Policy and Politics for Nurses and

Other Health Professionals 3rd Edition

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 Contents vii

The Future Outlook: The Way Forward���������������������243 Baseline Information�������������������������������������������������������294

Conclusion�������������������������������������������������������������������������247 Challenges Facing the Community Hospitals�������298
Hospital Strategies in a Competitive Market���������301
Chapter 12 Medicaid and the Financing The ACA and The Rationalization of Hospital
of Care for Vulnerable Care ���������������������������������������������������������������������������������303
Populations: A Story of Healthcare Policy, Health Reform, and the
Misconceptions��������������������� 255 Role of Hospitals���������������������������������������������������������306

Introduction�����������������������������������������������������������������������256
Chapter 15 Enhanced Primary Care
Health Outcomes in the United States in
Relation to 10 Developed Nations�����������������������257
Roles for Nurses and Other
Populations Served by Original Medicaid �������������259
Professionals������������������������� 313
Original Medicaid Is Different Program in Why Primary Care? The Case for Change���������������315
50 States and Washington, DC�������������������������������260 Overtreatment, Overuse, Waste, and
Traditional Medicaid Costs and Variation Healthcare Harm���������������������������������������������������������315
by State���������������������������������������������������������������������������261 Support for Value-Based Care as a Bipartisan
ACA Medicaid�������������������������������������������������������������������265 Approach�����������������������������������������������������������������������317
Who Is Left Out�����������������������������������������������������������������266 How Payment Reform Shapes Needs and
Opportunities in Primary Care�������������������������������318
Health Insurance and the Health of
Vulnerable People�������������������������������������������������������267 What Skills Do Nurses Need in These
Advanced Primary Care Settings?�������������������������324
Chapter 13 Innovation for the Delivery Nursing Education�����������������������������������������������������������329
System of the Future: Medical Mental Health�������������������������������������������������������������������331
Homes, Accountable Care Dental Care�������������������������������������������������������������������������331
Organizations, and Bundled Conclusion�������������������������������������������������������������������������332
Payment Initiatives ������������� 279
Chapter 16 Physicians: It Is Increasingly
Introduction�����������������������������������������������������������������������280
about the Team��������������������� 341
The Innovation Center: Promoting Care
Delivery Models for the Future �����������������������������280 Medical Professionalism �����������������������������������������������342
Rationale for New Models��������������������������������������������281 Physician Supply: Who Are the Doctors?���������������343
The Four Major Healthcare Service Delivery How Are Physicians Practices Organized and
Models����������������������������������������������������������������������������281 Reimbursed?�����������������������������������������������������������������348
Conclusion�������������������������������������������������������������������������286 Physician Accountability�����������������������������������������������353
Medical Errors, Physician Practice,
and the Barriers to Quality Care�����������������������������356
Health Care and
SECTION 5  Overcoming the Barriers to Quality Care���������������356
Conclusion: Choices and Interests�����������������������������358
Provider and Care
Delivery289 Chapter 17 Health Information Technology
and the Intersection of Health
Chapter 14 Hospitals: Consolidation Policy ������������������������������������� 371
and Compression������������������� 291
Introduction�����������������������������������������������������������������������372
Hospitals’ Role within the Delivery System�����������292 Federal Origin and Influence in Development
Hospitals in a Historic Context�����������������������������������292 of HIT�������������������������������������������������������������������������������373
viii Contents
Nursing and Health Information Technology�������378
Nursing Terminology and the Data of
Nursing Care�����������������������������������������������������������������380
A National Action Plan: The Macro
Perspective on HIT�����������������������������������������������������381
Nursing and the Electronic Health Record:
The Micro Perspective on HIT���������������������������������382
Health IT: The Intersection of Data Security
and Health Policy �������������������������������������������������������383
Conclusion�������������������������������������������������������������������������391
Chapter 18 Political Power of Nurses:
Harnessing Our Values and
Voices������������������������������������� 403
Origins of the Nursing Profession �����������������������������405
Nursing Definitions: Past and Present ���������������������406
Nurses and Policy�������������������������������������������������������������407
The Nursing Workforce �������������������������������������������������413
Transforming the Care Delivery System�����������������415
Pathways to Nursing as a Career Choice�����������������416
Specialization and the Evolution of Nursing
Roles���������������������������������������������������������������������������������419
Current State of the Profession�����������������������������������419
Enhanced Nurse Licensure Compact�����������������������421
21st-Century Nursing: Evolving Roles
for Nurses�����������������������������������������������������������������������421
Policy as a Tool to Influence Nursing
Professionalism and Nursing ���������������������������������425
Conclusion�������������������������������������������������������������������������427
Legislative Resources�����������������������������������������������������427
Federal Agency Sites�������������������������������������������������������428
Other Related Sites���������������������������������������������������������429
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
© Anthony Krikorian/Shutterstock
Acknowledgments
It is with sincere appreciation and gratitude that
we would like to acknowledge the many individ-
uals, including family, friends, professional col-
leagues, and students, who have made this third
edition possible. Special thanks go to those pro-
fessional nurses who have gone before us pav-
ing the way by being stewards of the discipline,
advocates, and activists in promoting nursing,
public health, and policy. As the editors, we are
profoundly grateful to continue in their foot-
steps, fulfilling our promise to safeguard the
health of society and ensuring that future gen-
erations of nurses recognize how health and
public policy are instrumental to their educa-
tion and practice.
To my co-editors, Donna J. Middaugh and
Veronica D. Feeg, your enduring friendship, men-
torship, and insight have made this book possi-
ble. With your profound trust and unwavering
commitment, this third edition is offered in the
ongoing quest to ensure all nurses harness the
power within and bring their voices and values
to the bedside, boardroom, classroom, and halls
of Congress to promote policies that educate and
inform the public about what nursing is, not just
what nurses do.
We also would like to acknowledge the
superior oversight and dedication of Tricia
Plummer, our team administrator, who help
coordinate all the essential activities that made
this third edition such a seamless success. Tri-
cia, your professional skills and support were
greatly appreciated.
To my husband, Michael, whose love, pres-
ence, and encouragement has allowed me to fulfill
my professional hopes and dreams. Thank you
for making this such an exciting journey and
always believing all things are possible. To my
children, Nick, Lili, Kate, Luke, and JP, your joy
and love have fueled my energy and enthusiasm
to live my life by the words of Mahatma Gandhi:
“Keep your values positive because your values
become your destiny.” Always be positive and be
an example so that others may follow.
— Donna M. Nickitas
To my husband Robert and our son Rob-
ert Guy, who have awakened my soul and are
my inspiration in everything I do. They have
taught me to love unconditionally, enjoy life,
live with purpose, take risks, and strive for ex-
cellence. Robert Guy: You have become such
a compassionate, dedicated nurse! We are so
proud of you! Also, to the memory of my mother,
­Alpha Duff, a teacher, who taught me to never
stop learning.
— Donna J. Middaugh
To my husband Alan, you are my rock and
my enabler. You have always given me space to
do what makes me happy and wings to make me
soar into new endeavors without fear of failing.
You make the days easy for me to be produc-
tive in my own way. You give me understanding
when I’m unraveled; you give me comfort when
I need it most; you give me love in all you do.
To my daughter, Kelly, you are my sun and
the light of my life. You have become my teacher
and my sage with your wise guidance and words
ix
x Acknowledgments

of wisdom. You provide me with creative in-
spiration in my work by modeling it in yours.
To my mother, Mary, and in memory of my
dad, Americo “Red” DeCarolis, you both nur-
tured my passion for learning and supported
me unconditionally and financially throughout
my years in college. You may not have finished
high school but you always valued the impor-
tance of education.
— Veronica D. Feeg
© Anthony Krikorian/Shutterstock
Preface
Sally S. Cohen
Why this book? Why now? Nurses and other
health professionals have many textbooks on
health policy to choose from. Donna M. ­Nickitas,
Donna J. Middaugh, and Veronica D. Feeg’s third
edition of Policy and Politics for Nurses and Other
Health Professionals has distinct features that
make it a wise investment for faculty, ­students,
and others seeking concise, expert, and useful
information on how to understand and influ-
ence health policy.
First, the editors have carefully chosen the
most salient issues on government agendas and
not overwhelmed readers with the plethora of
all possible health policy issues around us. This
is critical in order to make health policy mean-
ingful to and within reach of students and cli-
nicians who can be quickly overwhelmed by the
world of health policy.
Second, this edition’s addition of case stud-
ies is of tremendous benefit. Based on decades
of teaching health policy at all levels of nurs-
ing education and to interdisciplinary and in-
terprofessional groups of students and faculty,
I am convinced that policy case studies are es-
sential. They offer faculty options for innovative
assignments and discussions that encourage stu-
dents to write or speak about health policy in a
nonjudgmental context. The case studies, which
are strategically placed within the chapters, of-
fer real-life scenarios. These scenarios typically
have more than one possible solution to a policy
problem. Case studies also: (a) facilitate discus-
sions about policy problems, (b) teach students
to articulate significant themes in health policy,
(c) require synthesis of valid evidence, and (d)
demonstrate the importance of political analy-
ses. The editors have wisely included more than
one case study in some chapters to demonstrate
how one policy can be applied to many differ-
ent situations or issues.
The third advantage of this text is that the
editors have a well-honed vision of what health
professionals need to know in an era of con-
tinually shifting public policy sands. Nickitas,
Middaugh, and Feeg’s third edition is based on
the premise that health professionals need to be
as nimble in government arenas as they are in
clinical settings. Moreover, they recognize that
this entails linking local, national, and global
health issues because of their inherent inter-
connectedness. With media and technology
enabling rapid dissemination of information, the
editors have provided content and case studies
that encourage effective communication using
online resources.
Some of these issues primarily apply to
individuals and populations with access to the In-
ternet and other technologies. Nurses and other
healthcare providers recognize that vast parts of
the world lack such resources. People in such
locales are struggling to find clean water, erad-
icate severe hunger, and prevent common and
new infectious diseases. Moreover, the geopolit-
ical terrain has become increasingly complex as
war, terrorism, and natural disasters strike across
the globe. The realities of climate change and en-
vironmental health risks make the sweeping dif-
ferences in allocation of resources between the
“haves” and “have nots” an ever-present challenge
for health professionals. These global challenges
are in contrast to other public health issues, in-
cluding the proliferation of noncommunicable
xi
xii Preface
conditions such as obesity, cardiac illness, and
mental health and behavioral problems (espe-
cially substance abuse and addictions).
Nickitas, Middaugh, and Feeg wisely ad-
dress the diversity of these issues by including
chapters on global and population health as in-
tegral to the text—and not as “add-ons” at the
end. By addressing poverty and other socioeco-
nomic causes of health problems, they acknow-
ledge the importance of health policy beyond
the doors of the clinic or hospital.
Similarly, they frame the chapter on physi-
cians as an issue of interprofessional teamwork,
instead of trying to present physicians or any
other professional as separate components of the
healthcare delivery system. By emphasizing the
importance of team care, they have minimized
the risk of readers engaging in the familiar and
useless “physician–nurse” games.
Will this text endure forever? No health
policy text can meet that challenge. However,
given the complexity of health policy and the
significant problems of teaching it to nurses and
health professionals, this third edition of Policy
and Politics for Nurses and Other Health Profes-
sionals can facilitate teaching and learning across
diverse settings and student populations. In the
health policy and education arenas, which can
be characterized by considerable disagreement
and little consensus as players vie for scarce re-
sources, this text is a winner and one that can
bring players together as they find common
ground in addressing the global and local issues
on which people’s lives and well-being depend.
© Anthony Krikorian/Shutterstock

Contributors
Nancy Aries, PhD Ellen Chesler
Professor of Social Policy Senior Fellow
School of Public Affairs Roosevelt Institute
Director of Baruch Honors Programs New York, New York
Baruch College
Barbara Cohen, PhD, RN
The City University of New York
Professor of Health Services
New York, New York
School of Health Studies
Steven Baumann, PhD, APRN-BC, RN Berkeley College
Professor New York, New York
Hunter College
Wesley Cook, DNP(c), APRN, FNP-BC, CPSN
Hunter-Bellevue School of Nursing
Nurse Practitioner
New York, New York
Washington, DC
Claudia J. Beverley, PhD, RN, FAAN
Brigitte Cypress, EdD, RN, CCRN
Professor (Secondary), Department of Health
Associate Professor
Policy and Management
East Stroudsburg University
Professor
Department of Nursing
College of Nursing
East Stroudsburg, Pennsylvania
Professor (Secondary)
College of Medicine Patricia Eckardt, PhD, RN
Director, Arkansas Aging Initiative, Donald Molloy College
W. Reynolds Institute on Aging Rockville Centre, New York
University of Arkansas for Medical Sciences
Veronica D. Feeg, PhD, RN, FAAN
Little Rock, Arkansas
Associate Dean and Director
Linda Bradley, MSN, MPH, PHCNS-BC PhD Program in Nursing
Assistant Professor Molloy College
New York City College of Technology The Barbara H. Hagan School of Nursing
Brooklyn, New York Rockville Centre, New York
Pennie Sessler Branden, PhD, CNM, RN, CNE Stephanie Ferguson, PhD, RN, FAAN, FNAP
Consulting Associate Professor
Barbara Caress
Stanford University
Senior Consultant
Stanford, California
Service Employees International Union
Founder, President, and Chief Executive Officer
New York, New York
Stephanie L. Ferguson Associates, LLC
Amherst, Virginia

xiii
xiv Contributors

Shirley Girouard, PhD, RN, FAAN Donna Middaugh, PhD, RN

Professor and Associate Dean Clinical Associate Professor
College of Nursing Associate Dean for Academic Programs
SUNY Downstate Medical Center Coordinator, Nursing Administration Masters
Brooklyn, New York Specialty
College of Nursing
Valerie Gruhn
University of Arkansas for Medical Sciences
Doctors Without Borders/Médecins Sans
Little Rock, Arkansas
Frontières
Geraldine Moore, EdD, RN
Joyce Hahn, PhD, RN, APRN-CNS, NEA-BC, FNAP
Molloy College
Associate Professor
Rockville Centre, New York
School of Nursing
George Washington University Lois Moylan, PhD, RN
Washington, DC Molloy College
Rockville Centre, New York
Christine Hancock
Director Donna M. Nickitas, PhD, RN, NEA-BC, CNE, FAAP, FAAN
C3 Collaborating for Health Dean and Professor
London, United Kingdom Rutgers University School of Nursing
Camden, New Jersey
Lauran Hardin, MSN, RN-BC, CNL
Editor, Nursing Economic$, The Journal for
Senior Director
Health Care Leaders
Cross-Continuum Transformation
Pitman, New Jersey
National Center for Complex Health and
Social Needs Betty Rambur, PhD, RN, FAAN
Camden Coalition of Healthcare Providers Routhier Endowed Chair for Practice
Camden, New Jersey Professor of Nursing
University of Rhode Island
Olga S. Kagan, PhD, RN
Kingston, Rhode Island
Eileen Levy, RN, PhP
Roby Roberston, PhD
Nurse Practitioner at NSLIJ
Professor Emeritus
Huntington Hospital
School of Public Affairs
Huntington, New York
University of Arkansas – Little Rock
Sandra B. Lewenson, EdD, RN, FAAN Little Rock, Arkansas
Professor
Yael Rosenstock
College of Health Professions
Director of Programming
Lienhard School of Nursing
Center for Ethnic, Racial, and Religious
Pace University
Understanding
Pleasantville, New York
CUNY
Jennifer E. Mannino New York, New York
Nancy Rudner, APRN
Professor of Nursing
George Washington University
Washington, DC
 Contributors xv

Janice A. Selekman, DNSc, RN, NCSN, FNASN Marie Truglio-Londrigan, PhD, RN

Professor Professor
School of Nursing College of Health Professions
University of Delaware Lienhard School of Nursing
Newark, Delaware Pace University
Pleasantville, New York
Brenda Helen Sheingold, PhD, MBA, BSN, FNAP
Assistant Professor Ralph Vogel, PhD, RN
Director Clinical Assistant Professor
Health Care Quality Graduate Programs College of Nursing
George Washington University University of Arkansas for Medical Sciences
Washington, DC Little Rock, Arkansas
Lisa Sundean, PhD, RN Helen Werner, PhD, RN
Assistant Professor Assistant Professor
Department of Nursing Program Coordinator, Upper Division
University of Massachusetts, Boston Monroe College School of Nursing
Boston, Massachusetts Monroe, New York
Joel Teitelbaum, LLM Sara Wilensky, PhD
Associate Professor Faculty
Department of Health Policy and Milken Institute School of Public Health
Management George Washington University
Milken Institute School of Public Health Washington, DC
George Washington University
Washington, DC
Anh Phuong Tran, BSN, RN-BC, ONC
Adult Health Nurse Practitioner
New York, New York
SECTION 1
Introduction
CHAPTER 1 Nursing’s History of Advocacy and Action
CHAPTER 2 Policy and Politics Explained
CHAPTER 3 A Policy Toolkit for Healthcare Providers
and Activists

© Anthony Krikorian/Shutterstock

1
CHAPTER 1
Nursing’s History
of Advocacy and Action
Sandra B. Lewenson and Donna M. Nickitas

OVERVIEW
The American Nurses Association (ANA) reminds nurses of the social contract between nurses and the
public that “reflects the profession’s long-standing core values and ethics, which provide grounding
for health care in society” (American Nurses Association [ANA], 2010, p. 10). The ANA Social Policy
Statement has articulated nursing’s social obligation since it was first published in 1980. Nurses turn
to this document to understand how nursing fulfills this obligation by providing ethical and culturally
competent care to individuals, families, communities, and populations. It also helps nurses explain their
role in the larger society, to new members of the profession, and to nurses already working in the field.
New position statements about inclusivity and diversity by the American Association of Colleges
of Nursing (AACN) (2017) and the American Academy of Nursing (AAN) (2016) contribute to a sense of
responsibility nurses share to fulfill the social obligation to society. The AACN (2017) states that “to have
equitable systems, all people should be treated fairly, unhampered by artificial barriers, stereotypes
or prejudices” (p. 173). It continues to address unconscious and conscious bias of which we as nurses
must be aware to make a change. Advocacy includes, and if not, should include, the notion of
inclusivity and diversity.
This chapter explores political advocacy in light of nursing’s role and responsibility to advocate for
and act on behalf of those for whom nurses have contracted to provide care. The first section of the
chapter explains why nurses need to know history to be effective advocates and why knowing history
matters to advocacy. It provides historical exemplars to highlight how history informs the profession
as it continues to invoke the social contract that nursing maintains with society. The second part of the
chapter examines a more contemporary look at nursing’s political advocacy efforts and what it means
for nurses, the profession, and the health of the public at large.

© Anthony Krikorian/Shutterstock

3
4 Chapter 1 Nursing’s History of Advocacy and Action
OBJECTIVES
■■ Discuss why nursing history is relevant to health policy and nursing advocacy and action.
■■ Explore historical exemplars that provide evidence of nursing’s ability to advocate for individuals,
families, communities, and populations.
■■ Analyze nursing’s role in how political advocacy impacts nurses, the profession, and the health
of the public at large.
▸▸ Nurses as Advocates
Although society reportedly trusts nurses to
work toward accomplishing the goals set forth
for them by the profession (ANA, 2010), nurses
may not be grounded in how they reached these
“long-standing core values” that the nursing pro-
fession developed over time. As nurses advocate
for their patients—whether seen as individu-
als, families, communities, or ­populations—
an understanding of nursing’s enduring and
long-standing values that are rooted in its his-
tory provide depth and breadth to their efforts.
To this end, it is important to know nursing’s
historical role in ensuring access to care; it is
important to know nursing’s contributions to-
ward patient quality and safety measures; it is
important to know how nursing interventions
changed over time in response to the context in
which nurses practiced; and it is important to
know how nurses and the profession adapted
to shifts in the social, political, economic, and
cultural environment (D’Antonio & L ­ ewenson,
2011). Fairman (2017) writes that “our past
shapes everything we do, whether we explicitly
acknowledge it or not” (p. xi).
Why Study Nursing History?
Historian and nurse educator Ellen Baer and col-
leagues respond to the question of why nursing
history should be studied:
Just as a nurse can make little progress
caring for or curing a patient’s presenting
problem without knowing the patient’s
physiological, psychological, and cultural
history so is it for a nurse trying to make
sense out of the persistent problems and
possibilities in nursing and health care.
To make right decisions in planning
nursing’s future in the context of our
complex health-care system, nurses
must know the history of the actions
being considered, the identities and
points of view of the major players, and
all the states that are at risk. These are
the lessons of history. (Baer, D’Antonio,
Rinker, & Lynaugh, 2001, p. 7)
Some lessons from the past that support
the understanding of political advocacy and
action can be learned by examining how Flor-
ence Nightingale influenced the development of
nursing education programs that started in 1873,
and led to what became known as the Modern
Nursing Movement. It began with the first three
United States Nightingale training schools: the
Bellevue Training School for Nurses in New York
City; the Boston Training School for Nurses at
Massachusetts General in Boston; and the Con-
necticut Training School in New Haven, Con-
necticut. Following the opening of these three
schools, hospitals around the country recog-
nized the value that student nurses bring to the
hospital because care could be provided at rela-
tively low cost and the hospital would have no
obligation to hire the nurses when they gradu-
ated. Nurses, after their training was complete,
would need to find work elsewhere, typically
in private duty or in the emerging field of pub-
lic health nursing.
Twenty years after the opening of these
schools of nursing, early nursing leaders

recognized the need to organize nurses to con-
trol the quality of practice and training as a way
to protect the public. Between 1893 and 1912,
four professional nursing organizations formed
to do just that: the National League for Nurses,
formed in 1893 (originally called the American
Society of Superintendents of Training Schools
for Nurses); the American Nurses Association,
started in 1896 (originally named the Nurses’
Associated Alumnae of the United States and
Canada); the National Association of Colored
Graduate Nurses, which formed to address ra-
cial bias in nursing and health care and was in
existence between 1908 and 1952; and finally, in
1912, the National Organization of Public Health
Nursing, formed to control practice and educa-
tional standards during the rising movement of
public health and public health nursing in the
United States. This organization ended in 1952
when the National League for Nursing assumed
its role (Lewenson, 1993).
Even before women in the United States
gained the vote in 1920, nurses sought legis-
lation that would define nursing practice, and
they advocated for the protection of the pub-
lic by prohibiting anyone who was not profes-
sionally trained from calling him- or herself a
nurse. This required convincing lawmakers, at
that time only men, to support nursing legisla-
tion; the nurses knew they could not vote into
law the early nurse practice acts. While nurses
struggled for statewide nursing registration, they
had to “fight battles against long hours of work
and opposition to nursing education” (­Lewenson,
1993, p. 171). To accomplish their goals, some
nurses, either individually or through the early
nursing organizations, began to support the
work of the suffragist movement and aligned
themselves with the larger women’s movement
of the early 1900s. Individual nursing leaders, like
public health pioneer Lillian Wald and nursing
suffragist Lavinia Dock, advocated for health-
care reforms in the community and the legisla-
tive arena. The professional organizations that
formed during this period did so to protect the
public from uneducated nurses and to develop
standards for nursing education and practice.
Nurses as Advocates 5
Although an in-depth history of this p
­ eriod
is beyond the scope of this chapter, it is im-
portant for nurses to understand that political
advocacy was part of the profession’s early iden-
tity. Political advocacy and action in nursing
are not new or innovative. Nurses have a­ lways
been political advocates for those in their care
(Lewenson, 2012). As a result, the early efforts
made by nurses and their professional orga-
nizations provide a narrative for and insight
into today’s advocacy efforts, where protection
of the public means ensuring a level of educa-
tion for all nurses, the development of quality
and safety standards, and the ability of nurses
to practice to the fullest extent of their educa-
tion, as recommended by an Institute of Med-
icine report (2010).
History Counts
Fairman and D’Antonio (2013) wrote, “history
counts in health policy debates” (p. 346). Bring-
ing a historical perspective to discussions about
health care deepens our understanding of the is-
sues by recognizing the evolution of ideas across
time. In the debate about control of the “newly”
minted medical homes of today, understanding
the roles of early public health nurses in provid-
ing primary healthcare services to individuals,
families, communities, and populations in both
urban and rural settings can trigger some use-
ful ideas or solutions about what to call the new
entity, who should finance it, and who should
lead it (Keeling & Lewenson, 2013).
The current debate centered on medical
homes provides such an example. The term was
first coined in the 1960s and defined a medical
model of care for chronically ill pediatric pa-
tients that looked at control issues, inter- and
­intradisciplinary issues of providing care, and
the financial aspects of care. Physicians led the
earlier medical home movement that has evolved
to mean “a model of primary care that is accessi-
ble, continuous, comprehensive, family-centered,
coordinated, compassionate and culturally ef-
fective” (American Academy of Pediatrics, 2002,
as cited in Keeling & Lewenson, 2013, p. 360).
6 Chapter 1 Nursing’s History of Advocacy and Action
Nurses use the words that define the medical
home of today to describe nursing’s work of
providing accessible, continuous, comprehen-
sive, family-centered, coordinated, compassion-
ate, and culturally effective care. Knowing the
history of nursing serves to highlight the pro-
fession’s strong contribution to health care in
the United States.
▸▸ Advocacy and Public
Health Nursing
Exploring some of the public health initiatives
that Wald established—the Henry Street Set-
tlement and the American Red Cross Town &
Country—offers excellent examples of how nurs-
ing, history, and political advocacy and action
intersect. By studying the work of those nurses
and nursing leaders within these settings, we
not only learn about the role nurses played in
primary health care (as described by Keeling &
­Lewenson, 2013), but we can also learn about
the healthcare advocacy that public health nurses
sought for those individuals, families, and com-
munities. We also learn about the unconscious
and conscious bias shared by society, includ-
ing nurses, towards black nurses and the sub-
sequent outcome that race played in healthcare
outcomes. The next section uses these two early
20th-century public health initiatives as exam-
ples of political advocacy by public health nurses.
Advocacy at Henry Street
Lillian Wald graduated from nurses’ training in
1891 from the 2-year diploma-based program
at New York Hospital in New York City. Within
2 years of graduating, she and her school friend
Mary Brewster recognized the overwhelming
healthcare needs of immigrant families living
in the overcrowded and unclean conditions of
the tenement houses on the Lower East Side of
New York City. Filled with a sense of social ob-
ligation to improve the health of society, Wald
and Brewster began the Henry Street Settlement
and found support for the venture from philan-
thropists and other nursing leaders. Wald’s work
expanded from just nine public health nurses
working in one settlement house that was estab-
lished in 1893 to more than 250 nurses working
throughout the New York City area in at least
seven different locations (Buhler-­Wilkerson,
2001; Keeling, 2007; Lewenson, 1993). The
Henry Street Settlement was one of the few pub-
lic health organizations to hire black nurses to
care for black patients (Pitt-Mosley, 1996). This
policy of inclusion did not exist in most health-
care settings, and discrimination was typically
the order of the day, whether in the north or
south or whether conscious or unconscious.
While caring for the families, Wald saw a
close relationship between the health of the pub-
lic and civil responsibility. In a speech she deliv-
ered in 1900 at the sixth annual meeting of the
American Society of Superintendents of Train-
ing Schools for Nurses, Wald said that “among
the many opportunities for civic and altruistic
work pressing on all sides nurses having superior
advantages in their practical training should not
rest content with being only nurses, but should
use their talents wherever possible in reform
and civic movements” (Wald, 1900, as cited in
­Birnbach & Lewenson, 1991, p. 318). In keep-
ing with her beliefs, Wald and her colleagues at
Henry Street introduced several legislative ini-
tiatives that would improve the health of chil-
dren, such as the introduction of nurses in public
schools (Wald, 1915). Wald (1915) described how
she advocated for hiring nurses in the local pub-
lic schools to decrease truancy rates, given that
children were sent home due to illness and lack
of treatment. As of 1897, physicians had only
recently been hired by the New York City De-
partment of Health to assess children in school.
Doctors sent children home from school when
any contagious illnesses were found. However,
this did not address some of the pressing health
issues because the physicians did not provide
treatment for conditions such as trachoma, a
contagious eye infection that plagued school-
age children at the time. Wald (1915) wrote
about her experience convincing legislators of

the value of assigning public health nurses in the
schools in her book The House on Henry Street.
In 1902, when a reform administration
came into power, the medical staff was reduced,
the physicians’ salary was increased to $100 per
month, and they were expected to work only
3 hours per day. The health commissioner or-
dered an examination of all public school pu-
pils and was horrified to learn of the prevalence
of trachoma. Thousands of children were sent
away from school because of this infection.
Where medical inspections were the most thor-
ough, the classrooms were empty. It was ironic
that Wald watched the children who had been
turned away from school playing with the chil-
dren they had been sent home to protect. Few
children received treatment, and it followed that
truancy was encouraged:
The time had come when it seemed right
to urge the addition of the nurse’s service
to that of the doctor. My colleagues
and I offered to show that with her
assistance few children would lose their
valuable school time and that it would
be possible to bring under treatment
those who needed it. . . . I exacted a
promise from several of the city officials
that if the experiment were successful,
they would use their influence to have
the nurse, like the doctor, paid from
public funds. Four schools from which
there had been the greatest number
of exclusions for medical causes were
selected, and an experienced nurse,
who possessed tact and initiative, was
chosen from the settlement staff to
make the demonstration. . . . Many of
the children needed only disinfectant
treatment of the eyes, collodion ap-
plied to ringworm, or instruction as
to cleanliness, and such were returned
at once to the class with a minimum
loss of precious school time. Where
more serious conditions existed the
nurse called at the home. (Wald, 1915,
pp. 51–52)
Advocacy and Public Health Nursing 7
Within 1 month, the experiment was deemed
successful, and an “enlightened Board of Esti-
mate and Apportionment voted $30,000 for the
employment of trained nurses, the first mu-
nicipalized school nurses in the world” (Wald,
1915, p. 53). School nursing continues to be a
concern for those interested in political advo-
cacy to improve the health of our young and
vulnerable populations. Historian Mary G­ ibson
(2017) writes that:
Today’s philosophy still reflects the pro-
tective and hopeful beliefs of leaders in
education of 100 years ago concerning
the influence of child health on our
nation’s future. . . therefore, keeping
children in school, healthy and ready
to learn, is a universal goal throughout
the United States. (p. 37)
Advocacy in the Town & Country
Wald’s advocacy extended to families living in
rural settings. One of the most compelling ex-
amples is the establishment of the American
Red Cross Rural Nursing Service (later known
as the Town & Country). As Keeling and Lewen-
son wrote (2013), this organization “served as
the point of contact for families in rural com-
munities where remoteness, isolation, and fewer
physicians and nurses created barriers to care”
(p. 362). Wald believed that the American Red
Cross—already organized to provide nursing ser-
vices during wartime and natural or manmade
disasters—was the right vehicle in which to or-
ganize public health nursing services throughout
the country during peacetime (Dock, Pickett,
Clement, Fox, & Van Meter, 1922; Keeling &
Lewenson, 2013). Through Wald’s influence,
philanthropists supported the implementation
of this new rural public health nursing service.
During the first year, criteria were established for
nurses who would collaborate with community
leaders, physicians, and families to provide both
curative and preventive health care in rural set-
tings. The requirements to become a rural pub-
lic health nurse were far reaching and included
8 Chapter 1 Nursing’s History of Advocacy and Action
pragmatic skills. Nurses were expected to ride
a bicycle or a horse, or drive a car so that they
could access their patients.
© fotorobs/Shutterstock
More important, and often difficult to find,
were nurses who had an education that prepared
them to negotiate and collaborate with others in
the community. Typical nurses’ training programs
did not provide these skills. It was determined that
a minimum of a 4-month education was needed
to prepare nurses to work independently in com-
munities across America (American Red Cross
Rural Nursing Service, 1912–1914). Educational
programs were established, like the one at Teach-
ers College in New York, in conjunction with the
Henry Street Settlement and the rural District
Nursing Service of Northern Westchester, soon
after the American Red Cross Rural Nursing Ser-
vice formed. By 1914, the new public health nurse
curriculum offered courses in sociology, munici-
pal and rural sanitation, and experiences in rural
and urban public health settings. These courses
were valuable for nurses who practiced in rural
settings because they did not have the same sup-
port systems as urban areas.
Black nurses faced barriers to attending
some of these early public health courses and,
as a result, contributed to few entering this ser-
vice. Frances Elliot Davis, a graduate of the Freed-
man’s School of Nursing in Washington, DC, did
attend the 4-month program at Teachers College
and was admitted as a Town & Country nurse in
1917. She was considered the first black nurse to
be admitted into the American Red Cross (Hine,
1989; Lewenson, 1993). Influenced by the return-
ing soldiers and the influenza pandemic in 1918,
Davis, along with other black nurses, were finally
accepted into the American Red Cross reserves
at the end of World War I. The bias of the mili-
tary and, subsequently, the American Red Cross,
reared itself in several ways. One of the most bla-
tant ways was the designation of race on each of
these nurses’ badges, separating them from their
white colleagues. Frances Elliot Davis received
her badge with the number 1-A inscribed on the
back. This was one way the Red Cross that served
as the gatekeeper into the Army Nurses Corps
could maintain the practice of segregated living
quarters and segregated health care. The National
Association of Colored Graduate nurses advo-
cated changes in these practices that eventually
ended by mid-20th century (Lewenson, 2017).
Wald’s advocacy extended to the use of me-
dia to show the public what a rural public health
nurse could do and to garner support for the
initiative. While she was at the third meeting
of the American Red Cross Committee on Ru-
ral ­Nursing—the committee established by the
American Red Cross in 1912 to develop the cri-
teria for the Town & Country—Wald suggested
that the committee “get in touch with the Publi-
cation Syndicate, and Rural Nursing written up
possible [sic] in story form for the Ladies’ Home
Journal and other popular magazines” (American
Red Cross Town & Country Nursing Service, 1913,
p. 2). At the same meeting, it was noted that Wald
and others supported establishing a relationship
with the Metropolitan Life Insurance Company

and the Steel Corporation whereby the Rural
Nursing Service would “undertake nursing for
these large concerns” (American Red Cross Town
& Country Nursing Service, 1913, p. 4). Many of
the communities in question were rural mining
communities that required public health nursing
services. The committee believed this relationship
would be beneficial in many ways, including pos-
sibly raising the standards of other nursing asso-
ciations and economically supporting the cost of
nursing supervision in these locations.
Advocacy took many forms, which ranged
from sitting on national committees to seeing
that care was provided at local levels. The work
of the public health nurse was framed by the
needs of the community, the kinds of public
healthcare organizations that were organized,
and the geographical location. Each Red Cross
rural nurse chapter—whether in the moun-
tains of New Hampshire, in Kentucky, or in the
West—directed the kinds of work that public
health nurses would do, including bedside care
for frostbite, well-baby clinics, school nursing,
industrial nursing, classes in home hygiene and
care of the sick, advocacy on town boards, and
educational and publicity efforts about their work
(Fox, 1921). Sometimes there was only one pub-
lic health nurse in an area. At other times, pub-
lic health nurses shared a district. Sometimes a
nurse faced barriers by communities that were
uncomfortable with outsiders offering care. The
success of these American Red Cross Town &
Country nurses relied on the ability to recruit and
retain those who could handle the challenges of
rural settings. This concern remained a constant
and enduring problem throughout the life span
of the American Red Cross Town & Country.
▸▸ History and Political
Advocacy
Political advocacy requires the depth and breadth
of an evolving historical narrative to inform con-
temporary debates in health care, to reflect the
variety of perspectives that history can bring to
History and Political Advocacy 9
the debate, and to offer a “way to think about the
future” (Fairman & D’Antonio, 2013, p. 346). The
work of the nurses at the Henry Street Settlement
and the American Red Cross Town & Country
gives two examples that can stimulate discussions
about healthcare reform today. Readers are en-
couraged to explore the many historical studies
being completed and the early writings of nurses
that can be found in nursing journals, such as
the American Journal of Nursing. This journal
has digitalized its entire collection from 1900
to the present, allowing readers to access arti-
cles online and explore nursing advocacy over
time. The American Association for the History
of Nursing (AAHN) (www.aahn.org) also pro-
vides information and resources for where one
can go to find nursing archives, learn more about
historical methods, and attend the association’s
annual meeting where the latest in historical re-
search is presented. The AAHN also publishes a
well-respected journal, Nursing History Review,
where readers can find outstanding historical
research by leading historians. There are also
many archival centers around the country, such
as the Barbara Bates Center for the Study of the
History of Nursing at the University of Pennsyl-
vania and the Eleanor Crowder Bjoring Center
for Nursing Historical Inquiry at the Univer-
sity of Virginia. Centers such as these provide
a wealth of archival data and support for those
interested in historical research. The websites
for these centers and other resources are avail-
able on the AAHN website.
Nursing’s Political Advocacy
and Action
The next part of this chapter moves from the
historical to the contemporary and further ex-
plores the meaning of advocacy and action, as
well as what that means for nurses, the profes-
sion, and the health of the public. Today nurses
must be politically active in professional nursing
practice and health policy issues like the nurse
reformers and activists before them. Nurses who
can purposefully and effectively contribute to
10 Chapter 1 Nursing’s History of Advocacy and Action
shaping public policy at the national, state, and
local levels serve both the public and the profes-
sion by advancing the nation’s health and pro-
fessional practice. Nursing’s historical roots in
important advocacy and action have shaped
the profession’s political astuteness and work to
keep pace with professional regulatory, s­ tatutory,
and legal changes in education, practice, and
research. The profession must remain nimble
and responsive to policy changes by promoting
and protecting the well-being of the population
and nurses themselves. How can nurses have a
profound influence on health outcomes? The
answer is simple: We cannot afford not to. As
long as the United States lags behind other de-
veloped countries in care outcomes, despite the
fact that the U.S. spends more on health care—
$3.2 trillion in 2015, up 5.8% from the year be-
fore (Centers for Medicare & Medicaid Services
[CMS], 2015)—nurses need to advocate and act
to promote health, prevent disease, and eliminate
health disparities. Access to affordable, quality
health care is a basic human right for all peo-
ple (Daley, 2012).
In 2010, Institute of Medicine (IOM), now
known as the National Academies of Medicine,
published its report, The Future of Nursing, which
offered a blueprint for how the nursing profes-
sion should advocate to improve the health of
the nation, lead change in healthcare delivery,
and increase the educational preparation of the
nursing workforce. This blueprint is evidence
on how nurses uphold the dignity and well-­
being of society by revolutionizing how nurses
can be change agents and leaders in develop-
ing healthcare delivery systems that will address
health disparities and the social d
­ eterminants of
health like education, p ­ overty, transportation,
and housing.
To effectively manage the ever-evolving
healthcare delivery system, as well as the emerg-
ing needs of populations and the profession, ev-
ery nurse must understand and appreciate his
or her role in advocacy. Advocacy is the ability
to use one’s voice and position to address, sup-
port, and protect the rights and interest of an-
other (Zolnierek, 2012). The American Nurses
Association suggests that high-quality nursing
practice include advocacy as an essential aspect
of patient care (ANA, n.d.). Advocacy is consid-
ered both a philosophical principle of the profes-
sion and a part of ethical nursing practice that
ensures that the rights and safety of the patient
are protected and safeguarded. Advocacy is the
one professional construct that demonstrates a
complex interaction among nurses, patients,
professional colleagues, and the public (Se-
landers & Crane, 2012). It is important to note
that patients have rights and nurses have a le-
gal and moral obligation to protect those rights.
As patient advocates, the ANA Code of Ethics
for Nurses with Interpretive Statements (2015)
offers nurses a moral framework to help shape
their values to direct and influence actions so
as inspire their advocacy.
From the classroom to the bedside to the
boardroom, nurses can leverage their professional
expertise to provide the critical knowledge and
analysis to transform public health policy and
nursing practice. As stakeholders who are well
prepared to engage in the policy-making pro-
cess, nurses must stand ready to respond to an
array of healthcare reforms confronting the na-
tion’s delivery system by being full partners, with
physicians and other healthcare professionals,
in redesigning health care in the United States
(IOM, 2010). Just as our “foremothers” before
us, and in some cases fathers as well, nurses of
the 21st century have an integral role in shaping
and advancing policy solutions at a time when
there is tumultuous political climate and a health
care environment that may not clearly under-
stand the values and contributions of nurses and
nursing practice.
Berkowitz (2017) recently described how
important the need is for nurses to inform con-
sumers about what nursing care is, including
why and how it prevents illness, manages symp-
toms, treats disease, and transforms the health
of communities. Nickitas and Ferguson (2017)
note how critical it is to advocate for and ensure
that nurses globally can practice to the full scope
of their education and licensure, have equal op-
portunities for career development, and practice

in work environments that are free from vio-
lence, harassment, and discrimination; these
concerns are essential in today’s and tomorrow’s
healthcare delivery system. To become engaged
in advocacy, and to set the agenda for human
resources and nursing resources for health care,
nurses must be at the forefront of policy engage-
ment, dialogue, and implementation. This en-
gagement requires sound evidence and a political
strategy that allows for increased understand-
ing of the potential impact of linking the nurs-
ing workforce with the globalization of health
care, to ensure dignified and respectful health
care for all persons, regardless of sexual orien-
tation or gender identity (Nickitas & Ferguson,
2017). The demands for increased access and
better healthcare outcomes will require nurs-
ing to widen its influence in policy areas that
address the health and healthcare needs of un-
derserved and minority populations (Villarruel,
Bigelow, & Alvarez, 2014). Nurses are essential
healthcare providers and make significant con-
tributions to the body of knowledge of improv-
ing health and health care in the United States.
One way nurses can impact the nation’s health
is to meet the 21st-century challenge of pop-
ulation health management and population
health. To meet this challenge, the Robert Wood
Johnson Foundation (RWFJ; 2015) has com-
mitted to advancing a national initiative called
the Culture of Health by addressing key social
determinants of health and empowering sup-
port mechanisms to help people live healthier
lives. A Culture of Health involves creating in-
creased collaboration among healthcare systems.
For community organizations, this means mak-
ing health a shared value, creating healthier and
more equitable communities, and strengthen-
ing the integration of health services and sys-
tems (Martsolf et al., 2016).
As political advocates, nurses are uniquely
positioned to lead system change to improve care
for populations and contribute to a Culture of
Health in their communities by focusing on the
patient and family-centered care. Nurses natu-
rally view their patients holistically and seek to
include all aspects of family, community, and
Nursing Strong 11
work environment in their care (Smith, 1995).
By strengthening the protection of human rights
and health equity, and promoting a Culture of
Health, all can prosper and thrive. The next sec-
tion of this chapter discusses how nurses will
continue to amplify their voices and advocate
to meet the changing landscape of health care.
▸▸ Nursing Strong
Professional nursing care is essential to the
healthcare system. Of the more than 3.6 million
licensed registered nurses (RNs), approximately
84.7% are employed in nursing (62% in hospitals),
and approximately 10% are employed in primary
care or home care (U.S. Department of Health
and Human Services, 2010, 2013), making reg-
istered nursing the largest healthcare profession
(ANA, n.d.). As such, nurses must advocate by
bringing problems to the government and seek
decisions in the form of programs, laws, regu-
lations, or other official responses that create
innovations and care models to transform the
delivery and advance the nation’s health.
To begin, nursing must advocate for changes
within the profession. To successfully advance
health care, the nursing profession must make
significant strides to change the composition of
the future workforce. This will require greater
efforts toward the successful recruitment of
underrepresented minorities into n ­ ursing.
­Calculations of data from the U.S. Census
­Bureau (n.d.) reveal that the ­current RN work-
force ­remains primarily f­ emale; the percentage
of men in the workforce has ­increased to 12%
from only 9% in 2001. Nurses from minority
backgrounds represent 24% of the RN ­workforce.
Considering racial/ethnic backgrounds, the
RN population is composed of 75.8% white,
11.5% black or African ­American, 4.8% His-
panic or Latino, 5.8% Asian, 0.5% American
Indian, 0.028% Native Alaskan, 0.2% Native
­Hawaiian/Pacific ­Islander, 0.1% Other Native,
and 1% multiracial background (DATAUSA,
2018). The profession must do better to ensure
that future nurses mirror the patient population
12 Chapter 1 Nursing’s History of Advocacy and Action
for which they will provide nursing care. The
recruitment of indivdiuals from underrepre-
sented groups in nursing—­specifically men
and individuals from African American, His-
panic, Asian, American Indian, and ­Native
Alaskan backgrounds—is a major priority for
the ­nursing profession.
There is a moral imperative to achieve eq-
uity and diversity, which involves increasing
underrepresented groups in nursing, embrac-
ing the policy process, and creating a cultur-
ally and linguistically diverse care environment.
A diverse healthcare workforce increases both
minority participation in the health professions
and a commitment towards cultural compe-
tency in the treatment of all patients. A U.S.
Department of Health and Human Services
report (2006) ­reveals that increased diversity
among healthcare professionals leads to im-
proved patient satisfaction, improved patient–
nurse communication, and greater access to
care for racial and ethnic minority patients who
are best served by providers who are knowl-
edgeable about their backgrounds and cul-
tures. ­Increasing workforce diversity, ensuring
fair and equal access to quality health care and
healthcare resources, eliminating health dis-
parities, and achieving health equity is where
nursing’s political advocacy and action upholds
the dignity of all people through our actions
and our words. The U.S. Department of Health
and ­Human ­Services and Healthy People 2020
(2013) define health equity as the attainment
of the highest level of health for all people.
Achieving health equity for all requires
a collective effort across all disciplines and
all sectors, including those outside nurs-
ing. Therefore, nurses must align themselves
with other healthcare professionals to address
health disparities and health equity, specifically
within the context of the social determinants
of health. As an interprofessional healthcare
team, all professionals must “draw upon their
moral responsibility to respond to human
suffering and become acknowledged partici-
pants in the nation’s efforts to correct health
disparity” (Harrison & Falco, 2005, p. 261).
Fostering interprofessional education and prac-
tice builds the health team’s capacity to view
high-risk vulnerable and underserved pop-
ulations as a moral imperative and, as such,
bring important perspectives to designing and
­delivering health services that are transforma-
tive to ­improving health, lowering costs, and
increasing patient satisfaction.
To address care gaps and avoid service du-
plication, improve the quality of patient-centered
care, and control costs within and across set-
tings, nurses must understand and interpret
legislation and health policy. By being able to
interpret healthcare reform from a nursing per-
spective, nurses can determine how to best dis-
tribute resources to individuals, families, and
populations. For example, chronic disease is
the central healthcare problem in the United
States and is the leading cause of disability and
death in the United States (Centers for Disease
Control and Prevention, 2015; Miller, Lasiter,
­Bartlett Ellis, & B­ uelow, 2015). In fact, nearly
one in two A ­ mericans suffers from chronic con-
ditions such as diabetes, arthritis, hypertension,
and kidney disease; these account for 7 of 10
deaths among Americans each year and 75%
of the nation’s healthcare spending (Conway,
Goodrich, Macklin, Sasse, & Cohen, 2011). The
obesity epidemic and growing levels of prevent-
able diseases and chronic conditions greatly
contribute to the high costs of health care.
Additionally, an aging population has in-
creased the demand to address end-of-life care
in a cost-effective manner (Rice & Betcher,
2010). Because chronic disease remains the pri-
mary healthcare problem in the United States,
nurses can lead change to improve the healthcare
system at the population level (Lathrop, 2013;
Miller, ­Lasiter, Bartlett Ellis, & Buelow, 2015).
As skilled researchers and clinicians, nurses are
in key positions to advocate, lead, and partic-
ipate in interprofessional initiatives, commu-
nity ­coalitions, and policy enactments. Being a
nurse advocate means joining the ranks of the
nation’s care decision makers in order to become
full partners in redesigning health care (IOM,
2011; Peltzer et al., 2015).

▸▸ Conclusion
The concepts of advocacy and action serve as a
reference and model for the future, demonstrat-
ing that all nurses can develop their influence
and policy acumen to equip themselves with
the knowledge and tools needed to serve the
profession, healthcare organizations, and soci-
ety. As the nursing profession reflects upon its
historical roots in advocacy and action, nurses
will strive to find innovative ways to advance
the nation’s health to reshape healthcare de-
livery, policy, and payment. These innovations
must address the key social determinants of
health that will empower and support all peo-
ple to lead healthier lives.
Developing competencies in advocacy and
action requires a clear understanding of how to
create healthier and more equitable communi-
ties as well as strengthening health services and
systems, creating diverse policy solutions, and
building a consensus for evaluating policy solu-
tions. For those who are just beginning to learn
the advocacy process, it is important to recog-
nize that there will always be divergent views
around policy solutions, but the best solutions
are those where diverse viewpoints are always
heard, considered, and reflect consensus.
With over 3 million strong, nurses have pro-
vided evidence and reasoned solutions to health-
care problems. This chapter has addressed how
nurses have had a long and vital history of ad-
vocacy and social action. It is through this ef-
fort towards improving health outcomes for
individuals, families, communities, and popu-
lations that nurses are a valuable link to educate
policymakers about health issues and promote
policies to address contemporary public health
issues. These issues include public health and
emergency preparedness, food safety, hunger
and nutrition, climate change and other envi-
ronmental health issues, public health infra-
structure, disease control, international health,
and tobacco control (American Public Health
Association, 2017).
Fairman and D’Antonio (2013) note that
“nurses successes in moving policy forward will
References 13
depend on their ability to give voice to a his-
torical perspectives that recognize the political
and contextual forces that shape health care and
place nursing at the center of long-standing de-
bate about health services delivery, knowledge
formation, patient safety, technology and edu-
cation for practice” (p. 351). To design and de-
liver health services that are transformative in
the direction that our nation needs at this mo-
ment in time, we must remember how nursing’s
historical influences of the past shape our ad-
vocacy and actions of the future.
Discussion Questions
1. How does history inform nursing’s efforts
to provide primary health care?
2. What is the relevance of nursing’s history
to political advocacy today?
3. Describe the role of advocacy within the
history of nursing’s development in the
United States.
4. Select a community or population with
which you could become a full partner
in re­designing and improving health out-
comes to address a contemporary public
health issue impacting this community
or population, such as access to care,
transportation, water safety, pollution,
or gun safety.
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 16 Chapter 1 Nursing’s History of Advocacy and Action
CASE STUDY
Strength Is in Coalitions
Pennie Sessler Branden
CASE STUDIES
Purpose of the Case Study
The purpose of this case study is to describe
an exemplar where nursing advocacy can be
more effective through strong coalitions and
partnerships.
The Case Study
Breast cancer is the second most common form
of cancer in women and is the second leading
cause of cancer deaths. According to the American
Cancer Society (ACS) (2017) breast cancer will affect
1 in 8 women during their lifetime and about 1 in
37 women will die of breast cancer. The statistics
show that women of color and those in poverty
have a higher incidence of breast cancer than
white middle- and upper-class women.
Breast cancer screening has been utilized to
diagnose breast cancer early enough to improve
the treatments, interventions, and outcomes
for breast cancer. With 90% of registered nurses
(RNs) being female, the American Nursing
Association (ANA) (American Nurses Association,
n.d.) has educated nurses to better understand
breast cancer risk factors and the importance of
regular screening. Nurses and other healthcare
providers look to the ACS recommendations for
mammogram schedules. These recommendations
have gone through a number of permutations,
but since 2015 the American Cancer Society
recommendations state:
Women with an average risk of breast
cancer—most women—should begin
yearly mammograms at age 45. Women
should be able to start the screening as
early as age 40, if they want to. At age
55, women should have mammograms
every other year—though women
who want to keep having yearly
mammograms should be able to do
so. Regular mammograms should
continue for as long as a woman is in
good health. Breast exams, either from
a medical provider or self-exams, are no
longer recommended. (American Cancer
Society, 2015)
Therefore, women should have mammograms
as desired or as suggested by their healthcare
provider based on their personal medical history
and risk factor(s). This relies on the fact that a
person has health insurance that covers these costs
or is able to go to a free or reduced cost clinic such
as Planned Parenthood (PP) for health care and
screenings. Planned Parenthood and other clinics
rely on funding from the federal government
to assist in the costs for these services. Planned
Parenthood follows the recommendations of
the American Cancer Society regarding breast
self-exam and can refer a person to a medical site
where mammograms are done as needed. Planned
Parenthood may be the only option for a woman
to receive the necessary care for a breast cancer
screening referral. However, if the U.S. Congress
decides to reduce or completely remove funding
to Planned Parenthood, what will those women do
for breast cancer screening?
Congress assesses what monies will go to
what groups and establishments based on a
number of factors, including what is the agenda
of the president and Congress at the time, what is
beneficial for and needed by certain congressional
districts, and other special interests. According to the
American Public Health Association (APHA) (2017)
and other websites, the federal government does
not directly fund Planned Parenthood, but rather
reimburses states that have paid Medicaid bills for
services by such clinics as Planned Parenthood.
According to their annual report in 2015–2016,
Planned Parenthood received 41% of their
operating costs from government health services
reimbursement and grants. With a portion of this
money, Planned Parenthood did 321,700 breast
exams and diagnosed 72,012 incidences of cancer
through breast exams and Pap smears. If PP did not
have this funding, these numbers would probably
be much lower because some women would not
have this care due to the inability to pay for it.
For the past few years there has been a rolling
debate about healthcare access and whether
the federal and/or state governments will fund
the health care needed by the working poor and
uninsured who may not have the funds to pay
for a mammogram. Initially, it seemed as though

the Affordable Care Act (ACA) would reduce
these disparities, and it has. However, some state
governments have found ways to reduce the
potential advantages that the ACA offers. For
example, in New Jersey (NJ), Medicaid funding
for clinics that gave patients family-planning
and well-women care along with referrals for
mammograms was completely eliminated by
Governor Christie in 2010 (Culp-Ressler, 2015).
Christie vetoed those spending bills five times in
5 years. Consequently, between 2010 and 2015,
there was a 25.1% increase in breast and cervical
cancer cases in Latina women in New Jersey. This
was five times higher than women overall in that
state (Culp-Ressler, 2015).
Clearly the elimination of this funding has
affected and will affect overall screening and
care of vulnerable groups unable to pay for these
expensive services. Contrary to this, a mid-July
2017 article by Brodesser-Akner reports that
NJ legislators have enough votes with Democrats
and Republicans together to override a governor’s
veto for $7.5 million for funding to family-planning
clinics, including Planned Parenthood. They believe
that the previous vetoes have significantly reduced
opportunities for NJ women to obtain necessary
health care and that this funding is integral to
improving the health of all NJ women.
New Jersey is just one example of the
ongoing divisiveness that has taken place over
the funding of family planning and women’s
health clinics by state and federal governments.
This is not a new debate but one that has been
in discussion for decades. The American Public
Health Association (APHA) published a policy
statement in 1991 emphasizing that minority
women are at higher risk of death from breast
cancer than white women and that education
and regular screening are integral to the efforts of
healthcare providers to reduce the occurrence of
breast cancer and to improve overall outcomes.
Even with this data-driven information, the federal
government currently wants to eliminate funding
to Planned Parenthood, thus potentially reducing
access to breast exams and early detection of
breast cancer for the millions of women who
utilize these clinics annually. Nurses have been
involved in lobbying efforts to better educate
and assist our representatives to understand the
importance of breast screening for all women
regardless of socioeconomic status. Further, nurses
Case Study 17
have recognized the importance of building
partnerships and coalitions in order to maximize
their efforts and have deliberately partnered with
groups and organizations that support the many
issues that nurses support.
If Congress is only looking at the cost of care
given by Planned Parenthood clinics we must look
CASE STUDIES
at the entire picture of cost of preventive care
versus the cost of breast cancer treatment. With
these statistics, one would think that breast cancer
screening, which can reduce cost and suffering,
would be covered by insurance. The Affordable
Care Act (ACA) covers an annual mammogram,
as do most insurance companies as mandated by
the ACA. The average cost for a mammogram is
$456 (MDsave, 2018). According to a retrospective
analysis by Blumen, Polkus, and Fitch (2016), the
costs of complete breast cancer treatment for
1 year were from $60,637 for Stage I/II treatments
up to $134,682 for Stage IV treatments. Not only
will there be costs for breast cancer care but there
will be potential loss of wages affecting partners
and families in addition to an immeasurable
psychologic toll. This huge disparity in costs for
preventive mammograms and the overall cost for
treatment seems to emphasize the importance
of preventive care over the need to wait and treat
women who get breast cancer. However, with
the potential changes in the ACA and the current
unemployment and underemployment numbers,
what happens to those women who cannot afford
the cost of a mammogram or the cost of insurance?
Blumen and colleagues (2016) report that support
for programs for breast cancer screening need to
be implemented and strengthened to diagnose
breast cancer and begin treatment earlier.
With all of the political wrangling that occurs
over the health and well-being of women, nurses
have become advocates for these issues, and with
their coalition partners have taken to Capitol Hill to
educate their representatives and senators about
the importance of healthcare coverage to include
things like breast cancer screening. To accomplish
this, (1) nurses will continue to educate their
colleagues, patients, and families; (2) nurses will
continue to meet with their representatives on the
state and federal levels; (3) the ANA will continue
to write position statements and nurses will testify
in front of legislators; and (4) nurses need to bring
real stories to their legislators about women with
breast cancer who have benefitted from healthcare
 18 Chapter 1 Nursing’s History of Advocacy and Action
access and insurance, as well as stories where
a person suffered due to lack of access and/or
insurance.
Nurses will continue to advocate for their
patients and what is best for them by enlarging
their reach through coalitions and partnerships.
The Connecticut Nurses Association (CNA) is
CASE STUDIES
guided each year by their Connecticut (CT)
legislative agenda and their prioritization of
issues, which is informed by nurses and their
relationships and partnerships with organizations
across the healthcare and health spectrum.
The CNA regularly engages in advocacy on
health and nursing throughout the year and
during the legislative session. To address the
widespread impact of healthcare reform, the
CNA is actively involved in the campaign entitled
Protect Our Care CT (PCCT) (Connecticut Nurses
Association, 2017). PCCT represents a coalition
of organizations and individuals to support and
represent the health needs of people of CT,
including those who rely on the ACA, Medicare
and Medicaid, and women’s health programs
(personal interview Clear Sandor, 2017). For
example, the CT Senate Bill 586 supported
state Medicaid expansion of health benefits
for children and women (State of Connecticut
General Assembly, 2017). There is a long history of
CNA’s active participation in the state regarding
access to essential services and their partnership
with other groups and coalitions; the CNA
has supported this bill for increased essential
benefits and access to care and members have
been very vocal about this to their legislators
through lobbying efforts, letters, etc. Although
the bill does not increase funding for or access to
breast screening mammograms, it does mandate
breast cancer counseling, genetic testing, and
risk assessment. In the future this bill could be
expanded to include mandated mammograms
no matter what a person’s insurance status is. This
is an example of the impact of indirect action
by multiple groups, including nurses, in strong
coalitions. The CNA works collaboratively with
its coalitions to strategically exert its influence
and increase its voice on multiple healthcare
issues that affect women. Coalition building is a
key piece of being heard and getting legislation
passed. Coalitions have provided nurses with a
strong voice and enhanced their ability to provide
high-quality, safe care.
Summary
This case study is one relevant example of the
potential for possible negative outcomes related
to decreased funding by governmental agencies;
it also delineates the potential positive outcomes
that are achieved with partnering, collaboration,
and coalition building. Even though the issue of
continued funding for Planned Parent clinics is
not addressed directly, successes can be made
incrementally that will increase support of
important healthcare programs moving forward.
Advocacy, in order to influence policy,
is best operationalized through partnerships,
collaboration, and coalitions. Although someone
in power, such as Governor Christie, can veto a
bill to reduce funding to a particular group, the
representatives in the New Jersey legislature can
introduce bills that can, with a bipartisan majority,
override a veto by the governor. Similarly, the
Connecticut Nurses Association maximizes its
efforts through collaborating and partnering
with various groups to form strong influential
coalitions that can educate legislators about all of
the pieces of breast cancer prevention and care.
The combined efforts, along with the increased
numbers of individuals actively participating in
the process, enhances the work of lobbyists, who
in turn influence the policymakers. The overall
consequence is the increase in the voice of the
public that influences the outcomes. This influence
enhances the possibility of providing more
adequate healthcare services to all citizens.
Case Study Questions
1. This case is a good example of nursing
power through building partnerships and
coalitions that have similar missions. Can
you identify two coalitions that your state
nursing association actively works with? Can
you describe the policy issues that these
coalitions address?
2. Successful advocacy is best defined as
moving toward the ultimate goal(s) in a
positive, substantive manner. Explain what
advocacy you have done, besides direct
patient advocacy, to support health care in
your nursing specialty.
References
American Cancer Society. (2015, October 20). American Cancer
Society releases new breast cancer guideline. Retrieved from
Another random document with
no related content on Scribd:
 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN