Patronage

PATRONAGE (French patronage—observation, protection, care), usually refers to organized observation of a child's development and upbringing in a home environment. The word "patronage" must be distinguished from "patronat" (see Abandonment), which is understood as the system of placing abandoned children into working-class and peasant families for upbringing. History of the development of patronage. The rudiments of patronage arose in Europe by the beginning of the 20th century. In England, the patronage system developed gradually from sanitary housing inspection; female sanitary inspectors began to fulfill the role of sanitary-educational patronage nurses (health visitors). Somewhat later, the institution of patronage nurses appeared in the USA. In Germany and France, the emergence of systematic patronage dates back to 1915–1920. As a rule, in Western Europe, patronage developed from individual initiatives; the functions of sanitary-educational patronage were performed by charitable ladies from bourgeois society, and only gradually, by the 1920s, did the system of sanitary-educational and medical patronage, which exists at the present time, unfold. In pre-revolutionary Russia, the first attempt to introduce patronage should be considered the organization of home visits to children in Riga in 1911. Subsequently, patronage work was introduced at the Vasileostrovskaya consultation center in Leningrad (1912) and at approximately the same time at the 1st consultation center in Moscow. After the October Revolution, along with the powerful development of institutions for the protection of motherhood and infancy, patronage received wide distribution and became an integral part of the work of consultation centers and nurseries. The main task of sanitary-educational patronage at the present time is the establishment of a close connection between the child's family, on the one hand, and the consultation center or nursery, on the other. Only by winning trust, only by establishing an intimate connection with the family through a patronage nurse, does the consultation center gain the opportunity to influence the mother, father, and other persons surrounding the child in the matter of his proper care and upbringing. Patronage nurses, by becoming acquainted with the conditions in which the child lives and by systematically visiting the working-class or peasant family, practically teach mothers at home the rules of feeding, care, and the pedagogical regimen of the child, eliminating noticed shortcomings. The second task of patronage is the attraction of children to the consultation center at the earliest possible period after birth. Upon discharge from the maternity hospital, the mother is directed to the consultation center by the maternity hospital's pediatrician. Consultation centers, in turn, receive information about newborn children from maternity hospitals, and where not 100% of births are covered by maternity assistance, information about newborns is obtained by the consultation center's nurses from the district civil registry office (ZAGS). If not all children for whom there is information about their birth appear at the consultation center (usually the consultation center waits 10 days), then a patronage nurse is sent to the families of those who did not appear, who clarifies the reasons for the mother's non-attendance at the consultation center, helps the mother with advice, and convinces her to systematically visit the consultation center. Attracting a child to the consultation center in the first month of his life is very important, because that is when conditions are created for the most timely and complete influence of the consultation center on the mother regarding the proper care, feeding, and upbringing of the child. The third task of patronage—serving sick children at home (medical patronage)—has received especially great development in recent times with the introduction of home care in consultation centers and the zoning of consultation centers. The district nurse of the consultation center serves the district of her doctor with patronage. This nurse, knowing the home conditions of the children in her district, helps the doctor during the reception, reporting all necessary data about the family's daily life. While receiving a sick child, the doctor gives the nurse specific instructions about the medical measures that the nurse must carry out at home; here, too, the doctor learns from the nurse about the results of visits made the day before at his own instruction. Thus, a living connection is created, which is necessary in the district work of the doctor and the nurse. Visiting sick children by nurses is of very great importance: the nurse teaches the mother to perform the simplest medical measures—how to give an enema, how to feed a child with a spoon or a pipette, how to apply a mustard plaster, how to give a therapeutic bath, etc.; the nurse takes measures to create a hygienic environment, which is especially important for a sick child. In necessary cases, she directs the consultation center's doctor to the child. The fourth task of patronage is the prevention of infectious diseases in the child's family. A patronage nurse, knowing the working-class family and the surrounding environment, can timely provide instructions on how to protect oneself from childhood infections, syphilis, tuberculosis, gonorrhea, etc. As the work of the consultation center expands and deepens, the tasks of patronage also expand. Consultation centers cover children up to 4 years of age; pedagogical patronage is being introduced, which has the goal of introducing elementary, basic knowledge about the proper pedagogical regimen. Socio-legal (everyday life) offices, when a special investigation of a family is necessary, conduct their work through patronage nurses. Patronage, receiving ever greater development, is being carried out beyond the limits of the home environment, capturing in certain organizational forms the broad "children's street" (street patronage). To practically teach the proper conduct of walks, to eradicate the leaving of small children on the street without supervision, to conduct work on the prevention of childhood infections in places of walking and mass gathering of children, to introduce pedagogical principles into the street stay of children, to organize the "children's street"—these are the main tasks of street patronage. Technique of patronage. During the first visit to a child, the nurse fills out a patronage sheet, where she enters basic information about the child and the living conditions of the family: surname, name, age of the child, housing conditions, data from the examination of the child, data on care for him, feeding, etc. During repeat visits, the nurse notes all practical instructions given to the mother and all her subsequent observations, advice, and achievements. The patronage sheet is inserted into the child's development history, which is kept by the consultation center's doctor. In order for the patronage sheets to be filled out neatly, the nurse enters all the data of her observations at home into a special notebook, and upon arriving at the consultation center, she copies them into the patronage sheets. Based on the entries in the patronage sheets, the nurse compiles monthly and annual reports on patronage in her district. The number of patronage visits to each child varies depending on the cultural level of the parents, the success of the patronage, etc.; experience has shown that, on average, 5–6 visits per child per year are sufficient. In the first quarter of the child's life, visits should be more frequent—approximately once a month; later, the nurse visits the child less often, at moments especially important for the child (supplementary feeding, weaning, etc.), according to the instructions of the consultation center's doctor. There is absolutely no need to conduct patronage in relation to all young children living in the district of a given consultation center. At the present time, the majority of consultation centers conduct patronage only in families with a low cultural level and predominantly in families with their first child. To conduct in-depth dispensary observation, consultation centers in industrial centers single out industrial enterprises of the leading industry in their district and even individual, most important workshops in these production facilities, with the maximum of patronage work being concentrated on serving the families working in these "shock" sectors. Only recently, consultation centers focused their attention on the patronage of children in the first 3 months; with the introduction of pedagogical work in consultation centers, this special type of patronage also covers children after one year (pedagogical patronage). The tasks of sanitary-educational patronage in the countryside are basically the same as for urban consultation centers, but the content of the work is different and depends on the low cultural level of the population and the still widespread prevalence of harmful customs and prejudices, with which the patronage nurse must fight in the first place. A patronage nurse, sometimes being the only worker for the protection of motherhood and infancy in the village, conducts systematic preparatory work for the organization of summer and seasonal nurseries. The radius of a patronage nurse's district is usually no more than 5–8 km. To cover patronage in places more distant from the consultation center, primary points for the protection of motherhood and infancy are organized on the periphery, 8–10 km from the location of the consultation center, where the nurse living at this point conducts regular patronage work within a limited radius and where the consultation center's doctor systematically travels to receive children selected by the patronage nurse. A patronage nurse in the village, along with her direct patronage work, sometimes has to provide first aid, for which special training of the nurse is necessary. Patronage nurses of the rural consultation center and primary points arrange talks about the care of an infant, about the importance of consultation centers for children and women, about the organization of nurseries in collective farms and state farms, etc.

In order for the visiting nurse to have the opportunity to practically teach a mother how to care for a child, to carry out the medical instructions of a physician, and in rural areas also to provide first aid if necessary, a model of a special visiting nurse's bag has been developed, which contains basic care items and the simplest medical instruments necessary for carrying out a physician's instructions and providing first aid. If the sanitary-educational and therapeutic patronage of infants is highly developed, organized into specific forms, and is an integral part of consultations, then the patronage of pregnant women has received significantly less distribution. The methodology and forms of patronage for pregnant women are mainly built on the principles described above, but they are less fully developed. In the majority of consultations, both urban and rural, the patronage of pregnant women is carried out not by a special midwife, but by the general visiting nurse of the consultation.

Psychiatric patronage—the treatment and care of psychiatric patients in their own and others' families (patronage familial and secours a domicile)—is one of the forms of extra-hospital psychiatric care and is intended for the organized placement of chronic psychiatric patients. The ease of deploying family-based care without capital investments in construction, and the relative cheapness of maintaining a patient, who costs two to three times less in patronage than in a hospital, served as an economic factor in its development. In patronage, it is often possible to place psychiatric patients while bypassing the hospital; the presence of patronage at a hospital facilitates the discharge of recovering patients and frees up psychiatric hospital beds, which are always in short supply and expensive (patronage filter, patronage-evacuator according to Kashchenko). Family-based care of psychiatric patients has existed for several centuries and traces its origin to the famous Geel, a small town in the Flemish part of Belgium, where patronage grew on the soil of religious prejudices and, ultimately, for the purpose of exploiting psychiatric patients. The residents of Geel began to take in for family care psychiatric patients brought from various places who were awaiting miraculous cures, and gradually developed skills in dealing with such patients. The system of family-based care received wider distribution from the second half of the 19th century. Colonies of family-based care were deployed in Germany, France, Belgium, and Hungary. An interesting and peculiar system of patronage scattered throughout the country is implemented in Scotland. In Russia, the question of organizing patronage care for psychiatric patients was first raised by N. N. Bazhenov at the 1st Congress of Domestic Psychiatrists in 1887; he also set up the first experiment in organizing patronage near Moscow in the village of Semenovskoye. This patronage existed from 1894 to 1900, was closed by a resolution of the village assembly, and has now been revived in a number of other villages in the neighborhood. In 1893, patronage was established near Yekaterinoslav, in 1898 an exemplary colony of family-based care in Balakhna, etc. Before the imperialist war, there were already about 25 patronage systems in Russia with a total number of up to 3,000 beds, deployed by Zemstvo and city self-governments. The system of family-based care had particular distribution in Moscow and Moscow Governorate. A distinction is made between homo- and heterofamilial care of psychiatric patients, i.e., placing them in their own or others' families. The first form is an example of the scattered type of patronage and differs little from a purely social security organization. Placing psychiatric patients in other families allows for the concentration of patients, ensuring them with special psychiatric supervision (patronage physician, matrons or nurses, orderlies), placing more severe psychiatric patients requiring attention there, and using patronage for therapeutic purposes. Settlements or colonies of family-based care can be deployed in villages, in small towns, and finally on the outskirts of larger cities. In the center of the patronage, a reception ward is usually set up with a room for gathering patients, sometimes workshops, and a ward with several beds for temporary isolation during bouts of agitation or for patients who have become somatically ill. A physician and intermediate and junior personnel settle at the reception ward. Psychiatric patients are placed in families that have expressed a desire to take a patient into their care. One, two, or more patients are given to a family. The family takes upon itself all the care of the patient, feeds them, monitors their cleanliness, encourages them to work, etc., receiving a specific payment for the patient. The amount of payment in the pre-war period, depending on various conditions, fluctuated from 5 to 20 rubles per month. Sometimes, in addition to the payment for the patient, the family and the community were paid to interest the entire population of the town or village in monitoring the patient. The money received by the community was spent on the improvement of the settlement, roads, and wells. In the post-war period, a ration was sometimes issued for the patient, a supply of products was reserved in the cooperative, the apartment occupied by the patients was paid for, and families received the maintenance of hospital nannies. The main contingent of psychiatric patients suitable for family-based care are calm, capable-of-working chronic patients, residual states of various psychiatric diseases, schizophrenics, organics, epileptics with infrequent convulsive seizures, and oligophrenics. A contraindication for referral to patronage is danger to oneself and others, aggressiveness, impulsivity, stiffness and inhibition, a state of melancholy, delusional attitudes toward the environment, alcohol abuse, etc. With insufficient supervision, young women should not be placed in family-based care (danger of pregnancy, childbirth). Opponents of organizing patronage spoke about the admissibility of saturating the healthy population with a patronage element of no more than 10%. Accidents in patronage are not frequent; they also occur in psychiatric hospitals and are prevented by proper selection of patients and supervision. Bonnet considers family-based care the most humane way of treating psychiatric patients. A number of authors dwell on the therapeutic role of patronage and life in freedom in the conditions of a working, laboring family, contrasting it with the environment of usually overcrowded chronic wards of large hospitals with their semi-prison, semi-barracks regime, the idleness of patients, and the absence of any tonic impressions, which often lead to so-called "hospital dementia." Through patronage, which also served as a place for the trial discharge of patients and the adaptation of the latter to working life, patients often returned to their families and society. The imperialist war and difficulties with food led to the almost universal liquidation of patronage. From the first years of the organization of the neuropsychiatric section within the People's Commissariat of Health, attempts were made to restore family-based care for psychiatric patients. In 1927, the People's Commissariat of Health issued: regulations on hospital-based patronage, instructions for patronage personnel and wet nurses, a draft of agreements with peasants on the deployment of patronage, and inventory standards for equipping a bed (Circular No. 273-280, Izvestiya NKZdr., 1927). In recent years, patronage has been restored in Moscow and Moscow Oblast, in the Central Black Earth Region, the Western Region, the Middle Volga, the North Caucasus Territory, etc. The collectivization of the village and the construction of state and collective farms, however, made patronage in its old forms—patronage based on individual farming and the individual farmer—unacceptable in Soviet conditions. In connection with this, attempts have recently been outlined to solve the problem of placing psychiatric disabled patients in other planes. On the one hand, projects are being developed locally and experiments are being set up to transfer appropriately retrained psychiatric disabled patients, gathered into artels, to the care of collective and state farm associations, and to create labor colonies and settlements for psychiatric patients. On the other hand, the question is being raised about distributing the contingents of psychiatric patients in need of service between the health authorities and social security authorities. The health authorities are responsible for patients in the acute period, chronic patients during the exacerbation of their mental state, severe, asocial patients, and finally, calm chronic patients in need of follow-up treatment; the social security authorities are responsible for psychiatric disabled persons who do not require active treatment, psychiatric care, and supervision, as well as disabled persons in need of employment. In the system of institutions for disabled persons of the general type, social security has homes for the disabled, dormitories with production workshops, and artels. A portion of psychiatric disabled patients can be placed in general institutions for the disabled, while for others, the deployment of a special network will be required. The organization of medical service for these disabled persons and simple psychiatric observation of them will remain with the local health authorities. Psychiatric patronage.—Brukhansky, Family Care of the Mentally Ill, Izvestiya of the Moscow City Duma, Vol. XII, 1902; Soviet Medicine in the Struggle for Healthy Nerves, ed. by A. Miskinov, A. Prozorov, and L. Rosenstein, Ulyanovsk, 1926; Proceedings of the 1st Congress of the Russian Union of Psychiatrists and Neuropathologists, M., 1914 (reports by Brukhansky, Prozorov, Stupin). L. Prozorov.