EDITORIAL

Chronic Illness: ‘‘Chronic’’Boredom

As usual, I had been leafing through old volumes of thefirst Public Health Nursing, thinking about the past andwondering what the future holds. I’d gotten to the yearsafter World War II when I began to notice an increase innumber of articles related to chronic disease. They weredifferent from the optimistic, chatty descriptions of thework of public health nurses that characterized the firstthree decades of the journal. The content of articlespublished between 1947 and 1952 (when the NationalOrganization for Public Health Nursing merged with theNational League for Nursing and the first Public HealthNursing was integrated into the new journal, NursingOutlook) started to focus more on dealing with chronic-ally ill individuals in the community. Most authorsprovided tips for direct care for visiting nurses; a fewaddressed the organization of nursing care within visitingnurse agencies and public health departments.

Fatalism about chronic illness care as a part of publichealth nursing was illustrated in a fictional exchange inwhich one nurse supervisor asks another, ‘‘What are youdoing about your chronic case load?’’ The other shrugs,sighs, and responds, ‘‘Well, what is there to do about it?’’(Phillips, 1947). The author enumerated reasons whypublic health nurses needed to know and care aboutchronic illness. The health care landscape was changing,particularly in the postwar period when new technologieswere evolving and the Hospital Survey and ConstructionAct of 1946 had just begun to expand the capacity ofinstitutional care for people who had previously relied onin-home services. Demographics were changing, too.More people were reaching old age, giving impetus tothe nascent fields of gerontology and geriatrics. Unfortu-nately, Phillips noted, public health nurses, like theircounterparts in hospitals, avoided working with oldpeople and chronically sick or disabled individuals.Nurses found these ‘‘cases’’ boring and unchallenging.The rewards were negligible, ‘‘picking up the pieces’’ of

lives. Public health nurses of 1947 wanted drama—pa-tients wrested from the clutches of communicable disease,for instance—just like their hospital-based sisters.

Fast forward to 2003. Drama has been abundant thisyear, and nurses have played a definitive role inresponding to new health challenges. Despite our atten-tion to the acute outbreak of Severe Acute RespiratorySyndrome, the continuing threat of bioterrorism, andthe effect of the war in Iraq, the most costly healthproblems in the United States are the result of chronicdiseases. We have come a long way and, sadly, also havenot gone far.

Attacking the problem of chronic illness in Americapresents us with a set of challenges that is complex anddifficult to disentangle, especially when we focus onimproving outcomes for populations. Chronic healthproblems provide ample opportunity to engage in pri-mary, secondary, and tertiary preventive measures thatuse our nursing strengths. The equation for changinghealth status is not straightforward, though. Social,political, and economic variables influence our results.There is growing evidence that, across countries andhealth care systems, poor people die younger and aresicker than rich people and that there is a consistentgradient between wealth and health (Deaton, 2002;Marmot, 2002). Wealth is also a marker for somethingmore significant to health than actual income. Individualchoices are constrained by education, circumstance, andsocial position or rank. Marmot’s Whitehall I and IIstudies of British civil servants provide evidence thatsocial participation and control over life are powerfuldeterminants of health (Easton, 2003). Deaton observesthat, since the poor don’t have much wealth to spend,they use the capital they have, health—forcing a trade-offof long-term health for another more-immediategood—feeling in control. Behavioral change is not simpleand is seldom governed by pure rationality.

Public Health Nursing Vol. 20 No. 4, pp. 250–251

0737-1209/03/$15.00

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We need to pay attention and add to this on-goingdialogue about wealth, social position, and health out-comes, because we are on the front lines implementingsociety’s health care mandates. Disparities in health statuspersist, even when more money is allocated to programsdesigned to correct inequalities of access. Whole groupsof chronically ill people remain systematically marginal-ized. These are daunting obstacles to surmount in publicpolicy, in health services design, and programmatically,and we have the knowledge and the vision to help bringabout change. If this is boring, 1947 is just over there, onthe shelf.

Sarah E. Abrams, Ph.D., R.N., B.C.Assistant Professor of Nursing

University of VermontBurlington, VT

REFERENCES

Deaton, A. (2002). Policy implications of the gradient of healthand wealth. Health Affairs, 21(2), 13–30.

Easton, J. (2003). Survival of the richest. University of ChicagoMagazine, 95(4), 32–37.

Marmot, M. G. (2002). The influence of income on health:

Views of an epidemiologist. Health Affairs, 21(2), 31–46.Phillips, E. C. (1947). Chronic illness and the nurse. Public

Health Nursing, 39(2), 87–91.

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