Health Visits and In-home Education

While on a visit to a home, health visitors performed specific tasks – including washing babies and monitoring their nutrition. In her lectures, Kanthack also taught health visitors how to demonstrate best practices to mothers. For example, when bathing a baby, she advised health visitors to:

A health visitor’s most important duty was monitoring a baby’s nutrition, especially amid the growing concerns about consumption of spoiled milk as a cause of summer diarrhea. Kanthack instructed health visitors to pay attention to where food was stored, the quality of food being provided to the newborns, and the way mothers fed their child, because feeding was “the pivot on which the whole subject of Infant Mortality turns.” Implicitly commenting on the urban penalty, Kanthack further suggested that “in the country an infant will usually thrive even if it has poor food, because it has plenty of room and plenty of fresh air. On the other hand, even in a crowded city slum, as long as an infant has a plentiful supply of good breast-milk it will generally thrive, in spite of thoroughly bad surroundings.”6Kanthack, The Preservation of Infant Life, 36. To incentivize breastfeeding, Kanthack instructed health visitors to explain both the economic and health benefits of breastfeeding: bottle feeding cost money, and saving the money spent on cow’s milk for other expenditures (like a healthy diet for the mother) would ultimately benefit both the mother and child.7Kanthack, The Preservation of Infant Life, 44. If the mother could not breastfeed, health visitors explained how artificial foodstuffs (cow’s milk) were unsafe for the infant if the milk was improperly stored in dirty jugs or open tins, or if bottles or teats were exposed to dust or contamination by flies.8Kanthack, The Preservation of Infant Life, 49. Health visitors were taught to impress upon mothers two simple points in the hot summer months: “cover up all food, so that neither dust nor flies can get at it, and, where there is a child suffering from diarrhea . . . to observe extreme conscientiousness in dealing with soiled diapers.”9Kanthack, The Preservation of Infant Life, 80. In homes where the health visitors believed that sanitary or feeding practices needed improvement, they would often conduct a follow-up visit, and then try to remain available to mothers for consultation until the child reached school age.10Reid, “Health Visitors and Child Health,” 117. Thus, health visitors’ work aimed to make them simultaneously a “the mother’s friend,” “mini social workers,” and a “public health nurse.”11Baldwin, “Exploring the Professional Identity of Health Visitors,” 12.

Still, health visitors also served as a form of sanitary surveillance, intended to protect a child from hazards within the home. E.M. Evans, who also trained health visitors, described the “ideal health visitor” as having “the eyes of an inspector for defective and insanitary house property, the observation of a good housekeeper as to food, clothing and management, the quick perception of a nurse for symptoms of disease, an easy tactful method of imparting knowledge, and she must have the capability of being an official without appearing official.”12Evans, “The Essential Qualifications of a Lady Health Visitor,” 307. Health visitors thus had to be firm but tactful in offering their lessons on how to remedy unsanitary conditions and improper feeding techniques.

The practice of health visiting began as an act of private charity. The work emerged as a part of a larger, growing middle-class reform movement seeking to improve the lives of the working classes through education in hygiene and temperance.13Of course, we must be cautious about class here. Heggie, “Health Visiting and District Nursing,” 404, warns that in many cases, while philanthropy among women was truly rooted in sympathy, often working-class women were portrayed as (or at least believed to be) “incompetent or helpless in order to justify the middle-class woman’s intervention.” Social historian José Harris, by contrast, argues that most working-class British mothers were remarkably successful in maintaining “cleanliness, good health, and regular meals” in their homes in spite of the financial hardships of staving off poverty that often required them to supplement household income through work outside the home; Harris, Private Lives, Public Spirit, 82–83. Early charitable work, like that of the Manchester and Salford Sanitary Association, investigated living conditions in poorer neighborhoods and reported nuisances back to the sanitary officials. However, most observers attributed poor sanitation to a lack of education among slum dwellers, who middle-class visitors believed to be at the root of many of their own problems. Little direct intervention was offered by the Sanitary Association.14Apple, “Women’s Mission among Women,” 56. This was very much a case of the middle class imposing its values on poorer Britons from above. Still, the public health impact remains historically significant, as these observations drove some of the macro-scale reforms that we considered in Chapter 1. But elitist (male) organizations, like the Manchester and Salford Sanitary Association, did little to aid in the domestic sphere and had limited direct impacts on children’s health.

The first charitable organization to specifically offer infant health visits was the much smaller Ladies’ Sanitary Reform Association of Manchester and Salford, which was established in 1862 and renamed the Ladies’ Public Health Society in 1891.15Davies, “The Health Visitor as Mother’s Friend,” 42. Comprised of the sisters, wives, and daughters of the male-dominated Manchester and Salford Sanitary Association, as women’s historian Rima Apple notes, the members of the Ladies’ Sanitary Association believed that “the public meetings, the distribution of tracts, and the publication of editorials were not sufficient” to improve the lives of the working classes. Instead, the members of the Ladies’ Sanitary Association made “personal visitations” to the households of the poor to offer “affectionate suggestions” for improvement in a more intimate “sister-to-sister” meeting.16Apple, “Women’s Mission among Women,” 57–58. This would prove key to bringing public health inside the home. In Manchester, the Ladies’ Sanitary Association often employed working-class women, who lived within the districts they visited, to serve as role models for their neighbors, and to teach the lessons that the Ladies’ Sanitary Association sought to provide.17Apple, “Women’s Mission among Women,” 59.

Evans described how overcoming social or class barriers was a challenging part of the responsibilities of a health visitor. Evans suggested that visitors must have a “sort of dignity which permits a woman to talk to her fellow women . . . without regard to class, education, birth or income.”18Evans, “The Essential Qualifications of a Lady Health Visitor,” 306. Emilia Kanthack agreed. She advised health visitors to be mindful of “the class of persons who will come under your sphere of influence,” or else “you will not be a scrap of use to them or to their babies.”19Kanthack, The Preservation of Infant Life, 3. British mothers, she explained, may not know the purpose of their visit, and might greet a health visitor with suspicion. In response, a health visitor must explain her purpose in a sympathetic and courteous tone, taking an “amazing interest” in the mother as an individual. Kanthack advised her trainees to extend working-class mothers “the same little courteous considerations . . . that I would have observed towards a lady, say, in Park Lane.”20Kanthack, The Preservation of Infant Life, 3–4.

Funding health visiting was often a problem, as charitable organizations initially pledged the money to hire health visitors in their districts, but then sought donations to continue their salaries.21Apple, “Women’s Mission among Women,” 62. This was not always easy to come by. So, beginning in the 1890s, the supervision and employment of health visitors began to shift away from private charity to professional employment in municipal systems of public health.22Redford, “The Ladies Health Society,” 179. In 1890, Manchester was the first city to hire health visitors as municipal employees – six of the fourteen visitors working for the Ladies’ Sanitary Association became municipal employees. They were paid a salary of 14s per week and worked under the supervision of the Medical Officer of Health, John Tatham.23Heggie, “Health Visiting and District Nursing,” 409; Greenwood, “The Evolution of the Health Visitor,” 174. As agents (if friendly ones) of municipal public health systems, the health visitors’ work brought official sanitary and public health administration into the domestic sphere through increased scrutiny over infant welfare and their medically informed advice for mothers.24Rose, “Medicine, History and the Present,” 63.

This shift was historically significant. As health visiting became subsumed into professional public health, reporting to the Medical Officers of Health, the history of health visiting also reflects a new way that the state was slowly taking a firmer hand in directly guiding public health. Even as health visitors became agents of the state, however, their role still was intended to be “advisory” rather than punitive or compulsory. Yet, as Rima Apple has recently argued, the professionalization of health visiting complicated their work. As health visiting “professionalized and professionally trained nurses replaced the working-class neighborhood women,” some mothers began to fear a health visitor rather than welcome them. The result of the professionalization of health visiting created a perception among their charges that a visitor now had the authority to impose “fines or even eviction.”25Apple, “Women’s Mission among Women,” 63. The voices of working-class Victorian mothers are difficult to find. But in her collection of twentieth-century oral histories Beier, For Their Own Good, 25, quotes one particularly annoyed mother from Preston, who described health visitors as “interfering busybodies.” (In actuality, as far as I can tell, this power still remained with the Medical Officer of Health, to whom they reported, and never directly in the hands of the health visitors themselves.) Nevertheless, as the number of health visitors in each city grew in the decade that followed this professional shift, the number of babies that they visited annually also rose considerably.

While health visits might have become an important form of public health surveillance, this surveillance was obfuscated in particularly gendered ways. As we see in the directives from both Evans and Kanthack, a strong emphasis was placed on the ways in which health visitors should present themselves as women helping other women, rather than as agents of municipal public health. Whether this was intentional or not, this likely helped to cross the particularly gendered line between public health and private domestic life, in ways that the Medical Officers of Health believed would be minimally intrusive, while maximizing public health impacts. In particular, the work of health visitors played a critical role in the expansion of British public health and in its campaign to curb infant mortality.26Marks, “Mothers, Babies and Hospitals,” 49.

Examining how and why health visiting became especially critical in the campaign to curb deadly diarrhea and to improve infant wellbeing leads us deeper into the second stage of my argument that the approaches to public health were widening in the last decade of the Victorian era – becoming more intimate in nature – and that this intimacy would measurably improve children’s health. To do this, let us return to the story of our three case-study cities. Let us consider how their Medical Officers of Health made use of the power of health visits, and the resulting impacts on infant mortality.