Cultivating Constituencies: The Story of the East Harlem Nursing and Health Service, 1928–1941

摘要

I examine the history of the East Harlem Nursing and Health Service in New York City from its beginnings as a demonstration project in 1922 to its closing in 1941. I explore the less tangible goals, needs, and ambitions of the many different constituents that paid for, delivered, and received health care services. I place these goals, needs, and ambitions as critically important drivers of ultimate success or failure. The East Harlem Nursing and Health Service gained international fame among public health leaders for its innovative and independent nursing practice and teaching. However, it ultimately failed because its commitment was to a particular disciplinary mission that did not meet the needs of the constituent communities it served. From 1928 to 1941, the service focused more on the educational advancement of public health nursing and less on addressing the real health care needs of those in East Harlem. ON MARCH 10, 2010, PRESIDENT Barack Obama signed into law the Patient Protection and Affordable Care Act (ACA). Seven months later, a key feature of the bill, the Center for Medicare and Medicaid Innovation, opened its doors. Whereas the ACA looks to restructure key features of the US health care system, the Innovation Center will serve as an incubator of new ideas to deliver and pay for care that will improve quality and decrease costs. To this end, its $10 billion budget sets in motion demonstration projects to increase access to high-quality, cost-effective, coordinated health care for beneficiaries of Medicare, Medicaid, and the Children’s Health Insurance Program. Its charge is to rigorously and rapidly assess the progress of the demonstrations and to replicate those with a “high return on investment” in communities across the country. Its most recent initiative, Strong Start for Mothers and Newborns, calls for demonstration proposals that can be scaled up to national initiatives that will reduce early elective deliveries, test new approaches to prenatal care, and improve outcomes for mothers and babies. 1 The Center for Medicare and Medicaid Services (CMS) has a 30-year history of supporting demonstration projects, most recently in disease management, care coordination, and value-based payment systems. 2 It has an equally long history of policy and practice evaluations to consider the metrics of success and failure. However, demonstration projects in health care in the United States predate the initiatives of the CMS. I turn to one such nurse-led project, The East Harlem Nursing and Health Service, in New York City in the interwar years. The initial five years of its service, a demonstration project to test feasibility from 1922 to 1927, was a resounding success. Linking practice and research, it provided the quantitative data that definitively established the best way to organize the practice of public health nurses. 3 It also provided data on the actual costs of visiting nursing services, thus allowing public health nursing associations across the country to anticipate the higher cost of postpartum and sick (morbidity) nursing care when constructing their budgets. Buoyed by this success, the demonstration project institutionalized its work in 1928 by reconstituting itself as the East Harlem Nursing and Health Service. The service ultimately failed: it lost its financial support, and, without ties to any of the city’s public or private institutions, it closed in 1941. It would be easy to tell the East Harlem story as a conventional “rise and fall” narrative in which nursing’s ambitions failed to gather the sustained resources necessary to implement its vision of care. But a richer historical understanding of why and how some projects succeeded and others failed allows us to move beyond the clinical and economic metrics that have dominated, and will continue to dominate, the evaluations of the Innovation Center’s demonstrations. It allows us to understand the less tangible goals, needs, and ambitions of the many different constituents that paid for, delivered, and received health care services. And it allows a perspective that places these goals, needs, and ambitions as critically important drivers of ultimate success or failure. The East Harlem Nursing and Health Service gained international fame among public health leaders for its innovative and independent nursing practice and teaching. Yet it ultimately failed because its commitment was to a particular disciplinary mission that did not meet the needs of the communities it served. From 1928 to 1941, the service focused more on the educational advancement of public health nursing and less on addressing the real needs of constituents in its East Harlem home.