Sitting on a living room coach in a modest apartment, Linda Malchow holds a sleeping baby boy gently in her arms, counting the short breaths the tiny infant labors to take. When the baby wakes up and begins to cry, the veteran public health nurse notices his panting is growing worse.
This child, Malchow quickly concludes, needs to be seen by a doctor.
But for low-income patients on the rounds of a public health nurse, it's rarely that simple. In this case, there's a foul-up in the Medi-Cal paperwork, meaning that the mother probably can't get the 4-month-old examined at the hospital where he was born.
Malchow has an answer: Take the boy to a community clinic that accepts token payment. If the baby needs a specialist, she assures the mother, he will be referred to the hospital.
"Just make sure he gets to a clinic this week," Malchow says in parting.
Malchow is one of 121 public health nurses employed by Orange County, an exclusive crew specially trained to tackle a wide range of health problems, from tracking and controlling cases of food poisoning and communicable diseases to educating parents in the care of prematurely born babies.
This year marks the 70th anniversary of public health nursing in Orange County. It began when Idabel Durgan, a nurse from Boston, started working in January, 1922, as an assistant health officer, county nurse and dairy inspector. That was nearly a year before the county health department was established.
During her 25-year career, Durgan waged a campaign to clean up the area's dairy farms in an attempt to reduce tuberculosis-causing bacteria in locally produced milk. She is also credited with having almost single-handedly slashing the county's infant mortality rate.
In more modern times, public health nurses must cope with a resurgence of tuberculosis and other diseases spurred in part by the influx of immigrants from Third World countries, overcrowding and poverty.
The nurses' jobs are also becoming more difficult as hospitals release patients earlier to cut costs and as technology enables even the tiniest premature infants to survive, frequently with complications that require specialized care.
Of the public health nurses who work for the county, slightly more than half work in health clinics or a variety of other programs for the elderly, the mentally ill, alcohol abusers or severely disabled children.
The rest, including Malchow, ply their profession on the streets of Orange County, visiting the ill and their families in their homes to make certain that they are getting sufficient care.
"They form the foundation of what public health practice is all about because of their ability to reach out to the community to identify the needs of families and to connect them with the services that are required to keep them healthy," said Dr. Gerald Wagner, the county's medical director for adult and child-health services.
At 49, Malchow, an enthusiastic woman with only a touch of gray in her shoulder-length auburn hair, boasts the longest service among the county's field nursing staff.
She joined the organization in 1964, immediately after graduating from the University of Colorado School of Nursing. Malchow followed in the footsteps of her mother, Maybelle Snodgrass, who was a public health nurse in Orange County from 1959 until 1975.
A couple of decades ago, public nurses were considered among the "elite" of their profession because they were required to have a four-year college degree and state certification, Malchow said. They also worked alone, allowing them to exercise independent judgment to a greater degree.
More recently, many young nurses have been attracted to hospitals for the chance to work with advanced technology, she said.
But that isn't what turns on Malchow and her colleagues. "To me, nursing is people, it is not machines," Malchow said.
On a workday, Malchow loads a sheaf of case folders into the back seat of her Toyota, along with the canvas bag that carries her stethoscope and other tools, including a rattle that she uses to test the hearing of infants. She also hefts along a bright floral tote bag containing a baby scale. And she stocks up on baby formula, which she dispenses to mothers in need.
She wears regular street clothes. Some years ago, the nurses stopped wearing uniforms so as not to embarrass families whose neighbors might erroneously believe that an official visit meant that they had abused or neglected their children.
Malchow, who is assigned to Anaheim, usually handles a caseload of 50 families at a time, down from the 150 families she served in earlier years when the cases were less serious. Children and mothers are often referred to her by hospitals.
"There are a lot of babies sicker than we have ever seen before," Malchow said, noting that babies born prematurely may go home linked to a feeding tube and monitors to track their heart and respiratory rates.
She frequently visits the families of such "high-risk" babies to review cardiopulmonary resuscitation and other techniques that the mothers learned at the hospital and to check the babies' development.
Malchow said she has seen a lot of changes in both caseloads and agency policies since she began her career. "We couldn't even discuss family planning when I started. We went from that point to where we carry condoms in our bags to hand out," she observed with a laugh.
Another change, she said, has been the shift toward a Spanish-speaking clientele. Like many of the county's public nurses, Malchow speaks Spanish, and any new recruits who don't are sent to Berlitz classes.
When she started nursing, Malchow recalled, new drugs to cure tuberculosis were being introduced, raising hopes that the disease would be eradicated. Instead, after a short decline, TB has become prominent again in Orange County, she said.
On a recent afternoon, Malchow visited a Latino family where several members had tested positive for TB to tell the mother that they should go to a clinic for further testing to determine how contagious they are and to obtain treatment.
Tuberculosis, dysentery and even a few cases of leprosy have been brought into the county, Malchow said, by people immigrating from countries with poorer health conditions such as Mexico, Samoa and Cuba. Also, she said, elderly people who have carried TB germs since their youth are getting sick as their immune systems weaken and there is a growing TB outbreak among AIDS patients.
Malchow said she doesn't worry about catching diseases from her patients. About 15 years ago she tested positive for TB, but took drugs that suppressed it. Now she has a chest X-ray every two years as a precaution.
Malchow's job frequently takes her to some of Anaheim's seedier neighborhoods. Sometimes she treks through motels of low repute, looking for mothers and children who often can't be reached by telephone.
Some of the homes, she said, can be smelly and dirty with soiled diapers, cockroaches and swarms of flies. She tries to educate the parents in the importance of hygiene.
When she started in public health nursing, she said, "the poor people had the county hospital and most others were insured."
Now there is no county hospital for the poor in Orange County, she noted, and even many middle-class families can't afford health insurance.
To further complicate matters, public nurses complain that many doctors, including pediatricians, refuse to treat patients on Medi-Cal, the state's public health insurance plan for the poor, because of the paperwork and low reimbursement rates.
Even clinics set up to help the poor operate under regulations that can shut out some of Malchow's families, she said.
"Either they make too much for some clinics or too little for others or the insurance doesn't cover," she said, putting pressure on public nurses to "be creative."
As a stopgap measure, the nurses have established their own clinics to counsel women with high-risk pregnancies until they can enroll in Medi-Cal to pay for a doctor's care, she said.
Malchow said she is also frustrated by "the steady increase in drug-exposed babies." She is hardly making "a dent" in the problem, Malchow said, but there are encouraging individual success stories.
She talked of a 30-year-old mother of three children who was a heroin addict. Malchow said she talked to the woman and learned she professed to be a Christian.
"I told her when all else fails, try God," Malchow recalled.
Apparently it worked.
"She called me a year and a half later and said she wanted me to know she had kicked the drugs and was working to support her children," Malchow said.
Tending the Ill: Public Health Nurses in Orange County
Salary Range: $2,854 to $3,845 a month, plus a bonus of up to $104 a month for bilingual ability.
Education requirements: A bachelor of science degree in nursing.
Duties: Varied assignments in epidemiology, following up on the health of infants born prematurely or with complications, coordinating care of the handicapped and elderly, clinic work, teaching prenatal classes, following up on the health of mothers and infants released early from hospitals after delivery.
Good and bad: No weekend or nighttime assignments. Nurses work independently and have a lot of contact with patients, emphasizing preventive medicine and health education. But the job generally pays lower than nursing positions in hospitals or private home health-care agencies. Less opportunity to work with high-tech equipment.
The future: Orange County is instituting a three-level career ladder to permit public health nurses with special experience or ability to advance to a higher salary level in positions with greater responsibility. It will make the $3,845 top salary--received only by a few "liaison" nurses who coordinate with outside programs--available to more.
Source: Orange County Health Care Agency personnel services