One of the most fascinating—and humbling!—experiences you have working for a 102-year-old institution is discovering new stories of the organization’s work and impact. We recently received a visit in The Rockefeller Foundation’s New York offices from the leaders of the Bikuben Foundation, a Danish philanthropy. Over the course of our discussion, they mentioned the role The Rockefeller Foundation had played in the creation of one of Denmark’s signature social programs, the visiting nurse program for mothers and infants. Intrigued, I set out to learn what I could about the work, and ended up encountering a powerful example of partnership between the Foundation and national health leaders—as well as a case study in catalytic grant-making.
When George Strode, a program officer from The Rockefeller Foundation, visited Copenhagen in July of 1928, he wasn’t necessarily thinking about infant mortality.
In fact, his Rockefeller colleagues had already turned down a proposal for the study of this very topic in Denmark. But in talking further with health officials, he began to see an opportunity.
The Danes, led by Dr. Thorvald Madsen and his colleagues, wanted to understand why infant mortality rates in their country exceeded those of Norway and Sweden. Strode saw a way to develop momentum for public health nursing, one aspect of the Foundation’s larger work at the time to build the field of public health.
From this collaboration—motivated by two complementary but distinct objectives—emerged a five-year study on infant mortality and nursing interventions that the Foundation supported through a series of grants to the Danish National Health Board. The study would help Danish health officials better understand the root causes—and potential solutions for—infant mortality. And it would give Strode the proof point he needed to make the case for public health nursing in Denmark and globally.
Three districts were selected for treatment, as described by Strode:
“The nurse must visit each new-born as soon as possible after birth. She establishes friendly relations with the mother, wins her confidence, and proceeds with instructions regarding the hygienic care of the infant. The routine is to impress on the mother the need for breast feeding at regular intervals; to provide the infant with its own bed; demonstrates how it should be bathed and clothed; keeps track of stools and infectious diseases; enquires regarding feeding when the infant is older, and finally gives instructions concerning the mother’s care in the next pregnancy.”
Nurses made visits each week for the infant’s first six weeks of life, then twice a month. Careful records were kept on specialized forms to enable statistical analysis. Strode’s journals and letters document his early concerns about the work. Assuming the results were positive, would public health officials champion the effort?
Over time, reports on the work became increasingly positive. Officials were pleasantly surprised by the near-universal uptake of the program by mothers. Midwives and doctors—who at first “received rather cooly [sic]” the public health nurses—began to embrace them. Strode reported in 1930 that, “today all three nurses hold the esteem and confidence of both groups. The county officials are also pleased with the service which has been rendered.”
Ultimately, the demonstration proved hugely successful. After six years, infant mortality rates had dropped significantly in the treatment districts, and in 1937 the Danish government began to implement the program in partnership with individual municipalities. By the 1970s, the program was country-wide and compulsory. A 2014 working paper by the Danish National Social Research Centre cites evidence that the program ultimately saved 5-8 lives per 1,000 live births. And the impact of the program has persisted over time; as adults, program recipients are less likely to die in middle age or suffer cardiovascular disease.
“The program ultimately saved 5-8 lives per 1,000 live births.”
Strode’s letters and journal entries on the program leave a number of tantalizing questions unanswered, especially for those of us who work to shape grant-making strategies in health today:
- Why did new mothers so readily embrace the nurses and accept their novel advice?
- What prompted the medical establishment to shift their perspectives on the public health nurses so quickly and so positively?
- How did Madsen and his colleagues marshal the demonstration results to spur national policy change?
Perhaps the most striking takeaway, though, is the long-term impact and scale achieved by this thoughtfully designed and well-timed demonstration. Whether through scanning for global trends or modeling complex systems, when we develop strategies at The Rockefeller Foundation today, we look for the kind of catalytic opportunity Strode and Madsen recognized in 1928—where pressing problems meet new windows of opportunity. Together with our partners, we then design and execute our initiatives to help contribute the evidence needed to spur broader change. The story of the Danish public health nursing program endures to this day, providing a good reminder of the power of this approach.
Thanks to Elizabeth Peña, Matti Bekkevold, and the Rockefeller Archive Center for their assistance with this post.
Archival sources used:
- Interim Report on Public Health Nursing in Denmark Report, May 27, 1930, Folder 374A, Box 158, RG. 5 IHB, Rockefeller Foundation records, Rockefeller Archive Center
- Review of the Public Health Nursing Demonstration-Denmark, July 7, 1930, Folder 23, Box 2, Series 713, RF. 1.1., Rockefeller Foundation records, Rockefeller Archive Center
- Notes on Additional Projects, Divisions of Public Health Nursing, November 2, 1935, Folder 23, Box 2, Series 713, RF. 1.1, Rockefeller Foundation records, Rockefeller Archive Center