September 2013

Our Emphasis on “Health for All”

By Bobbie Berkowitz, PhD, RN, FAAN

Dean, Columbia University School of Nursing

Henry StreetThe Henry Street Settlement, founded by Lillian Wald, provided home-based health care to area residents based on their ability to pay.

Twenty-first-century nursing at Columbia is characterized by a dynamic interplay of innovation and continuity. New and fresh ideas come at a fast pace — yet we continue to honor and learn from our time honored tradition that everyone should benefit from good health. The World Health Organization calls this approach "Health for All."

Our emphasis on community and population health today is an outgrowth of the public health movement that started well over a hundred years ago right here in New York City. In 1877 the Women's Branch of the New York City Mission first sent educated visiting nurses into the homes of the poor. Later, Lillian Wald, who was born into a comfortable family but chose to work in the tenements of New York, and her colleague Mary Brewster founded the Henry Street Settlement on the Lower East Side. Settlement nurses educated tenement residents in their homes about infection control, disease transmission, and personal hygiene, and provided acute and long-term care for the ill. The Visiting Nurse Service of New York, established by Wald at the Settlement, emerged as a separate entity in 1944 and of course continues to this day.

Wald, who coined the phrase “public health nursing,” persuaded the New York Board of Education to hire its first nurse, which lead to the standard practice of having a nurse on duty at schools nationwide. By the early 1900’s, public health nurses began to appear in local health departments focusing on child health. In 1918, public health nursing became a standard part of nursing education, and the American Nurses Association established its first certification for community health nurses in 1975. While the scope, breadth, complexity, and education of public health nursing has changed over time, public health nursing has always been focused on the health of populations, practice within community settings, and advocacy for social justice, prevention, and health promotion.

My own nursing career began as a public health nurse in a rural county in Washington State. I drove hundreds of miles during the course of a week — visiting families, schools, clinics, migrant labor camps, churches — anywhere individuals and families needed guidance about promoting health and preventing illness. My car and backpack were full of supplies and I often traveled on foot when families lived “off the grid.” Most of the families were very poor, vulnerable to child abuse, with poor education, inadequate housing, and lack of regular access to health care. Often there was mental illness and chronic disease. The work was exhausting, at times dangerous and scary, and often heartbreaking, but without a doubt some of the most fulfilling work I’ve done. I developed a strong sense of what social justice means and why advocacy is so important. My early experience in public health shaped my viewpoint of health, society, and nursing.

Today, terms such as public health, community health, and population health are often used interchangeably. While there are some distinctions between the terms, it’s important to focus on the common goals of these overlapping genres. Chief among these are serving whole communities by assessing the group’s needs and addressing broad determinants of health, such as individual behaviors and choices, and economic status.

So what are we doing today at Columbia Nursing to further the vision of individuals such as Lillian Wald?

A good example is the Washington Heights/Inwood Informatics Infrastructure for Community-Centered Comparative Effectiveness Research (WICER), whose goal is to understand the health of the Washington Heights and Inwood neighborhoods of northern Manhattan in order to improve the health of the community. Towards this goal, Suzanne Bakken, PhD, RN, FAAN, FACMI, the Alumni Professor of Nursing and Professor of Biomedical Informatics who serves as the Principal Investigator, and an interdisciplinary research team from Columbia University Medical Center and the Visiting Nurse Service of New York, have collected and integrated data from a variety of sources into a virtual health databank. They have also developed a set of tools and processes for accessing the data, and conducted research studies that take advantage of the infrastructure.

A key aspect of WICER was visiting households within the targeted community and interviewing more than 6,000 community members to gather data about health behaviors and other factors that influence health. With permission from the interviewee, the interview data have been linked with clinical data from NewYork-Presbyterian Hospital to create a more complete picture of the health status of community members.

WICER represents an unrivalled opportunity for finding meaningful relationships among diseases and such variables as environment, lifestyle choices, and genetics. It offers a chance to connect the dots by helping researchers, healthcare providers, community-based organizations, and community members better understand the factors that contribute to disease and the best ways to address health needs at the individual and community levels. In fact, engaging such stakeholders for data use is the focus of WICER 4 U, which was recently funded by the Agency for Healthcare Research and Quality.

While this may seem a world away from the door-to-door visits of Lillian Wald and her associates, it is in fact a vital part of the direct line of descent from the pencil-and-paper world of a hundred years ago to today’s cauldron of big data and meta-analysis. And nursing is the common linkage.