Spanish Flu and the rise of public health nursing

Public health nursing is a branch of nursing … concerned with family and community welfare, with bedside nursing … and … work that tends to prevent disease …

“Victorian Order of Nurses for Canada” by J. Charlotte Hannington, in The Canadian Nurse and Hospital Review, XVII:9 (1921), p. 557.

Public health nursing took root in Canada during the Great War. Mass mobilization was the order of the day. Hospitals overflowed with the injured and the sick. A huge shortage of nurses developed. At the same time, it was becoming apparent that the physical condition of Canadian’s fighting forces had some serious deficits. Would-be recruits were rejected for service at alarming rates, whether for disabilities, malnutrition or disease. The sorry state of the nation’s health pointed to the need for better health education and in-school examinations. Provincial governments started to place nurses in schools when, during the war, scarce health care funds were once again channeled into treatment, not prevention.

Then came the Spanish Flu epidemic in the fall of 1918. The cold light of necessity revealed that home-visiting nursing orders provided cost-effective services in rural areas where health care facilities were few and far between. The Victorian Order of Nurses so successfully fulfilled its public-health-nursing mission in Greater Victoria that their services were immediately credited for measurable gains in public health and for a reduction, albeit marginal, of the burden on the public purse.

British Columbia was the second province to adopt public health nursing: Manitoba established a public health nursing program in 1916 and had six nurses on the ground that year.(1) The newly-established Victorian Order of Nurses for Saanich opened a contract with the District of Saanich in 1917.(2) Public health nursing was intended, although not named as such.(3)

1. See “Public Health Nursing in Manitoba,” by Miss E. Russell, R.N., A.R.San.I., Superintendent of Provincial Public Health Nurses, Manitoba, read before the annual convention of the Sanitary Inspectors’ Association of Canada in Winnipeg. In The Public Health Journal, Vol. 16, No. 12, December 1925.  ❡ 2. “Saanich Will Have District Nurse,” The Daily Colonist, December 1, 1916, p. 10. ❡ 3. “[T]he first public health nurse was appointed in 1917, in the Saanich district of Vancouver Island,” according to “Public Health in British Columbia,” in History of Public Health in B.C., edited by Mark Ewan and John Blatherwick. FJB Air Publication, no date. Their source was a 1950 article, “The Development of Health Units in British Columbia” by John F. Murrell in the Canadian Journal of Public Health, Vol. 41, No. 9, September 1950, pp. 389-398, that did not itself cite a source.

“Public health nursing” was a name given to practises whose origins were found in the organizational work of English nursing pioneer Florence Nightingale beginning in the 1850s. Outreach workers came to be known as “district nurses” and “visiting nurses.”

Florence Nightingale with her candle making the night round of the wards at Scutari hospital [Istanbul, Turkey] during the Crimean War. Mezzotint with aquatint, c. 1855, by Charles Algernon Tomkins, after J. Butterworth. “When all the medical officers have retired for the night, and silence and darkness have settled down upon those miles of prostrate sick, she may be observed alone, with a little lamp in her hand, making her solitary rounds.” — Letter from Scutari, in the [London] Times, February 1855. Wellcome Images via Wikimedia Commons.

Nightingale’s models spread into North America within decades. The Training School for Nurses established in St. Catharines, Ontario in 1874 was the first so-called Nightingale school in Canada. Followers in the United States developed Nightingale precepts into full-fledged public health nursing services. In 1893, Lillian D. Wald founded the Henry Street Visiting Nurse Service in New York City.(1) In 1912 Wald became the first president of the National Organization for Public Health Nursing of America; Ella Phillips Crandall was its executive director. Another founder of public health nursing was Dr. Alfred Worcester, professor of hygiene at Harvard University and founder of the Waltham [Mass.] Training School for Nurses in 1885. The first government-supported public health centre in America is thought to have been established in Yakima, Washington in 1911.(2)

1. “The Origins of Public Health Nursing: The Henry Street Visiting Nurse Service” by Elizabeth Fee, PhD and Liping Bu, PhD. American Journal of Public Health, 100:7, July 2010, pp. 1206–1207. ¶ 2.

Public health nursing got established more slowly in Canada, and under different names.

The Victorian Order of Nurses for Canada was established in 1897 with an energetic outreach very much in concert with Nightingale’s movement. The medical community took a while to overcome its suspicions the V.O.N. would not submit to its authority. (It did.) Many eastern Canadian doctors took a dim view of royal charters and suspected the V.O.N.’s noble patrons Lord and Lady Aberdeen, the governor-general of Canada and his chatelaine Ishbel — the driving force behind the nursing order — of bringing upper-class condescension to bear on Canada’s disadvantaged. Would they take into the homes of “the poor” an outright missionary condemnation of the sort that blames the unfortunate for their misfortunes? (It did not.)

This paragraph is a précis of the interesting narratives in the first half of The Victorian Order of Nurses for Canada 50th Anniversary 1897 … 1947 by John Murray Gibbon. Privately published. In the Saanich Archives library.

Another indicator of the rate of uptake of the concept in Canada is in the periodical literature. The Canadian Public Health Association was established in 1910, with a monthly publication The Public Health Journal. It was Ontario-centred and thematic in nature — one searches in vain through early issues for mention of actual public health nursing in Canada.

The nursing profession also took a while to incorporate the public health nursing message into The Canadian Nurse and Hospital Review, the journal of the Canadian National Association of Trained Nurses (forerunner of the Canadian Nurses’ Association). The term “public health nursing” first appeared in that journal in advertisements for graduate schooling based in Boston, Mass. An editorial of the January 1917 issue appears to broach the subject for the first time, calling it a “tremendous, many-sided problem:”

The subject of community nursing is one that is interesting people more and more, and the need of providing proper nursing care in their own homes for people of moderate means. People are looking to nurses to solve this problem, and will hold us strictly to account if we broadly state that if people need nursing, let them go to hospitals. To begin with, our hospital accommodations are inadequate, and in many cases it is impossible for the sick ones to leave home. This magazine is trying to get some articles on this subject, giving the result of several great efforts in places where this tremendous, many-sided problem is being, at least in some measure, solved.

The Canadian Nurse and Hospital Review [Vancouver, B.C.], XIII:1, January 1917, p. 737.

By November 1917, the journal had a Public Health Nursing Department. Its first entry was a report on the formation of a Committee on Public Health Nursing “under” a “Convenor on Public Health Nursing” in the association.

Canadian Nurse, XIII:11, November 1917, p. 709.

At that time the recently-formed Saanich branch of the Victorian Order of Nurses, a district nursing service administered by a local board of management, was headed by Mrs. Evangeline MacLachlan. In January 1918, Mrs. MacLachlan appeared in the news as president of that body announcing the appointment of Miss Catherine Headington as head nurse in Saanich, and Miss Ellis, of Ottawa, her second.

The Daily Colonist, January 26, 1918, p. 6

Mrs. MacLachlan — variously known as “Vangie” or “Mrs Mac” — was an organizer on the cutting edge of the women’s movement in 1918. A school principal in her native Nova Scotia, she and her family moved to B.C. and took up farming in Saanich. MacLachlan joined the local Women’s Institute in 1909. Ten years later she was secretary of the association of British Columbia Women’s Institutes.

Evangeline MacLachlan. In “BC Women’s Institutes: Movers and Shakers” on the British Columbia Women’s Institute website.

Jessie Forshaw took over as Saanich head nurse in September 1918, when Miss Headington “left to take up war work.”* Nurse Forshaw fought the battle with Spanish Flu in the trenches — the households of the district. She had a bout of Spanish Flu herself.

* The Victorian Order of Nurses for Canada 50th Anniversary, p. 74.

The nurses’ remarkable work in Saanich during the epidemic — ten house calls a day each, every day during the onslaught of October 1918 — earned the V.O.N. a stellar reputation. After the war, Forshaw took the message of public health nursing on the road. Having practiced public health nursing to the hilt, she was well qualified to preach it.

The Victorian Order of Nurses for Saanich was the motivating force in a historic chain of events growing out of the Spanish Flu epidemic. Forshaw and such notable individuals as Mrs. MacLachlan and provincial health officer Dr. Henry Esson Young variously supported, built and operated the nation’s first public health centre.

For more about Saanich and V.O.N. nurse Jessie Forshaw in the epidemic, go to Attack and Counterattack. A biographic sketch of Jessie Forshaw, pioneer Canadian public health nurse, is under construction.

Health care professionals attending the British Columbia Hospitals Association convention in Victoria in July 1919. (Published in Report of Proceedings of the Second Annual Convention of the Hospitals of British Columbia, July 8-10, 1919.) Henry Esson Young, M.D., provincial health officer and secretary of the BC Board of Health, is in the front row second from  R (in morning coat). Jessie Forshaw, R.N., who gave a paper on Rural Public Health Nursing at the convention, may also be in the front row.

At that summer meeting of B.C.’s health care professionals, Dr. Young announced a beginning on establishing the Saanich public health centre. He made it clear that it was Nurse Forshaw’s idea:

Some months ago Miss Forshaw called and suggested the establishment of a health centre in Saanich district, adjoining Victoria. I did not tell Miss Forshaw how overjoyed I was, but I formed the opinion that I had met a very active young woman and gave her every encouragement possible. She has gone along and I believe now that the idea is taking practical shape and that we are going to have a public demonstration of what will ultimately be an every-day occurrence in British Columbia, and that is the service carried to the home.

Report of the Proceedings of the Second Annual Convention of the Hospitals of British Columbia. Held at Victoria, B.C., in the Empress Hotel, July 8th, 9th and 10th, 1919, p. 56.

Dr Young’s annual report for 1918-19, written that same month, conferred high praise on Mrs. MacLachlan, another key proponent of the health centre:

Mrs. V. MacLachlan, Secretary of the Women’s Institutes for the Province, was largely instrumental in starting the Saanich Health Centre, and I am very pleased indeed that I was able to Secure Mrs. MacLachlan’s help and hearty co-operation in bringing the matter to the attention of the different Women’s Institutes. Mrs. MacLachlan is an enthusiastic worker, a splendid speaker, a good writer, and, with a thorough knowledge of her subject, is able to present the facts in a manner that carries conviction.

Twenty-third Report of the Provincial Board of Health … for the year ending June 30th, 1919. British Columbia. Legislative Assembly. Sessional papers [microform], 1872-1920. British Columbia. Archives. Library Call No. D-24. Reel 32 [of 33]. P. B7.

The health centre was to be “a hospital for small operations, maternity home, a haven of rest for the aged, a lecture hall in which will be given instruction to mothers in the care and feeding of children, and a home for the Victorian Order of Nurses.”

The Daily Colonist, August 21, 1919, p. 9.

At a public meeting at the Tolmie School in August 1919, the need for a health centre was represented as an extension of the work of the “district nurses” [the V.O.N.] :

[D]uring the epidemic of influenza many cases of whole households being totally incapacitated and brought to the verge of starvation were recorded, and the work of the district nurses at this period saved many lives. The health centre is a furtherance of this principle, and will be an example of the fact that prevention is always better than cure.

 A plan was advanced to raise the $25,000 cost of the centre via a municipal debenture to be voted on by the electorate. “The residents of Cloverdale district, under the leadership of the reeve, Mr. C. V. Jones, declared themselves as heartily in favor of the scheme.”

The Saanich War Memorial Health Centre opened in 1921 at 4353 West Saanich Road.

Saanich War Memorial Health Centre, circa 1941. Saanich Archives. Catalog No. PR-203-2002-001-004. The building stands today. Owned by the Society of Saint Vincent de Paul, it provides accommodation for seniors.

The story of the Saanich public health centre is revealing of the galvanic effect of the influenza pandemic on health care services in Canada; on the institutions, largely staffed by women, that provided many such services; and on individuals in those institutions who rose to heroic heights of service when challenged.

Jessie Forshaw published at least four papers on public health nursing:

“Rural Public Health Nursing,” in Report of Proceedings of the Second Annual Convention of the Hospitals of British Columbia. Held at Victoria, B. C., in the Empress Hotel, on July 8th, 9th and 10th, 1919.

“The Public Health Nurse as an Organizer in the Rural Community,” in The Public Health Journal, Vol. 12, No. 4, April 1921, pp. 163-166.

“How Child Welfare Work Can Be Assisted in the Rural Districts of British Columbia,” in The Public Health Journal, Vol. 12, No. 6, June 1921, pp. 283-288.

“The Need for Co-Operation between the Hospital, The Public
Health Nurse, and the Community,” in The Public Health Journal, Vol. 12, No. 10, October 1921, pp. 455-458.

In “The Need for Co-Operation,” Forshaw argued for devoting more health care dollars to preventing disease:

Until prevention of disease, mental and physical, is considered the standard of efficiency in medical science and community administration, just so long will we continue to build, year after year, additional wings to our hospitals and add to our taxes for the up-keep of institutions for dependents and delinquents.

The missing link, may, to a certain extent, be covered by the public health nurse, who will be the chief educator of the public as her school rooms will be the homes of the people, and her offices of administration the community welfare house.

Forshaw’s prediction of the growing cost of cure proved prescient. The B.C. government’s biggest-budget ministry by far is Health — three times that of Education and more than a third of all expenditures in the Province’s 2018 budget.