No Place Like Home

Karen Buhler-Wilkerson. No Place Like Home: A History of Nursing and Home Care in the United States. Baltimore: Johns Hopkins University Press, 2001. 336 pp. Illustrations. $45.00.

In 1887 Florence Nightingale wrote: "my view, you know is that the ultimate destination of all nursing is the nursing of sick in their own homes . . . I look to the abolition of all hospitals, but no use to talk about the year 2000" (p. 1). Like Nightingale, many nurses throughout history have argued that home care is the preferred, rationale, cost effective alternative to institutional care. Yet the history of home care suggests otherwise. Buhler-Wilkerson explains that home care has remained a marginalized experiment in care giving for over one hundred years and has yet to find its place in modern health care. She examines how race, ethnicity gender, disease and illness, and patterns of practice and custom have sculpted the history of home care.

In 1813 the ladies of Charleston, South Carolina, were the first to organize home care under the auspices of the Ladies' Benevolent Society (LBS) in the antebellum south developing a system of care that was compatible with the needs of the poor and the southern way of life. At that time privately endowed institutions, administered by boards appointed by city government, provided care for orphans and the sick and the elite distributed charity from both public and private sources. In addition, more than thirty private and religious organizations included "charity" to the destitute, the poor, the insane, vagrants, chronic invalids, and drunkards. The LBS provided relief to those who lay outside the extant Charleston "health care system," namely, free blacks and poor whites sick in the home. Organized by 125 women of Charleston's wealthiest families, the LBS women believed the rich were obligated to improve the conditions of the poor while the poor, in turn, were expected to manifest their gratitude to the rich (p. 5).

According to the ladies, the LBS was not a mutual benefit association, but rather one that depended on an intimate understanding of the poor and reflected the "proper" female attitude of meekness, humility, and desire to serve. During the first decade (1813-1823), the ladies cared for 290 patients, who were mostly women, each year. While the patients were screened to insure they possessed the proper "need," the vexing problem of the chronically ill revealed the complex relationship between mission and money. Chronically ill patients exhausted the budget. Yet discharging the patients, when they were still in need, depleted the ladies' benevolent spirit. With a limited budget, their mission, which was associated with the elements of "faith" and religious impulse, conflicted with "finance" and the business of home care. Eventually, the necessary redefinition of LBS's role to the chronically ill changed its relationship to the patients; by 1860, the society's existence was in peril.

In the late nineteenth century, the social context redesigned the care of the sick poor in the home. In cities, communicable diseases revealed a relationship between death and poverty. Medicine demonstrated only its impotence in the treatment of illnesses such as cholera and fevers, underlining the need for careful nursing as Charles Rosenberg has observed in The Care of Strangers (1987). Schools of nursing, initiated on the East Coast in 1873, promised a more intelligent, skilled, and reliable nursing corps, capable of managing the challenge. Trained nurses were to become an army of disciplined and well-bred women, bringing the message of health and protecting the public from the spread of disease with "forceful yet tactful" lessons in physical and moral hygiene. The nurse, armed with training but compliant as any proper "lady," was supposed to convince patients—over whom she had no authority—to follow her directions (p. 24). The goal of nineteenth-century home care had moved beyond the idea of "charity" to "public reform." As Helen Jenks, founder of the Visiting Nurse Society of Philadelphia noted, freedom from disease in homes...