Melanie Beals Goan. Mary Breckinridge: The Frontier Nursing Service and Rural Health in Appalachia. Chapel Hill: University of North Carolina Press, 2008. xi + 348 pp. $45.00 (cloth), ISBN 978-0-8078-3211-0.
Reviewed by Kelly A. Minor
Published on H-SAWH (September, 2009)
Commissioned by Antoinette G. van Zelm (TN Civil War Nat. Heritage Area Center for Historic Preservation)
Minor on Goan
Melanie Beals Goan argues in her engaging study of the Frontier Nursing Service (FNS) that its founder, Mary Breckinridge, "performed a careful and very successful balancing act throughout her life" (p. 2). Goan makes a convincing case for Breckinridge's skills and also makes it clear that the apparently fearless Breckinridge was anything but. This forceful woman was never timid, but she was deeply affected by a host of personal and social circumstances that required her to navigate her various worlds as they came together in the FNS. Goan's biography of Breckinridge, Mary Breckinridge: The Frontier Nursing Service and Rural Health in Appalachia, fleshes out the context of the service from its inception in 1925 until its founder's death in 1965. Indeed, the real strength of Goan's work is that she anchors both Breckinridge and the FNS so firmly in their historical context. In doing so, Goan adroitly avoids the temptations of such a study--to worship or vilify her subjects, to set them apart as singular, or to dismiss them as mundane--and presents the contributions of both Breckinridge and the FNS as complex and important. Goan hopes that "a balanced, complicated picture of a dynamic and enigmatic woman emerges" from her study; in this she has succeeded (p. 11).
Born into nineteenth-century wealth and status, Breckinridge liberally used both to gain social and monetary support for her rural health care system in the Kentucky mountains. Yet Goan makes it clear that Breckinridge's social background was only one component of what shaped her mission to bring quality care to Appalachian families through professional nurse-midwives, as a start toward health care for all Americans. Despite her privilege, she endured significant personal loss. Breckinridge lived to be eighty-four, but her daughter died soon after birth and her beloved son, Breckie, died just after his fourth birthday. Her mother died unexpectedly, and Breckinridge's two marriages ended prematurely, the first in widowhood and the second in divorce. Goan argues that Breckinridge overcame crippling grief partly by throwing herself into saving other children.
Ambitious, determined, connected, and influential, Breckinridge formulated the FNS out of earlier initiatives, including the FNS's immediate predecessor, the Kentucky Committee for Mothers and Babies. During her long tenure as the FNS director, Breckinridge adeptly raised funds and cultivated support among wealthy donors and the American public; fended off government intervention in her private enterprise; supplied narratives chronicling the FNS's achievements and correcting critics' stereotypes of Appalachia; and built a close-knit cadre of female nurses, couriers, and volunteers. She managed to guide the FNS through the trials of the Great Depression and the drain on manpower that took place when many of Breckinridge's British nurses left to return home during World War II. Slowly but surely, her policies built trust among Appalachian patients, and the FNS eventually cared for whole families and communities rather than just mothers and babies.
Goan argues, however, that the qualities that made Breckinridge successful for most of her career were the same things that nearly cost the service its relevancy and opened the door to sweeping changes after she died. The FNS entered the 1960s facing a number of challenges, many of which Breckinridge dealt with by stubbornly refusing to alter the service. Particularly problematic for her were the potential acceptance of black nurse-midwives, the rapid development in Appalachia, an expanded government with health care plans that might negate the FNS's raison d'etre, and even the jeeps and roads that replaced the rough trails and horses that had made the FNS "angels on horseback" famous. As Breckinridge aged, and certainly after she died, the FNS weathered these changes and endured, though Goan points out that today few outside rural Kentucky have even heard of an agency that once was a household name.
Goan's study has several interrelated strengths, all hinging on her characterization of Breckinridge's life as "rich with complexity and at times marked by seeming contradictions" (p. 249). First is Goan's attention to Breckinridge's experience with gender expectations and reforms. Breckinridge quipped that she was more comfortable living in the nineteenth century than in the twentieth, but she was an independent, outspoken, socially (and at times politically) active woman. Like many female reformers of her ilk and period, Breckinridge negotiated two roles--"feminine" caregiver and "male" activist--by relying on the socially acceptable argument that elite women had a duty to care for others. Goan rightly refers to Breckinridge as a "maternalist," anchoring her in the reform and social context of her early life. In doing so, Goan has added yet another wrinkle to the rich study of female reform, for Breckinridge was no ordinary maternalist. She was a twice-married socialite with a home in the mountains; she cultivated support from wealthy donors whose daughters served the FNS as a badge of social honor while temporarily casting aside social conventions. What is more, Breckinridge focused on "uplift" among people she classed as the finest American stock, and she advocated modern scientific health care even as she ardently believed in spiritualism and her own ability to communicate with the dead. The second strength in Goan's book is that in her focus on the FNS she offers another variation on the study of the rural South and Appalachia. Many historians dealing with Appalachia focus on arts and culture, but Goan has zeroed in on the apparently more mundane but critical issues shaping Appalachian life, such as health, maternity, and isolation.
How Breckinridge responded to her Appalachian patients was not entirely based on stark reality, however, for she was as captivated by the stereotypical image of mountain folk as most Americans. This is the third strength Goan's study offers. By assessing Breckinridge's assumptions about, and reactions to, her corner of Appalachia, Goan has altered the well-worn debate about the interference in, and preservation of, Appalachian culture by interlocutors alternately fascinated and repulsed by mountain life and its place in American society, history, and prosperity. Breckinridge, though hardly sharing her patients' upbringing, spent much of her life in the mountains rather than entering them as an urban tourist, so she came prepared with a native interest. Unlike many reformers, she consciously avoided reshaping her patients' religious, political, social, and even legal systems. Health was her priority; as Goan points out, if a family could afford better care because they operated illicit stills, well, that was not the FNS's business, in Breckinridge's opinion. She repeatedly warned her nurses that they must allow families to adopt the care the FNS offered as they saw fit. This respect for Appalachian autonomy had limits, though. For example, Breckinridge grew frustrated when Leslie County residents left their communities to seek better prospects elsewhere during and after the Depression; though she wanted them to succeed, she expected that it would be at home. Place gradually supplanted people for Breckinridge, and she grew anxious that her own foothold was giving way.
Just as she resisted adopting changes to the FNS that she feared might undermine its unique position (and her leadership role within it), she resisted social changes that threatened the need for the FNS or challenged her nurses' autonomy. Goan argues that as traditionally female as the FNS appeared, the demands of mountain service necessitated a high level of independence. Once FNS nurses overcame their initial shock at the realities of Appalachian nursing--they realized they would not be fulfilling the image of women in neat white smocks bathing fevered brows--the nurses reveled in the challenges of the work, even the dirty jobs of shoeing horses, repairing jeeps, and mucking out stables. Even the more romantic, but no less alarming, necessities of FNS work proved rewarding for nurses: riding through the wilderness alone, supervising male carpenters, and wearing a uniform suitable for mountain travel--including pants! Breckinridge's personal resistance to government assistance to supplant dwindling private donations, her refusal to raise wages for her nurses so she could balance strained FNS budgets, and her continual suspicion of non-FNS publicity (usually well founded) all reflect her larger attempt to keep the FNS autonomous and flexible. Perhaps this is the most compelling component of Goan's study: Breckinridge's FNS, the life she built for its nurses, and the options it offered its patients captures the very real tensions between image and reality that defined the various relationships formed in rural Appalachia early in the twentieth century. Most important, Goan emphasizes that what predominantly shaped Breckinridge and the FNS was not overweening altruism, urban snobbery, male dominance, or Appalachian resistance, but sheer negotiation. Everything Breckinridge did was a negotiation, usually subtle and astute, to accomplish as many of her goals as possible with as much outside support, and as little interference, as possible. She fiercely protected her patients' privacy and dignity while revealing enough of their troubles to build sympathy and outrage on their behalf. She balanced, though not always well, the dual images of an impoverished, sickly community and a hearty, intelligent folk of "pure" American ancestry.
Those tensions highlight the best characterization of the FNS, which is made clear through Goan's study: these women lived on a frontier, as Breckinridge wisely argued in her attempt to make donors and recruits equate the FNS with adventure and renewal. Through Goan's analysis, we can see the FNS and Breckinridge's role in it as a collision of worlds along the symbolic and temporal crest of Appalachian Kentucky. Appalachia offered an alluring frontier between image and reality for Americans of all walks of life, while the FNS offered a challenging frontier between comfort and independence for professional women. In addition, health care activism offered a tenuous frontier between tradition and change for patients and practitioners alike. The confluence of these individual frontiers in Breckinridge's FNS offers modern readers a glimpse of the frontier between "nostalgia" and "progress" as the nation rolled from one century into the next.
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Kelly A. Minor. Review of Goan, Melanie Beals, Mary Breckinridge: The Frontier Nursing Service and Rural Health in Appalachia.
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