Book Review

No Place Like Home: A History of Nursing and Home Care in the United States

N Engl J Med 2002; 347:542August 15, 2002

Article

No Place Like Home: A History of Nursing and Home Care in the United States
By Karen Buhler-Wilkerson. 336 pp., illustrated. Baltimore, Johns Hopkins University Press, 2001. $48. ISBN: 0-8018-6598-0

Not the least of the achievements of Ian McEwan's recent novel Atonement (New York: Doubleday, 2002) is its vivid portrait of the work of nurses in London during the Second World War. These nurses worked in the hospital rather than at home, and at heart, the nurse and the hospital are synonymous. In contrast, the history of nursing at home — what we might call public health nursing — is not well known. The long history of domestic nursing notwithstanding, home care remains shadowy territory for most historians.

The aim of this new book is to try to understand why home care, and by extension, home nursing, has remained a marginalized experiment in health policy. It covers a long period in the history of the United States, from the 1880s to the mid-1960s, and discusses the influences that shaped access to services and the quality of home care during that time. It examines both local ideas and national events during a period of dramatic shifts in the setting of care — from the home to the hospital and then back to the home again.

The author describes how home nursing was first practiced by the Ladies Benevolent Society in Charleston, South Carolina, to care for the sick as early as the 1840s. Later, home nursing became particularly concerned with the health of the “dangerous immigrant,” and most nurses were black. In the 1920s, the Metropolitan Life Insurance Company had home nurses visit policyholders. Nevertheless, with the building of hospitals, the need for home care declined, and the main tasks for home nurses were redefined to focus on the areas of infectious diseases, chronic illnesses, and maternity care. The result was a drop in home nursing, so that by 1955 only 4000 nurses were working in home care, and visiting-nurses' associations faced a financial crisis. Subsequently, there was a revival of home care, which was seen as a way of reducing occupancy of hospital beds and was covered by Medicare. Now, home care accounts for about 10 percent of Medicare's costs, or around $16 billion annually. Even so, the sector has failed to shake off its history as a marginalized experiment in health care.

Buhler-Wilkerson's exploration of this history has some weaknesses. The opening section of the book, with its case study of Charleston, South Carolina, takes the reader by surprise, and some of the evidence seems descriptive and anecdotal. At times, the focus on personalities is reminiscent of the traditional approach to the history of nursing; the profiles of nursing pioneers such as Anna DeCosta Banks, although arguably necessary, ultimately seem rather limiting. The author shifts between Charleston and Philadelphia, giving the book a disjointed feel, and one is unsure how representative some of the case studies, such as that of Boston, really are. Greater recognition of the methodologic difficulties involved in determining what actually went on in the privacy of people's homes is warranted. Perhaps it is the paucity of sources that makes the early sections of the book less than satisfactory.

The authority of the book grows as the story gathers pace, and the reader who sticks with it will be richly rewarded. It is solidly based on thorough research involving archival sources, and it has many virtues. Given the prominence of the Charleston origins of home nursing, the book is particularly strong on such topics as the key role of black nurses; ethnicity; migration to other cities (Philadelphia, for example); racial prejudice and the complexities of racial segregation; and the construction of the “dangerous immigrant.” Throughout, it is clear that access to care was shaped by race, class, and sex. A particularly interesting section describes how the Metropolitan Life Insurance Company used the visiting-nursing service to contain costs, as well as sponsoring research into the effects of nursing on mortality. Buhler-Wilkerson discusses the way in which the newly invented telephone affected the organization of nursing; what the work of nurses actually consisted of; and the reality of caring for patients with typhoid or tuberculosis. She explores the work of the Henry Street Settlement in New York and the Henry Phipps Institute in Philadelphia; the invention of the term “public health nurse”; and the way chronically ill patients were constructed as the “uninteresting” sick. The book has many illustrations, and the problems involved in using photographic evidence are explored with care.

The most interesting questions deal with the changing status and place of home care within health policy as a whole. In this respect, Buhler-Wilkerson is particularly good at locating the various narratives of the origins, decline, and revival of home nursing within the economic, political, medical, racial, and technological contexts of different periods. She acknowledges the vulnerability of home nursing but also shows its potential contribution to health care, arguing that although it is not an inexpensive option, its future depends primarily on political will. The writing of No Place Like Home has clearly been a labor of love. It is a compelling history with profound contemporary relevance.

John Welshman, D.Phil.
Lancaster University, Lancaster LA1 4YT, United Kingdom
j.welshman@lancaster.ac.uk