Barbara Shaw
Chicago, Illinois, United States

“Reform can be accomplished when attitudes are changed.”¹
—Lillian Wald

In the teeming tenements of New York City’s Lower East Side in the 1890s, Lillian Wald, a young nurse, came to the aid of a young immigrant girl whose mother was hemorrhaging. She was drenched with blood after giving birth in squalid conditions in a tenement, had been abandoned by her doctor for inability to pay, and lay dying.^1,2,3 This experience, which Wald later described as her “baptism of fire,”^2,4,5 illuminated the profound impacts of the social determinants of health — the non-medical factors that impact health outcomes.⁶ Wald did not merely treat her patients; she sparked a movement that placed nursing at the critical intersection of medicine and society and continues to resonate in the face of today’s challenges.⁷

The birth of community healthcare and public health

Born into privilege in Cincinnati, Ohio, to second-generation Jewish immigrants, Wald could have chosen a life of comfort.^1,3,4 However, her path was profoundly altered when she witnessed a skilled nurse caring for her sister during a difficult childbirth.⁴ Inspired by this experience, Wald set out to study nursing.

Referring to herself as a “practical idealist,”⁴ she committed to creating a more just society. She graduated from the New York Hospital Training School for Nurses in 1889 and supplemented her education by attending the New York Woman’s Medical College the following year. Her subsequent encounters with poverty-stricken immigrant communities during a medical school rotation further exposed her to the devastating effects of poor living conditions on health.^3,4

The settlement house movement

In the late nineteenth and early twentieth century, the settlement house movement arose in Europe and the United States to address the challenges of rapid urbanization, industrialization, immigration, and poverty by embedding or “settling” reformers in working-class and immigrant neighborhoods.⁸ These community centers provided services including education, healthcare, childcare, recreation, and legal assistance while advocating for labor rights and housing reform, and the movement catalyzed enduring changes in public welfare and urban policy.⁸

The Henry Street Settlement: A radical innovation in nursing      

In 1893, Lillian Wald and Mary Brewster founded the Nurse’s Settlement on Henry Street (later the Henry Street Settlement).⁶ Although the Henry Street Settlement had its roots in the settlement house movement, its focus was unique. Wald later reflected:

I induced my friend Mary Brewster to come with me, and we two together made up our minds not only that we would give our services as nurses, but that we would live in the neighborhood in order to participate in its life and its problems.⁵

Unlike other settlement houses, Henry Street prioritized healthcare, provided by professional nurses living alongside residents and delivering care directly in their homes.^7,9,10 Nurses fostered trust by working tirelessly to meet the needs of their patients, and the communities they lived in. Despite numerous challenges including unsafe buildings, exposure to hazardous conditions, and climbing up and down tenement dwellings from roof to roof, they transformed entire communities.⁹

Transforming public health and expanding the role of professional nurses

Under Wald’s leadership, the Henry Street Settlement introduced groundbreaking programs that reshaped American healthcare, including establishing the first public school nursing program, creating pioneering occupational health initiatives, developing early models of disability care and rehabilitation, and launching initiatives to reduce infant mortality.⁹ These innovations laid the foundation for developing community-based nursing care as a cornerstone of effective healthcare delivery. By 1926, the Henry Street Settlement nurses had grown exponentially, making over 300,000 home visits each year, treating conditions such as pneumonia, tuberculosis, influenza, burns, and polio.⁹ During the devastating 1918 influenza pandemic, Wald and her team played a critical role in organizing New York City’s crisis response through the Nurses Emergency Council, providing direct care, distributing essential resources, and advocating for improved public health policies. This work underscored the enduring importance of accessible, community-based healthcare during crises. In the aftermath of the COVID-19 pandemic, which disproportionately affected vulnerable populations, Henry Street Settlement’s community-based model is more relevant than ever.¹⁴

Continuing impact

Today, the Henry Street Settlement remains a vibrant institution,¹¹ adapting Wald’s principles to address contemporary challenges. Initiatives such as community health workers and social prescribing programs build on her legacy,⁷ and her integrated approach to health and social justice provides an enduring blueprint. 

References

1. Wald LD. The House on Henry Street. New York, NY: Henry Holt and Company; 1915.
2. Wald LD. Windows on Henry Street. Boston, MA: Little, Brown; 1934.
3. Women of Valor: Lillian Wald. Jewish Women’s Archive. https://jwa.org/womenofvalor/wald. Accessed January 2, 2025.
4. Filiaci AM. Lillian Wald. www.lillianwald.com. Accessed December 21, 2024.
5. Feld MN. Lillian Wald: A Biography. Chapel Hill, NC: University of North Carolina Press; 2008.
6. Kuehnert P. Defining the social determinants of health for nursing action to achieve health equity: A consensus paper from the American Academy of Nursing. Nursing Outlook 2022;70(1):10-27.
7. Pittman P. Rising to the challenge: Re-embracing the Wald model of nursing. Am J Nurs. 2019;119(7):46-52.
8. Hansan J. Settlement houses: An introduction. Virginia Commonwealth University Libraries Social Welfare History Project. https://socialwelfare.library.vcu.edu/settlement-houses/settlement-houses/. Accessed January 2, 2025.
9. Fee E, Bu L. The origins of public health nursing: The Henry Street Visiting Nurse Service. Am J Public Health. 2010;100(7):1206-1207. doi:10.2105/AJPH.2009.186049.
10. Buhler-Wilkerson K. Bringing care to the people: Lillian Wald’s legacy to public health nursing. Am J Public Health. 1993;83(12):1778-1786. doi:10.2105/ajph.83.12.1778.
11. The Henry Street Settlement. www.henrystreet.org. Accessed December 6, 2024.
12. “When the city is a great field hospital”: the influenza pandemic of 1918 and the New York City nursing response. J Clin Nurs. 2009;18(19).
13. Wanyo CA. Wald’s leadership: Public health nurses’ response to the 1918 influenza pandemic. Public Health Nurs. 2023;40(6):868-75. doi:10.1111/phn.13242.
14. Keeling A. Historical perspectives on an expanded role for nursing. Online J Issues Nurs. 2015;20(2).
15. “Carrying ointments and even pills!” Medicines in the work of Henry Street Settlement visiting nurses, 1893–1944. Nurs Hist Rev. 2006;14.