderful a mechanism that we no longer can expect any one man to be expert on all its ailments. If one desires to secure the best medical service, he goes to a large city hospital or a sanitarium, where various specialists can be consulted and where laboratory facilities are available for their aid. In the average village or country town both specialists and laboratories are lacking and the physician is dependent on his own knowledge and resources. The well-trained physician who appreciates his own limitations and that he cannot give many of his more difficult cases the care they ought to have, sends those who can afford it to the nearest hospital, and does the best he can for the others, but he is keenly aware that he cannot always give them the treatment they should have and he envies his city colleague who can take his patients to specialists for examination.