Trenches of Medicine : Public Health Nurses Play Key Role in the Prevention of Disease

From the moment Sherry Ceccanese met him, she knew something was wrong.

Ceccanese, a county public health nurse, had knocked on the door of the North Park apartment in search of another client. But the stranger who answered seemed to need help as well. He was recently widowed, he said, and was raising his two toddler sons alone. Look at them, he demanded--weren’t they doing great?

Ceccanese didn’t think so. The barely furnished apartment contained no toys other than a tiny piano that the children poked at listlessly when asked to play. One boy had a cleft lip in need of repair. But the man refused repeated offers of health services--anything that Ceccanese couldn’t do in the apartment, he didn’t want done at all.

“I just had to wonder: Were these kids his?” said Ceccanese, who acted on her hunch and called the police. Soon, her suspicions were confirmed: the boys had been missing for a month, an officer told Ceccanese later, kidnaped from their Escondido home by their estranged father who was suspected of molesting them. Within hours, they were reunited with their mother.

Although hardly an every-day event, Ceccanese’s story shows how unpredictable--and how vital--public health nurses’ work can be. Providing free services in unfamiliar terrain, often speaking more than one language, these nurses meet patients on their own turf. They are not social workers--they do not have the authority to mandate care. But the community is where they do their best work, combining teaching and detective work to help their clients stay well.

When a teen-ager came down with malaria in Oceanside earlier this month, public health nurses visited the family to determine how the illness was contracted. When the county’s measles epidemic hits new highs, it is PHNs, as Ceccanese and her colleagues are called, who sound the call to immunize San Diego’s children. When a baby is born prematurely, these same nurses visit regularly with the parents, teaching them to watch for developmental delays.

Traveling from downtown hotels to uptown condominiums, from houseboats in Point Loma to migrant camps in North County, PHNs are widely regarded as the county’s front lines of disease detection and prevention. But every year around this time, many joke that, instead of measuring their clients’ blood pressure, they are worried about their own.

“Each budget year, public health nurses are always vulnerable to budget cuts, and even this year the budget is still unsettled,” said Betty Ann Collins, San Diego County’s chief public health nurse. “We never rest easy.”

As yet, it is unclear how much state funding San Diego County will receive this year, according to Bob Lerner, the county spokesman. But, regardless of the overall total, he said, a recent court order requiring the county to reduce jail crowding will mean even more belt-tightening than expected. On Sept. 11, the Board of Supervisors is scheduled to decide “what programs we abandon,” Lerner said.

With the specter of cuts, PHNs are realistic about their chances.

“When times are tight, money goes to the visible problem. Public health is oftentimes invisible,” said Rose Marie Fox, one of the county’s eight supervising public health nurses, who has heard the arguments against funding her programs. “They say, ‘Look at all these people--they’re doing fine. They don’t need you.’ ”

It is the nature of the work: The more effective PHNs are, the more unnecessary they appear. Charged with teaching their patients how not to get sick, they often find their accomplishments difficult to measure. How do you estimate how many fewer drownings have occurred because of PHNs’ parent safety lessons? Is it possible to quantify the neglect and abuse PHNs prevent by counseling troubled families?

One thing, however, is easy to measure: San Diego’s PHNs are spread thinner than ever.

In 1923, when 130 PHNs first ventured into county, they served roughly 112,000 residents. Since then, as the county population has grown 20 times over, the public health nursing staff has been cut nearly in half. Today, 71 PHNs serve the county’s 2.5 million residents, fielding more than 13,000 requests for services each year.

“We have so few nurses to meet so many needs,” said Collins, whose staff now limits its cases to those of highest priority--mostly those related to mother-child health and communicable diseases. “However, almost everything we get is of a high priority--a woman who has not had access to prenatal care, a premature infant, possibly a drug-exposed infant, the gamut of child abuse and neglect cases . . . . “

The list goes on, and Ceccanese, like each of her co-workers, seems to have seen them all. With 80 or so families on her caseload at all times, she meets psychotic mothers and retarded mothers, AIDS babies and crack babies. Recovering tuberculosis and measles patients are regular stops on her daily rounds--a loop that takes her into the homes of wealthy businessmen and Navy wives, gang members and drug addicts.

The job can be dangerous. Ceccanese has been confronted by bullying boyfriends. She has had clients who keep guns by the door, and been in one home where an acrid odor betrayed the presence of a methamphetamine lab. Twice, she has discovered 10-foot pet pythons slithering around the homes of newborn babies.

Her experience is not unique. Another PHN dropped by a client’s home unexpectedly and found the door ajar. When she stuck her head in and called the person’s name, she was yanked into the room by a police officer. She had walked into the middle of a drug bust, and only her county ID badge pinned to her blouse convinced law enforcement officers that she wasn’t a customer.

Ceccanese acknowledges the risks--she owns a canister of Mace and has an alarm and a steering wheel lock on her car. But she describes her career as rewarding, not frightening. Eleven years ago, when she made the decision to become a PHN, she had worked as a hospital nurse for five years--an experience that left her well-trained, but frustrated. More often than not, she had been haunted by the feeling that she had reached the patient too late.

“I’d be taking care of a diabetic who just lost their foot, and I’d think, ‘If I only could have found them earlier,’ ” she recalls.

Making the switch to preventive nursing had financial consequences. Although PHNs must have more training than registered nurses, they are usually paid less.

At top scale, a San Diego County PHN makes less than $40,000 a year, according to Michele Molotsky, a union organizer at the California Nurses Assn., which is making a bid to represent the county’s 400 nurses in collective bargaining. Since January, those nurses--who include PHNs, juvenile hall nurses and mental health nurses, among others--have been working without a contract, having rejected the county’s offer of a 5% raise.

“Compare the wages of San Diego nurses to those of other counties, and they’re really inadequate,” Molotsky said. “People count on the dedication they feel to their jobs. But it’s very hard work.”

Indeed, the PHN is charged with evaluating a client’s environment as well as their illness--what Fox calls “filling in the blanks” of a person’s health profile. As PHNs get to know their patients, they find medical care is only part of the solution.

“Maybe (the patient) is required to take showers as part of their treatment. But do they have a shower? They may be living in a garage,” Fox said. “Maybe for religious reasons, they don’t want to take medicines. You don’t find some of this out until you go into the home.”

Collins agreed, noting that the PHNs must often help people find other services before they can focus on their health.

“It’s real difficult to talk about the importance of bringing an infant in for immunizations when there’s no food in the house,” she said. “Before they’re interested in following through with prevention, you’ve got to get them fed.”

So, as well as her baby scale and her files, Ceccanese also carries around a three-ring binder she calls her “resource book.” Inside, she has compiled dozens of telephone numbers and brochures to help connect her clients to hospice care, on-the-job training programs and county welfare benefits.

What she learns from one client she passes on to the next. One AIDS patient told her about Auntie Helen’s, which provides laundry service to people with the deadly illness. When she next saw one of her families with an AIDS baby, she spread the word.

Earlier this week, she heard from the sister of one of her recovering tuberculosis patients. The woman said her brother, a legal immigrant from Honduras, had been mistakenly picked up by the Border Patrol and had no access to his medicine. Ceccanese got the man his pills, which make him noncontagious, and urged his sister to contact a lawyer, who was able to win his release.

Ceccanese’s clients say the best part about her visits is that she is generous with her time.

“Doctors always rush in, rush out,” said Karen Henderson, whose 10-month-old daughter Rebecca was born two months premature. Henderson, whose neat apartment is filled with toys and baby pictures, is not lacking for medical care--she has a pediatrician and, thanks to Ceccanese’s networking, a physical therapist for her daughter. But it is in the privacy of her living room, she says, that she has learned the most about how best to care for her “preemie.”

“It was Sherry who taught me how to tell if she was dehydrated and who told me how much formula to feed her,” Henderson said. “She’s given me a good part of the information I need.”

“When she gets here, we talk her head off,” said another woman who is recovering from tuberculosis and asked that her name not be used. Ceccanese’s visits to her plush apartment overlooking Balboa Park have been a welcome alternative to her hurried doctor’s appointments, she said. “When you know she’s coming, you start thinking of all the questions you didn’t get answered.”

What would be worst about budget cuts, PHNs say, is that they would have less time to spend answering such questions.

“The basis of our jobs is trust,” Fox said. “You don’t develop trust by seeing someone once or twice.”

If nothing else saves PHNs from extinction, Fox predicted grimly, their arch enemy will: infectious disease. Fewer PHNs translates into fewer soldiers in the fight to wipe out completely preventable illnesses like measles. This year alone, San Diego County has had about 900 measles cases--one that resulted in the death of a 10-year-old boy. And if county health officials are serious about combating its spread, Fox said, they will have to turn to PHNs.

“All you need is an epidemic” to remind people of the PHN’s vital role, she said. “It’s awful, but it’s true.”