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WORKING PAPERS 8 INTIMATE ENCOUNTERS: PUBLIC HEALTH NURSING AND THE HYGIENIC DISCIPLINEMENT OF CONDUCTS Olivia Fiorilli Institute of Social Sciences, University of Lisbon, Portugal
2014
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COMISSÃO EDITORIAL Sofia Aboim (coordenação) Andrés Malamud Dulce Freire João Mourato João Vasconcelos Rui Costa Lopes
2014
Intimate encounters: public health nursing and the hygienic disciplinement of conducts
Olivia Fiorilli
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Abstract Public health nursing emerged in Italy in the aftermath of World War I under the auspices of the American Red Cross. Public health nurses were female health workers who were intended to teach working class people the hygienic norms and healthy bodily conducts necessary to gain a “happy and vigorous life”. Appraising hygienic education as a disciplinary technology of bodily management, in this paper I will read the emergence of
public health nursing against the backdrop of the paradigms
underling the bio-politics of health after the Great War. I will also explore the way femininity was mobilized to construct this hygienic education practice.
Key words: bopolitics, disciplinary technologies, gender, hygiene
Olivia Fiorilli graduated in contemporary history at the University of Rome and completed a PhD in gender studies at the same University in 2014. She is currently a post-doc fellow in the ERC funded project “TRANSRIGHTS - Gender citizenship and sexual rights in Europe: transgender lives from a transnational perspective” coordinated by Sofia Aboim and hosted at the Institute of Social Sciences of the University of Lisbon (ICS-ULisboa).
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As cultural and post-colonial studies have demonstrated, hygiene can be appraised as something more then a mere technique for the safeguard of health: it can also be understood
as
a
source
of
notions
of
pure/polluting,
clean/dirty,
regenerating/degenerating that are racially, sexually and socially resonant (Bashford, Hooker, 2002; Bashford 1998, 2004; Frevert, 1984; Molina, 2006; Anderson, 1995; Giuliani, Lombardi Diop, 2013): these notions have been used to organize and hierarchize bodies and to administer them both in metropolitan and colonial (as well as postcolonial) contexts. But hygiene, and especially personal hygiene, can also be appraised as a technology of body management. Indeed personal hygiene is a situated and located “technical discourse on bodily practice, mundane contact, and the banality of custom and habit” (Anderson, 2006). Prescribing proper practices and attitudes, aiming at disciplining and standardizing minute gestures and habits, hygiene can be thought of as a form of management of individual conducts. The history of hygienic education, then, is not only the story of a specific technique of disease control but also the story of bodies’ and population management and regulation. In both these guises it can be thought of as part of the history of biopolitics and biopower (Foucault 1978, 2003). In this paper I want to approach the history of hygienic education – considered as a bio-political device (Berlivet, 2004) - from the perspective of one particular practice: public health or visiting nursing, and in particular the way it developed in Italy in the aftermath of World War I. The genealogy of public health nursing traces back to the end of 19th century NorthAmerican female middle and upper class philanthropy and its role the settlement movement as well as to the British tradition of district nursing (Buhler-Wilkerson, 2001). Public health nurses, also known as visiting nurses, were female health professionals meant to teach working class people, and especially women, “proper” hygienic habits in the guise of "modern" bodily practices and “techniques du corps” (Mauss, 1936) that would allow them to gain a "happy, vigorous and productive life" for themselves and their family. In the interwar period public health nursing gained momentum and - while still struggling to be institutionalized and fully professionalized in the United States and Great Britain – it was disseminated in continental Europe as
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well as in Asia and South America (Brush, 1996; Abrams, 1998; Fouché, Diebolt, 2011; Popova 2011; Vickers, 1999; Knibiehler, 1999; Saunier, Tournes, 2009; Shultheiss, 2001; Rafferty 2013) by transnational North-American philanthropies and international health organizations such as the Rockefeller Foundation, the League of Red Cross Societies and the American Red Cross (Solomon, Murard, Zyklberman, 2008; Farley, 2004; Weindling, 1995; Ocaña, Zylberman, 2008; Murard, Zylberman, 1986). It is thus in the frame of the new transnational connections designed by global biopolitics (Bashford, 2006) that this hygienic education practice emerged in Italy. In this paper I want to show that public health nursing – that I read as part of the new landscape of biopolitical institutions and practices developed after the Great War - provides a productive lens to explore the shifts occurred in the ideas and paradigms that informed the governance of population's health in that period with a gendered perspective. The case of Italy is interesting because at the end of the great war nursing was intensively debated by social and health reformers, physicians, hygienists, and nurses themselves. In this context, public health nursing came to be described as a fundamental tool for a much needed health reform. In the next pages I will analyze the discursive construction of public health nursing in Italy, exploring its peculiar features and the role gender was meant to play in it. As I will try to show, public health nursing can be regarded as symptomatic of an emerging new paradigm of public health, that, privileging the preventive moment, was focused on the hygienic disciplinement of conducts and on the involvement of the individual in the administration of his/her own biological resources.
Contextualization The governance of citizens’ bodies and the management of population’s “vital functions” – birth and death rate, morbidity etc - had been important to Italian nation building from its inception. In the last decades of 19th century a series of laws started to design the health institutions that were intended to foster the management of population’s health. Nonetheless it is only after Warld War I that the State actually begun to take direct and material charge of population’s health (Silei, 2003; Detti,
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1993; Vicarelli, 1997; Cosmacini, 2005). As most historians of public health and welfare in Italy have noted, the foundations of the welfare system in this country lay in the first total war in history. The conflict had been the biopolitical laboratory where new forms of rational and centralized administration of the “human resources” of the nation had been experimented. On the other hand the war had acted as a “litmus paper” to show the new national priorities. The massive conflict had dramatically showed off that the “efficiency” of the “human capital” was vital to the nation’s interests. If “state’s budget suffers the consequences of a spoiled human capital” (Di Targiani Giunti, 1925, p. 38), as asserted by many contemporary observers, then social hygiene was an investment worth being done: “hygienic effort is not only a source of physical wellbeing for population, but also a source of wealth earning a high rate in the short-term” (Lutrario, 1924, p. 19) explained the head of Health Bureau Alberto Lutrario a few years after the end of the war. This “hygienic effort” had to aim at limiting the losses generated by disease and death and at optimizing the “human stock” more broadly. This idea, that became an hallmark of the fascist regime, was absolutely common in Italy even before the advent of the regime and it gained momentum in the aftermath of the war (Cassata 2006; Mantovani 2004; Pogliano, Ciceri, 2009, Quine, 2002). What did it mean to ameliorate the human stock? First of all it meant making it more productive (Cassata 2005, Padovan 2005). After the great waste of human capital provoked by the big carnage it was necessary to improve the “productive possibilities” of the “manmachine”, as explained Ettore Levi (1921), president and founder of the Istituto di previdenza e assistenza sociale, an institution devoted to developing and promoting social medicine and forming social workers in this field, in his pamphlet La medicina sociale in difesa della vita e del lavoro (Social medicine in defense of life ad work). On the other hand, if it was necessary to ameliorate the productive performance of the social body, it was also fundamental to increase its reproductive capacity (Horn, 1993). Since the human capital was the most important resource of the nation – as stated many social and sanitary reformers - it was vital to increase it for the sick of national power. But the quest for numerical increase of population went hand in hand with the concern for the optimization of the human stock. No surprise that eugenics had its golden moment in the aftermath of the war (Pogliano, 1984; Mantovani 2004). Furthermore, not only was it necessary to “produce” healthy children, it was also 5
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fundamental to raise them “properly” as to let them arrive healthy to the “productive age”. “Fundamental interest of the nation is the development of a strong population which – once the causes of infant mortality are over – can reach its maximal efficiency in the productive period of life” (Silei, 2003, p. 283), read the conclusions of the X section of a Commission settled in 1918 to indicate the priorities of post-war Italy. If the optimization of the nation’s human capital and the improvement of its productive and reproductive capacity was the main concern of public health, what were the means necessary to reach it? “Sanitation alone cannot defend individual life and keep the individual at its maximum efficiency: it’s the daily effort of the individuals who – being aware of the laws that regulate life – impose themselves a correct regimen the only means to reach this goal” (Baglioni 1928, p. 10) summarized some years later – in 1928 - the well known physiologist Silvestro Baglioni (Cassata, 2013). The only way to act efficiently on individual conducts was the spread of hygiene and the raise of what contemporaries would call “hygienic conscience”1. Health education was considered the best instrument to reach this goal. Everyone had to be pushed to safeguard his/hear health (i.e. have a productive and reproductive body) and become a responsible administrator of his/her own biological resources. And, of course, everyone had to be taught the “techniques” necessary to do it. The years following the war were characterized by the proliferation of health institutions dedicated to the active promotion of health: colonies, preventories, preventive dispensaries, health clinics, demonstration units, mobile units for the promotion of personal hygiene and infant care (Dogliani, 2008; Cosmacini, De Filippis, Sanseverino 2004)2. This set of ideas was not at all purely Italian as international public health historians have demonstrated (Ocaña, Zylberman, 2008).The new public health preached “a gospel of
1
“[...] the work (of public health, Editor's note) will be less ardous and the road easier if we find the people ready to accept what is proposed for their good, namely, if they acquire what is called in Italian ‘a hygienic conscience’” explained malariologist Ettore Marchiafava at the 1919 Conference where the League of Red Cross Societies was founded (Proceedings, p. 69). 2
As Wickliffe Rose, president of the International Heath Division of the Rockefeller Foundation, explained during the League of Red Cross Societies foundational Conference in 1919 “public health work is about 90% education of the common man. There are some things you can do in public health work autocratically, but much of your work as public health officers is with human material which is not always very plastic. You must have the cooperation of the people whom you are serving, and nine tenth of your task is educating these people” (Proceedings, 1919, p. 65).
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positive, active, vigorous physical and mental well-being”3 as explained in the Report of the Rockefeller foundation’s Health Board in 1926.
The active promotion of
“health” and the hygienic management of conducts were the new priorities of a new public health that started to privilege the productive and preventive moment to the negative, repressive and defensive one. Active search of targeted population, dépistage, active preach of the “gospel of health”: these were the new keywords of the interwar transnational public health. It is in this discursive framework that public health nursing emerged in Italy at the end of the war, as one of the brand new practices aiming at improving and optimizing the “human capital” of the nation through the spread of “hygienic conscience” and the management of individual conducts. As stated beforehand, this public health practice emerged under the auspices of a transnational north-american philanthropy, namely the American Red Cross, which – in the frame of the relief programs implemented in the country during the conflict (Rossini, 2008, 2007; Irwin 2013, 2011) – created a Commission for Tuberculosis whose aim was not only aiding the struggle against this social disease, but also helping the inception of a public health and welfare system responding to “international standards” (Report, 1919). As part of what Paul Weindling has named the “new world of international health organizations” (Weindling, 1995) that stepped in the global arena during and in the aftermath of the Great War, the American Red Cross (Irwin 2013, Irwin) actively engaged in the standardization of public health systems as a way to foster “the development of good citizenship and the quieting of unrest and dissatisfaction among the peoples in the world” (American Red Cross, 1919). Side by side with the Rockefeller Foundation and the League of Red Cross Societies, the American Red Cross actively contributed to the development of public health nursing in western and eastern Europe, since it considered this service “the most important implement of an active campaign in public health”. American Red 3
“The modern health movement is not content with sanitation and the control of communicable diseases; it goes on to the hygiene of groups and individuals. It is not satisfied with a negative prevention of disease; it preaches a gospel of positive, active, vigorous physical and mental well-being. […] Food, clothing, posture, sleep, occupation, exercise, recreation, social relations, personal adjustments are becoming concerns of public health. […] the public must be brought, through the education of children, the wide diffusion of information, and the concrete services of clinics, health centers, and visiting nurses, to appreciate and support the idea of preventing diseases and of promoting health”, The Rockefeller foundation annual report, 1926, http://www.rockefellerfoundation.org/uploads/files/4db335c2-f981-4cba914e-7de58d969e83-1926.pdf (accessed on the 15th of December, 2014), p. 10.
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Cross officers in Italy, and among them the chief of the Nursing section Mary Gardner, actively worked to create a “market” for their “product” (American Red Cross, 1919) by promoting public health nursing among philanthropic associations, women’s clubs, health professionals, social reformers, physicians, local communities and governmental authorities. On the other hand they helped the inception of the first public health nursing schools in Rome, Genoa and Florence, thus creating the basis for the circulation of ideas models and practices between Italy and the United States. This circulation was further developed in the following years through visiting fellowships and international conferences. Since 1919 the number of schools kept growing under the auspices of the Italian Red Cross and in 1925 the first law regulating nursing in Italy established that they could only be attended by professional nurses graduated in nursing boarding schools. Given the persistent scarcity of fully trained nurses in Italy during the '20s and '30s, the number of registered public health nurses grew slower then expected. Nonetheless, the increasing number of voluntary health visitors and the proliferation of professional and semi-professional figures – assistenti di fabbrica, assistenti sociali, visitatrici fasciste etc. – whose functions overlapped with those of the public health nurse, points to the success of the model of hygienic education that the latter was meant to embody.
Intimate encounters After a brief overview of the discursive framework in which public health nursing emerged and the analysis of the transnational connections that fostered its inception in Italy, it is now necessary to analyze the peculiar features and goals of this figure, who was supposed to bring “the gospel of sane living into the homes of the classes to which such knowledge never before had penetrated” (Stoudman, 1919: 67). Though the boundaries of the public health nurses' work were controversial – as it was not clear whether she had to practice sick nursing and to which extent – her primary goal was teaching hygienic norms, “modern” infant care principles, “healthy lifestyles”. She had to teach working class people, women especially - as they were the designated caregivers and housekeepers - “how to live”.
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Public health nurses were supposed to dissipate “superstitions” and “ignorance” and to bring the “light of modern hygiene” directly into people's houses. They were intended to convince mothers and housewives not to trust the “superstitious advices” of the women of the neighborhood and to listen to the doctor. No surprise, then, that their work was often spoke of in the language of the “civilizing mission”. Not only had public health nurses to convince people to distrust “traditional knowledge” on healing: they also had to act on people’s ideas, perceptions and experiences of the body. More specifically, they had to promote medical notions of health and sickness while eradicating “subjugated knowledges” (Foucault, 2003) on bodies and healing. For instance, many descriptions of public health nurses’ work (either in nursing journals or activity reports) stressed the necessity to persuade people that they were sick and “needed” to be cured. For instance, Anna Celli, wife of the well known malariologist Angelo Celli and nursing reformer, reporting the activity of public health nurses in areas affected by malaria, wrote in 1928:
A peculiar characteristic of the sick peasants born in the marches is that they don’t want to show that they have the fever, so they often refuse to be cured in the hope that nature will help them. Malaria is a fatality to them and they refuse to take special measures in order to avoid it. The daily contact with an educated person who tries to limit their prejudices, that persuades them to be cured, that explains that malaria is a danger for their family and for the entire village, is extremely useful. (Croce Rossa Italiana, 1928, p. 32)
“Convincing” people that they “needed” to be cured was indeed not at all a rare and paradoxical situation, as the “apostles of quinine” (Snowell 2007) had discovered during the campaigns for the distribution of the drug and the eradication of malaria at the beginning of the century. Peasants often rejected quinine: as Paola Corti has noted (Corti, 1984), one of the causes of this rejection – that contemporaries would inevitably trace back to “superstition”, “ignorance” and “fatalism” - laid in the fact that they didn’t think they needed to be cured and didn’t consider themselves sick when they were affected by lighter forms of malaria.
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On the other hand, public health nurses’ goal was not only dealing with sickness but also - and primarily - preaching “a gospel of positive, active, vigorous physical and mental well-being”. Public health nurses were supposed to teach people how to wash, dress up, rest, eat properly, manage babies hygienically - follow a breast-feeding schedule, weigh children etc. - clean and furnish the home in a rational, safe and hygienic manner: doing all these things in a proper, rational and efficient way would have led people to live a “productive and happy life” (Fiorilli, 2013). The goal of public health nurses' educational activity was regulating people's most mundane and intimate habits, practices, aptitudes in order to make them more healthy and efficient. They had to teach working class people to live a regular, ordered, life not for the sake of morality but in order to defend and improve their own health. Furthermore, the work of public health nurses actively contributed to the medicalization of everyday life. Not only, as we have seen, public health nurses were supposed to convince people to rely on medical knowledge in order to evaluate their physical condition and to seek for physicians' help. Through their educational work, these health workers were supposed to show that the most mundane habits and practices had a direct relation to health and well-being and thus could – or better, had to – be “problematized” in medical terms (Berlivet, 2011). Official medical knowledge was thus proposed as the ultimate referent for the “correct” and “rational” organization of even the most humble and ordinary activity (Tomes, 1999): this was a powerful standardizing tool vis-à-vis the multiplicities of bodily practices that were linked to different geographical and sociocultural contexts. As we have stated at the beginning of this paper, hygiene can be appraised as a technology of body management. As it tends to regulate and standardize bodily practices, conducts, aptitudes and interactions and distribute and organize individual bodies in space and time, it could also be be regarded as a disciplinary technology (Foucault, 1979). Paradoxically, while the content of the hygienic norms that public health nurses were intended to spread was indeed “disciplining”, as it tended to produce a dréssage of the body, the way these heath workers were supposed to spread the “gospel of health” was rather flexible. Public health nurses were indeed supposed to be “persuasive” in order to convince people to implement hygienic norms
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in their daily intimate life. “People’s mind […] cannot be changed by means of authority” (Valenzano, 1923, p. 158), read an article published on Difesa Sociale by nursing leader Maria Valenzano in 1923. Public health nursing textbooks and journals insisted on the fact that it was necessary to be friendly rather than authoritative and that the ideal public health nurse had to become the “friend and counselor” of the assisted family. She had to become a “confidant” to the people she assisted in order to make them “confess” their conducts and hidden “defects”. As a public health nursing trainee would explain on the pages of the nursing review “Infermiera italiana”, the journal of the Fascist Union of trained nurses “a public health nurse must display common sense and tact: […] during the much needed domestic inspections, she must gain people's sympathy and must give the impression that she is helpful and can give useful advices while she is finding out the needs of the people she assists and their hereditary physical and moral defects in order to act on them” (Agnini, 1938, p. 17). The ideal public health nurse was supposed to “study the psychology” of the women of the family (as those were her primary target) in order to decide the best “tactics” to make them follow their advices, as many reports produced by Italian Red Cross nurses explained. She was supposed to “adapt the principles and norms of hygiene to people’s everyday life” (Sartori, 1927, p. 5) in order to truly act on their habits. Numerous articles published on “Infermiera Italiana” discussed these “tactics”. For instance an article written by public health nurse Federica Pittini suggested that fellow nurses should write down all the data collected during the home visits so that they were able to remember every detail of a family’s story: “the mother – suggested the article – seeing that the nurse remembers every detail about her baby, her husband or herself, is satisfied […] and she’s proud, she feels important to the nurse, and she’s more likely to listen to her advices” (Pittini, 1935, p. 18). On the other hand, public health nurses were invited to avoid the reprimand – that could raise diffidence and resistance – and to teach the hygienic norms through persuasion. As it is clear, the particular “style” of health education that public health nurses were supposed to embody privileged flexibility and tended to mobilize, engage and solicit the individual rather than coerce or force him or her. Scholars has often described hygienic education’s style before the second world war as imperative (see for instance Boltanski, 1969). As we can see, instead, public health nurses were openly invited to 11
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embody the “friendly”, “familiar”, “homely” (but not less paternalistic) face of hygiene and public health. All the characteristics that public health nurses were expected to display in order to perform a kind of hygienic education that would have the features we have examined hitherto were supposed to be naturally present in women, and especially middle class women. Since tact, sensitivity, ability to persuade with gentleness, educational vocation, civilizing tendency were characteristics naturalized as “essentially feminine”, or – better – as “natural” qualities of middle class femininity – middle-class women were deemed more suitable for embodying the “familiar face” of public health. As physician Giovanni Selvaggi would explain in an article on school nursing published on the medical journal Il Policlinico, “Even the advices of the school physicians about needed medical interventions are more likely to be followed when brought and illustrated by the school public health nurse, since the natural distrust that some people nourish toward not required medical advice – that is sometimes interpreted as an imposition – melts away when this advice is brought by a woman that is able to insinuate with a homely language the utility of a given advice” (Selvaggi, 1924, p. 12). The qualities culturally attached to middle class femininity as well as the “essential” link between femininity and domesticity (Bashford, 1998) were also the characteristics that would make middle class women - and consequently public health nurses particularly suitable for bringing the “gospel of hygiene” directly into the intimacy of working class houses. As the chief of the nursing section of the American Red Cross Tuberculosis commission, Mary Gardner, explained to the first trainees of the public health nursing school she helped open in Genoa, in 1918, “Hygienic rules must be taught individually to every man, woman and child; the long experience that we have gained in America has taught us that the best place to teach people hygienic rules is their own house. And the best teacher is a woman who – entering this house – brings with her competence, knowledge and sympathy” (Gardner, 1918, p. 1). The emphasis on sanitizing houses had been a characteristics of health movements from 19 th century (Tomes, 1999), but as the analysis of public health nursing's peculiar features shows, the centrality of the house in the discursive horizon of the new public health emerged in the aftermath of the war had a different meaning. The house was coming to be
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perceived not only as a space that had to be sanitized, but also as the best location for hygienic education. As domestic space was constructed as the most private and intimate - and health education reinforced this idea as it essentially preached “domesticity”4 - the house was considered the best setting for establishing a confidential and intimate relationship with the people assisted and thus to get the chance to deeply influence their habits and conducts. Generally, when discussing discipline and the disciplinement of the body, we usually refer
to institutions such as schools, hospitals, sanatories, colonies: disciplinary
institutions, we would say in Foucaldian terms (Foucault, 1979). All to the contrary, public health nursing can be an interesting lens through which we can observe the operations of disciple outside of these institutions. If confinement and/or separation is a core feature of disciplinary institutions, the peculiarity of public health nurses’ practice was the fact that, through their educational work, discipline - via hygienic education – was brought directly to the individual in his/her own milieu so that it could be “insinuated” and implemented in his/her peculiar daily life rather then imposed impersonally. The aim of these health professional's educational mission was indeed soliciting the voluntary and willing co-operation and engagement of the subjects in the management of their own health. In order to “insinuate” hygienic norms, public health workers were supposed to be flexible and persuasive rather than authoritative, so that they could “penetrate” the milieu where they entered. Penetrate is a verb that recurs with astonishing frequency in discourses about public health nurses, that Ettore Levi would define “personnel of social penetration” (Levi, 1924, p. 24). These women were thought to have the possibility to get where the more authoritative figure of the (male) doctor would have not be able to arrive thanks to the ability to become “friends and counselors” to the people they had to discipline and educate.
4
Public health nurses themselves participated in the construction of domestic space as “the intimate” and “the private” as they educated women to domesticity and they trained them as “modern housewives”, capable of rendering their house not only sanitized, but also “comfortable” in order to prevent men and children from spending their spare time on the streets or in bars. See for instance Biondi, 1925.
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Conclusions The public health nurse can be appraised as a paradigmatic figure of an emerging new “style” of public health governance – profoundly embedded in the transnational circuits of global biopolitics developed after World War I – centered on the the improvement of the population's biological resources and the productive optimization of the “human capital” through the hygienic management of individual conducts. In this regard hygienic education was of utmost importance. The “best” means through which this goal could be reached was the mobilization of the willing cooperation of the individual. For this aim persuasion was considered more effective than imposition and repression. As we have seen in the previous pages, the public health nurses perfectly embodied this “new style” of public health also thanks to their gender. Being middle class women, and thus supposed to bear the characteristics that were culturally constructed as quintessentially feminine (gentleness, sensitivity, persuasiveness etc.) public health nurses were supposed to be suitable for soliciting population's “hygienic conscience” through education and convincing people to implement hygienic norms into their daily and intimate life, thus assuming healthy conducts and lifestyles. “Naturally” embodying the friendly face of public health, these women could be mobilized in the effort to optimize the resources of the social body. In this sense we could say that, through public health nursing, the traditional repertories of femininity were put at work in the development of new bio-politics of population management.
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Edição . ICS Working Papers Coordenação . Sofia Aboim Design . João Pedro Silva Apoio técnico . Ricardo Pereira
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