Origins of Public Health Nursing in Israel

OPSOMMING Israel is nou dertig jaar oud, m aar sy gem eenskapsgesondheidsdienste dateer van die begin van die eeu toe die land nog onder Turkse heerskappy w as. Die eerste geskrew e verslae oor verpleegdienste in Israel het in 1912 in New York-stad in the notule van 'n groep Joodse vroue (later die H adassah-vroueorganisasie) verskyn. Som m ige van die lede het die H eilige Land besoek en was so geskok deur die gesondheidstoestand van die arm es onder die Jode dat htille verbeterde sorg as dringend noodsaaklik beskou het. Die H adassah-vroue het twee verpleegsters na Jerusalem gestuur. M ejj. Rachel Landy and Rose K aplan h et, vergesel van die Am erikaanse filantroop, M nr Nathan Straus2 en sy eggenote, in Januarie 1913 daar aangekom. Tot in 1918 was daar so goed as geen staatsgesondheidsdienste nie. H ospitale en ander m aatskaplike inrigtings soos w eeshuise eri tehuise vir bejaardes is deur godsdienstige en vreem de volksgroepe van Jode en C hristene beheer. Die m eeste inrigtings vir gesondheidsorg was in Jerusalem gekonsentreer en kon nie in die behoeftes van die hele Joodse bevolking voorsien nie. Sanitêre toestande wat vir die gesondheidstoestand van 'n bevolking belangrik is, was betreurensw aardig en openbare sanitasie was so te sê onbekend. Die toestand was egter nie so totaal som ber nie, want daar is sekere gem eenskapsgesondheidsdienste deur vryw illige Joodse groepe ingestel. Die Joodse G esondheidsburo wat in 1912 gestig en geldelik deur Nathan Straus gedra is, het met die uitw issing van m alaria en tragoom begin. Die Pasteur-instituut in Jerusalem wat in 1913 deur Joodse dokters gestig is, was die enigste produsent van entstof teen pokke en hondsdolheid totdat die Britte op die toneel verskyn h e t.20 D ie verpleegsters moes aanvaar word in 'n gem eenskap waar vroue, onder die A rabiere so wel as die O rtodokse Jode, 'n baie lae posisie beklee h e t.22 Bow endien het hulle met liggaam like ontbering te kam pe gehad. Teen Junie 1915 is albei verpleegsters teruggeroep en met hulle vertrek is die ontw ikkeling van gem eenskapsverpleging by wyse van 'n distriksverpleegprogram onderbreek, om dat daar geen opgeleide verpleegsters was om die program oor te neem nie. Die sukses wat m ejj. Landy en Kaplan behaal h et, het egter die grondslag gelê vir gem eenskapsverpleging w aarm ee ander verpleegsters weer in 1922 begin …

I SR A EL is now thirty years o ld , but its com m unity health services date back to the early years of this century when the land was still under Turkish rule.The first written reports on the nursing services appeared in 1912 in New York City in the m inutes o f a group o f Jewish women later known as Hadassah W om en's O rganization.Some o f the members had visited the Holy Land and, shocked by the state o f health of the Jew ish poor, saw the urgent need for improving care.It was decided to start with a system o f community maternity nursing which would be carried out along the lines o f the New York State Legislation.The nurses would be given funds to employ m idw ives, to supply linen to m others and babies, and to distribute money for medicine and food to the poor.Furtherm ore, the nurses were to train probationers for com m unity nursing, give talks to mothers and girls and nursing care to the sick poor.They were to be in contact with Hadassah by letters, monthly reports, and were to use an approved system o f bookkeeping1.
W ith the exam ple o f Lillian W ald's Henry Street Settle ment nursing program and its philosophy o f care for the poor in mind, the H adassah women sent two nurses to Jerusalem.The M isses R achel Landy and Rose Kaplan arrived in January 1913 accom panied by the American philanthropist Mr. Nathan Straus2 and his wife.W hat they saw, heard and learned o f the area m akes fascinating reading for nurse and non-nurse alike.
The Canaan o f Genesis XVII:8 was Palestine to Greeks, Rom ans, Christians and Arabs.In 1516 it became part o f the Turkish empire and was known as the southern part o f the vilayet or province o f Syria3.To the Jew s, Palestine had a special significance not shared with earlier or later rulers; it was Eretz Israel -the land promised to their forefathers: Lift up thine eyes and look from the place where thou art northw ard, southward, eastward and westward; for all the land thou seest, to thee will I give it, and to thy seed forever4.
O f the peoples who had crossed and inhabited the area, some disappeared from history, but Jews, descendants o f the Babylonian exiles, stayed in the country into modem times.Beside these, there were com munities set up by Jews who had been expelled from Spain in the fifteenth century and settled in the holy cities o f Jerusalem and Safad5.These Jews and some co-religionists from Eastern Europe lived in closed, poverty-stricken com m unities, filled with illness and neglect, and waited for the M essiah6.

Zionism
The latter half o f the nineteenth century saw the emergence in Europe o f a nationalist m ovement, called Zionism , which had as its aim the return o f Jews to Palestine, and the estab lishment o f a Jew ish state there.As a result o f this awaken ing, the first wave o f organized im m igration7 came into the country between 1882 and 1903 from Russia and Roumania, spearheaded by a group that called itself the " B ilu " 8.It was in these years that the New Yishuv began to form; twentyfive thousand Jews from those countries came to Palestine after the pogroms o f 1881 to find freedom.Although the Turks forbade Jews to settle in Palestine, the latter managed, by bribery and by virtue o f their Russian passports, to re main.W ith the help o f the French philanthropist Baron Edmond de Rothschild, twelve villages were established, including Zikhron Yaacov, Rishon le Tzion, and Rosh Pina.Thus the capitalist house o f Rothschild and the socialist dream ers from Eastern Europe cooperated in rebuilding the country.
In the late nineteenth century Zionism, as a political m ovem ent, came into being.Its origin is usually dated from the appearance o f a seminal book, The Jewish State, written by Theodor Herzl, a journalist sent to report on the Dreyfus trial in Paris in 1894.The violent anti-semitism then man ifesting itself in supposedly liberal France shocked him.The book and the man fired the imagination o f many young Jews in the late nineteenth and early twentieth centuries9, and inspired new waves o f Jewish immigration to Palestine.
The second Aliyah, between 1904 and 1913, numbered some 40 000 persons from Eastern Europe, among them m any o f the future leaders o f Israel, David Ben Gurion, Levy Eshkol, and Itzhak Ben Zvi; others were to become the founders o f the labour unions and political parties.W hile nationalism , socialism, and manual labour were the ideals, more then half o f these immigrants left for the United States or returned to Europe because o f the hard work in agriculture, for which they had little experience, and because o f illness and economic difficulties10.
At the same time that immigrants from Europe with their various political leanings sought dignity and independence in Palestine, Jewish groups from the surrounding Arab coun tries also came, seeking a haven11.The Oriental Jews num bered about 20 000 before the First W orld W ar, and some 70 000 came after 1918.According to Eisenstadt, the Euro pean Jews for the most part negated traditional religious culture in the m odem society they wanted to build; the Oriental Jew s, among them pedlars, unskilled labourers, and some wealthy traders, wanted to remain as large patriarchal fam ilies with religion and tradition as the way o f life12.
T hus, the Jewish population, estimated at about 85 -90 000 out o f a total o f 650 000 inhabitants between 1912 and 191713, was made up o f the Middle Eastern Jews in closed communities with Messianic hopes, some religious Jew s from Eastern Europe, and new groups o f European Jew s with ideas frequently diametrically opposed to those of the others14.

C onditions in Palestine
To the Jews coming from more advanced countries, condi tions in Palestine must have been a shock.Transportation and com m unication were most primitive.The Turks had done almost nothing, except the building o f some main roads; secondary and local roads were few and poor, the means of tra n sp o rta tio n being som e horse-d raw n vehicles and, m ainly, cam els, m ules and donkeys.In 1914 there was one m otor car in Palestine and two narrow-gauge railway lines connected Jaffa with Jerusalem , and Haifa with Damascus.Telegraph and telephone services were nonexistent, and postal services were conducted under the aegis o f several European powers.The currency o f the country was Egyp tian, but Turkish gold coins and a few M aria Theresia thalers were also used in com m erce15.
Almost no governm ent health services existed until 1918.A lthough the Turks had a plan for a medical service, it was never im plem ented, except for the em ploym ent o f municipal doctors at very low salaries16-H ospitals and other social institutions, such as orphanages and old persons' homes, were run by religious and foreign national groups o f Jews and Christians.M ost health care institutions were concentrated in Jerusalem and could not meet the needs o f the entire Jewish population.M oreover, Jew s, wary o f Christian missionary activities, would use only Jew ish facilities, thus overloading them 17.
Official preventive care facilities were nonexistent, and, judging by later reports o f the British, typhus, relapsing fever, typhoid, and paratyphoid were endem ic, at times epidem ic, and nearly everyone suffered from trachom a18.It must be noted that under the Turks there was no reporting o f vital statistics or disease, so that quantitative statements are at best o f limited value.
Sanitary conditions, important for the state o f health o f a population, were deplorable, and public sanitation was al most unknown.Besides the heaps o f refuse on which, in antiquity, generation after generation had built their com m unities, sim ilar heaps were accumulated by people living in the first decades o f the twentieth century.Flies were consi dered a nuisdnce at m ost, but never a source o f disease.W ater supplies came from uncovered wells and cisterns, breeding places for mosquitoes, and unprotected from dust and foreign bodies19.
The situation was not totally dism al, for some public health services were instituted by voluntary Jewish groups.The Jew ish Health Bureau, founded in 1912 and supported financially by Nathan Straus, began m alaria and trachoma eradication; the Pasteur Institute in Jerusalem , founded in 1913 by Jew ish physicians, was the sole producer o f sm all pox and anti-rabies vaccine until the British cam e20.
The Jew ish population the nurses saw w as poor and hun gry; the homes often had no bedding, no w ater, no heating.The saving grace was that these hovels w ere on the ground floor, and for most o f the year one could easily be out o f doors.Superstition regarding health practices was rife, and treatm ent by the wise man often more acceptable than that of the physician.Nursing care in the home was given by the women in the fam ily, according to the prescription o f the native practitioner and to the lore which had been passed on from generation to generation21.
The nurses had to be accepted in a com m unity where women had very low status among Arabs as well as among the Orthodox Jew s22.In addition, they had to cope with physical hardships.W ater had to be carried from the pump into the settlement which was part clinic and part home.H eating and cooking w ere done on the evil-sm ellin g kerosene stove or on a dangerous contraption w hich was as likely as not to explode if not treated with circum spection.

The Nursing Program m e 1913 -1915
The nurses considered health education, social work, cooperation with physicians and com m unity agencies an integral part o f their care program.A report sent to Hadassah Organization by the nurses illustrates their work and also describes the people with whom they worked.
" One o f our obstetrical patients gave birth to triplets, two boys and a girl.In saying 'our obstetrical patient' I made a m istake, for the patient was not confined by one o f our m id wives, but by a relation, an old Urfaly wom an.She (the patient) is partly ours, as we are assist ing her w ith groceries, underw ear, and, o f course, visit her and watch w hether anything will develop.So far, there is no indication o f anything unforeseen turning up, except m alaria, which is almost a general affliction in Jerusalem , few escape.The triplets are so far not worse and seem to hold their o w n .Two o f them do not seem to promise a long life, but one cannot tell.The m other has plenty o f milk for them all.W hen they are a little older, and I am able to persuade the parents to let me photograph them , I will do so and send the pictures to you.The Urfaly, the Y em en ites, and som e o f the P ersian Jew s strenuously object to being photographed, think ing it will bring them ill luck23." The nurses supervised local m idw ives, followed up the postpartum patients and neonates, cared for both the acute and the chronically ill.They referred patients to the physician for home visits, and perform ed other m edical and nursing regim es as well as social services, such as supplying groceries and clothing for needy fam ilies provided through funds from Hadassah.In a letter o f June 7, 1914, the nurses wrote that there was a great deal o f sickness in Jerusalem , and that they were very busy.
" W e have not sent patients to Shaare Zedek Hospital up to now , for like a miser I kept the $500 for use during the sum m er, knowing from experience from last sum m er what it brings in its wake24." The patients cared for at home included all age groups suffering from m any ailm ents.A lonely old woman with kidney disease, living in squalor, was on the n urses' case load and the nursing care consisted o f hygiene, nourishm ent, medicine, and a physician's visit.There were always patients with malaria, typhoid fever, m eningitis, and typhus in need o f care25.In addition, the nurses started an anti-trachoma service in the schools under the supervision o f Dr. Abraham Ticho, the ophthalm ologist.D r. Ticho exam ined the children and families and gave prescriptions for treatm ent; the nurses treated the patients, and later trained probationers, i.e., women from the com m unity, to do this work, as the case load increased26.These brief notes indicate that cooperation ex isted between the nurses and some physicians, there was supervision o f m idw ives, and, above all, there was aware ness o f patient and com m unity needs.
The nurses also started health clubs for schoolchildren.Language seem ed to be the main difficulty.In one school, children spoke Yiddish, Spanish, Arabic and French, lan guages that the nurses did not speak, except for Yiddish.However, the report stated that the nurses managed to get along.Children w ere taught hygiene and nutrition by using the children who spoke Y iddish as translators.The Evelina de Rothschild School had English as the teaching language, and, according to one o f the nurses, more health teaching could be done there, if only because she could speak in English27.
When the w inter rains ended and the dry heat of the sum m er cam e, the nurses wrote: "T h e w eather is beautiful, but it is very hot during the day and one looks forward to the evening co o ln e ss."They were very busy in the sum m er with m alaria and intestinal disease.A typhoid case was treated at hom e, where the mother slept with the sick child and six other persons in the same room .It was a struggle to get the family to open the two small windows.The parents refused hospitalization for the child because an older sister had re cently died o f typhoid and pneum onia at Shaare Zedek Hospital28.
Summer was an especially busy time with m alaria patients being treated at home under supervision o f the doctor who visited from Rothschild Hospital.Some patients received injections o f arsenic for anaem ia; some had to be given milk and eggs because they could not afford these necessities.Almost all the patients were malnourished.Not only did the nurses concern them selves w ith all the needs o f the patients, they also looked for bargains in supplies in order to stretch their funds29.
A typical w orking day for Miss Kaplan and M iss Landy consisted o f giving trachom a treatm ent for half a day in the schools, and w orking in the settlement in the afternoon, where people were waiting with various requests.In addition to caring for the sick, the nurses tried to provide for the homeless orphans, the lonely elderly, and the insane.Many requests had to be refused for lack o f resources.
The reports o f M ay, June, arid August 1914 give graphic descriptions o f the nurses' work.The home visits multiplied in sum m er, probably because o f an increase in gastro intestinal diseases, although this is not mentioned.It is also surprising that the reports do not specifically mention the infants and preschoolers under care.In a hot climate and under primitive conditions, infants are particularly suscepti ble to dysentery and dehydration, and the mortality is high.It is possible to speculate that the statistical reports requested only certain information and that the nurses saw no need to differentiate between age groups.Another reason may have been that infant welfare care on a planned and organized basis was only begun in 1906 in Cleveland30, and the two nurses in Palestine had not had the opportunity to observe preventive care for infants and preschoolers.The "treatm ent in schools' ' refers to trachom a and the high numbers for May and June reflect the heavy work load.In August the num ber of eye treatments had gone down; this may have been due to the sum m er vacations and to the lack of material for treat ment.The report for August 1914 also mirrors the tense and difficult situation in Jerusalem .The total num ber o f applic ants for help had gone up from 127 in June to 334 in August; the num ber o f "patients treated" had increased from 75 to 138, and the figure for "persons otherwise assisted" was almost double that for May.
In their letters from the outbreak o f the war in the summer o f 1914 until O ctober 1915, the nurses showed their concern regarding w ar developments.There were no ships arriving at Jaffa to bring money or supplies; the money question was of param ount concern to them as well as to the whole popula tion.The banks were paying only 10 percent o f any savings account; money was losing its value; prices had gone up.The health institutions were in trouble; Ezrat Nashim, the mental hospital, had discharged patients, and these people were bringing added difficulties to their families.Shaare Zedek Hospital was taking people who could pay, and accepted only very few who could not.The eye hospital, Le Maan Zion, directed by Dr. Ticho, was expected to close soon, although the eye clinic was to continue.Schools were closed since there was no money to pay the teachers.The nurses themselves were ready to continue working w ithout salary, as they had some money in the Anglo-Palestine Bank and could subsist as long as the bank would pay out funds31.
The nurses bad always helped their patients materially with funds from Hadassah, but now this stopped.Milk was obtained on credit.Lack o f cotton hindered the treatm ent o f trachom a, and the nurses looked for a substitute.M edica tions for treatm ent were given by the Le Maan Zion phar macy until the stocks were exhausted32.Despite the hard ships the two nurses continued their work until January 1915, when M iss Kaplan left Palestine for New York because of illness33.
Miss Landy rem ained in Jerusalem , assisted only by two probationers in treating trachom a.She wrote that the general practitioner o f the Rothschild Hospital had been expelled from Palestine because he was not an O ttom an subject, and, as a result, there was much less nursing work34.It is unlikely, however, that in a Jerusalem without the general practitioner and with few er hospital beds, the nurse refrained from diag nosing and giving treatm ent and care to patients.It may be that her nurse's training as well as her modesty made her reticent about her expanded role.In addition to her routine work during the wartime period, Miss Landy taught a class in home nursing in one of the schools35.
In January 1915 " quite a num ber" o f newborns died.The nurse believed that the cause o f these deaths was starva tion brought on by w ar conditions.Even the trachom a treat ment, when given, was not as successful as before; this, too, she felt, was due to lack o f food." I wish I were a better letter writer.You should see the people in the streets," she wrote to Hadassah.
" They are perfect studies o f pain, misery, and starvation.I never saw such faces.You can imagine how it feels to meet people w ho, you can see, are hungry, yet you don't like to ap proach them , and they are ashamed to approach you.The Straus soup kitchen is open.W hat a blessing that is36." There were difficulties in obtaining kerosene and soap.All this, the lack o f supplies and the hunger, was hard to bear, but the new physician, Dr. H elena Kagan from Rothschild H os pital, was most helpful, and she did not take fees for all her visits37.
In June 1915 Miss L andy's contract was up, her family demanded her return, and although she wanted to stay on Hadassah recalled her38.The settlement was closed, and Miss Landy transferred the care o f the patients to Dr. Ticho and Dr. Kagan39.But Miss Landy had plans for the future.She wanted more nurses, and both she and Dr. Kagan wanted a clinic for women and children in Jerusalem .Miss Landy wrote: " I d o n 't know w hether I had m alaria or w hether my fever was due to your telegram , but my tem perature went up to 39 (Centigrade) and stayed there on and o ff until I sent you my rep ly ."She had becom e attached to Jerusalem and had strong feel ings about leaving it at this stage; she had planned to leave it in a different way40.
The nurses' departure marked a pause in the developm ent o f public health nursing in the form o f a district nursing program , since there were no prepared nurses to whom the program could be transferred.H ow ever, the success o f the Misses Landy and Kaplan laid the foundation for public health nursing that was begun again in 1922 under other nurses.The first nurses had dem onstrated the value o f care directed to families and com m unities as well as individual patients41.In addition to their professional contribution, the two women through letters and reports had sketched the Jerusalem o f the day for posterity.
H ad assah B u lletin , n o. 15, N o v em b er 1915, 2 -3 1915.M iss L andy w as a grad u ate o f the M o u n t S inai H o sp ital N u rsin g S ch o o l o f C lev elan d in 1904, an d b ecam e S u p erin ten d en t o f N u rse s, H arlem H o sp ital, N ew Y ork C ity , in 1911.A fter sh e left P ale stin e, M iss L an d y en tered the U nited States A rm y N urse C o rp s in 1918 and serv ed fo r tw en ty -se v en y ea rs.F ro m the o b itu ary by H adassah O rg an iza tio n , N ew Y ork C ity , 1947.41.L etter from the A m erican C o n su l, M r.G laz eb ro o k , in Je ru sa le m , to M iss L éo n , a H adassah m em b er, ap p earin g in H ad a ssa h B u lle tin , no. 14, O cto b e r, 1 9 1 5 ,2 no. 7, F eb ru ary , 1915, n .p.;in H a d a ssa h B u lle tin , no. 18, F eb ru ary , 1916, 3, M iss K ap la n 's letter o f 8 D ecem b er, 1915, w e fin d M iss K aplan in A lex an d ria, E g y p t, carin g fo r w om en and ch ild ren w ho had been ex iled by the T u rk s an d w ere living in ca m p s put up by th e B ritish.
G reat B ritain and P alestin e, Inform ation D ep a rtm en t P a p ers n o. 2 0 a , T he R oyal Institu te o f In tern a tio n a l A ffa irs, 1915 -1939, (L o n d o n ; O x ford U niversity P ress, 1939), 4 14. S .N .E isen stad t, " T h e S o cio lo g ical S tructure o f the Jew ish C o m m u n ity in P alestin e" , Jew ish S o cia l S tu d ies, 10 (Jan u ary , 1948), 3 -18 15.H erbert S am u el.R ep ort o f th e H igh C o m m issio n e r on th e A d m in istr a tio n o f P a lestin e, 1920 -1925, (Jeru salem ; G o v ern m en t O ffice, 22 A p ril, 1925), 6 -24 16.G o v ern m en t o f P alestin e, R ep ort on P a lestin e A d m in istr a tio n , (L o n d o n ; H is M aje sty 's S tationery O ffice, 1922), 57 17.L eague o f N ations P erm an en t M andate C o m m issio n , A n ex es to M in u te s o