Nursing during the Spanish Civil War and its post-- war period ( 1936-1949 ) : forgetting and disabling

Revista de Enfermagem Referência 2020, Série V, no2: e20019 DOI: 10.12707/RV20019 Abstract Background: The health model during the Second Spanish Republic (1931-1939) and the care practices developed by the nursing staff transformed the health conditions of the country. During the Civil War (1936-1939), social and health care was unequal. Objective: Analyze the influence of health care during and after the Spanish Civil War. Methodology: Historical-descriptive research related to health care during the Civil War. Information collected from nursing documents, newspapers, books, laws. Interpretative analysis by dates and events of the period under study. Results: Between 1939 and 1949, the laws enacted revised the work carried out by health professionals, leading to the repression and elimination of the health professionals who were alien to the prevailing political ideas, which meant a process of purification. Conclusion: The government of the Second Republic attributed importance to sanitary and household hygiene. After the Civil War, Spain suffered from a lack of healthcare at both civil and military levels. During the post-war, the identity of part of the nursing profession was forgotten.


Introduction
The beginning of the professionalization of nursing during the second half of the 19th century is intimately linked to several events. On the one hand, in 1860, Florence Nightingale opened her first school at St. Thomas Hospital and King's College in London (Moreno Sánchez, Fajardo Daza, Ibarra Acuña, & Restrepo, 2017). During this period, the international movement of the Red Cross emerged, being founded in Spain in 1864, which promoted health education for all those who provided care for the wounded in armed conflicts . Likewise, in Spain, the humanist Concepción Arenal, impregnated by this philosophy, defended in 1870 that nursing care should be carried out with quality in Spanish hospitals. This woman looked after the weakest and appealed for respect for vulnerable people, considering that institutional charity should help the neediest and should not abandon poor and sick families to their fate (Siles González, 2009). In 1896, Federico Rubio y Galí, motivated by this new way of understanding nursing care, founded in Madrid the Royal School of Nurses of St. Elizabeth of Hungary, considered to be the first in Spain . However, it was not until 1915 that the nursing degree was created by the Royal Order of May 7 (Gómez et al., 2018). Until then, in Spain, nursing care was carried out by nurses and midwives, professionals considered to be the physician's assistants. Female nurses administered care at the hospital level, while male nurses, recognized as the ancestors of Spanish nursing, performed their care functions in rural areas, as the population could not be treated by a surgeon (González, 2011). Healthcare provided by midwives was aimed at women and extended to both urban and rural areas. They assisted women during childbirth and ensured their recovery and feeding. They were even in charge of instructing the mother in the hygienic and dietary care of her child (Moreno Sánchez et al., 2017). They had also to prove that their blood was clean, since in case of emergency they were in charge of administering the sacrament of baptism (López Vallecillo, 2016). At the beginning of the 20th century, Spain was unhealthy and the country's healthcare administration was disorganized. The main reason for morbidity and mortality was infectious diseases (Checa Peñalver et al., 2019). The Spanish healthcare system at that time had many shortcomings and consequently had to undertake a profound renovation in the State Administration, promoting major changes and inserting social medicine within the health framework (Ocaña & Navarro, 2005). The government of the Second Republic (1931)(1932)(1933)(1934)(1935)(1936)(1937)(1938)(1939) attributed importance to healthcare and household hygiene. That interest in health had multiple social, moral, and political implications, being considered an indispensable element for the economic and social prosperity of the country (Ruiz-Berdún & Gomis Blanco, 2017). Since 1931, this government, with the support of the Provincial Councils, implemented Primary or Secondary Rural Hygiene Centers throughout Spain, intending to alleviate existing health problems where preventive healthcare was provided (Ocaña & Navarro, 2005). In short, this initiative was a replica of the North American model of Rural Health. Thanks to it, Spain was a guiding example in public health matters for neighboring countries during the 1930s (Rodríguez Esteban, 2008). Many studies have been carried out on the social wounds that the Spanish Civil War produced in the civilian population, due to the existence of two sides (National side and Republican side), on the repression that the teaching community endured during the war and postwar, as well as on the fragmentation and paralysis experienced by the public institutions (Mirón-González, 2013;Ruiz-Berdún & Gomis Blanco, 2012). However, Spanish society is still unable to accurately quantify the demographic footprint of the conflict among health professionals (Atenza Fernández, 2008). There are very few studies that address the repression suffered by health professionals after the end of the war (Pérez Aguado, Bruguès, Leiva, & de Leiva Hidalgo, 2012), and in the specific case of nursing personnel even more limitations are found (Mirón-González, 2013). Oblivion erases the existence of nurses and midwives who were not in tune with the war winning ideology. Even in the documents analyzed, little or nothing highlights the professional careers of representative nurses of that time. As an example, Sister Fernanda Iribarren, promoter of the approval of the Nurse Diploma; Mercedes Milá Nolla, founder of the Professional Association of Health Visiting Nurses; Trinidad Gallego, promoter of the Committee of Lay Nurses, and Aurora Mas Gaminde, visiting nurse from Madrid who extended the Spanish model throughout the world (Amezcua & González, 2015). Even the books commemorating the centenary of the founding of various nursing schools address in a very limited way the work carried out during the Civil War and the post-war period by their members (Álvarez, 2013;Checa Peñalver et al., 2019). This study was developed within the scope of the structuring project: History and Epistemology of Health and Nursing, specifically within an objective of the HIS-AG-EP Associated Study (History, Health, Gender: Spain and Portugal), of the Health Sciences Research Unit: Nursing (UICISA: E). Its objective is to answer the question of the social circumstances, policies, and legislation that led to health professionals being forgotten during the Civil War and even disqualified during the Spanish post-war period. The research aims to analyze the impact of the professional activities of nurses and midwives during the Spanish Civil War and post-war period.

Methodology
A historical-descriptive and exploratory review of the objective of the study was carried out, through direct and indirect knowledge of the events that took place in the period between 1936 and 1949 (Spanish Civil War and post-war period), concerning the professional activ-Revista de Enfermagem Referência 2020, Série V, nº2: e20019 DOI: 10.12707/RV20019 ity carried out by midwives and nurses. To carry out this review, a series of phases were established. The first one consisted in a literature search in the electronic databases: Scielo, Dialnet, Cuiden, MEDLINE/PubMed, CI-NAHL (Cumulated Index of Nursing and Allied Health Literature), Science Direct as well as Google Academic. During the second phase, due to the historical nature of the study, documentation was reviewed at the Library of the University of Castilla-La Mancha (Toledo Campus), at the Public Library of Castilla-La Mancha, at the archive of the Faculty of Medicine of the Complutense University of Madrid, at the archive of the Documentation Center of the Spanish Red Cross and the Toledo Municipal Archive and Provincial Historical Archive of Toledo. Likewise, documentation found in the archives of the Provincial Council of Toledo was investigated, and historical manuals such as newspapers of that time were consulted concerning the objective of the study. Finally, the third phase focused on a manual and electronic review of official documents taken from the Official State Gazette (BOE), the Ministry of Education and Vocational Training, and the Ministry of Culture and Sport. The following criteria for inclusion were established: 1) documentation related to the professional activity carried out by midwives and nurses during the years studied; 2) publications with social content from the period under study; 3) documents written in Spanish, English, Portuguese, and French. The exclusion criteria were: 1) documentation not adjusted to the topic; 2) duplicated material; 3) material not found in full text. Once the inclusion and exclusion criteria were applied, a total of 73 documents were obtained, of which 20 documents and 2 primary normative sources were selected for analysis (Table 1).

Results and discussion
During the administration of the Second Republic, it was necessary to debate in plenary sessions the creation of a position of midwife or nurse in any town in Spain, agreed by the members of the local corporation, and finally signed by the mayor. It was also the government that agreed to pay the professional's salary, being 40% of a doctor's salary (Ocaña & Navarro, 2005). Once the position was created, it was essential to present the official academic title in the corresponding town council as a guarantee of professionalism. (Figure 1). During this time, the training was carried out through accelerated courses on basic care notions to treat the wounded on the battlefield, responding to the demand for qualified health personnel to care for civilian and military personnel on both sides of the conflict when it was over. In the Spanish Civil War (1939), with the surrender of the Republican side and the ceasefire came the disqualification and purge of public employees (Díaz Díaz, 2016). The penal system in the post-war period was characterized by repressive mechanisms, many of them exceptional and outside the law, which resulted in a weakening of procedural guarantees. The crimes included damage to persons (damage against health, family, love, work disputes, homosexuality, etc.), socio-economic crimes (animal theft, food theft, etc.), and crimes against honor (abuse, rape, etc.), where the woman appears as the main victim (Valle Calzado, 2016). These crimes were closely related to the rural environment, so that the essential protagonists were mainly day laborers and women, including widows who, because of their difficult living circumstances, endured the worst torture and humiliation, leading some women to even lose their lives (Díaz Díaz, 2016). As a result, people in rural areas were trapped between two fires. Their lives were regulated and controlled down to the smallest detail, leading families to go into exile, under pressure from both sides, forsaking their work activities and their property (Díaz Díaz, 2016). During the Civil War, Francoist regime enacted the Political Responsibility Law of February 9, 1939, which established the rules for the purge of public employees. Therefore, all persons who had worked for the state, including health professionals, had to go through a purging process (Pérez Aguado et al., 2012;Domínguez Isabel et al., 2019;Ruiz-Berdún & Gomis Blanco, 2012). Maintaining their employment depended on the sworn statement that each of them had to provide. This declaration contained their personal and professional data, including positions held and possible periods of disqualification, if any. It also included their political and trade union affiliation before the war. They had to state their relationship with political parties, trade unions, or specific associations in the healthcare field, as well as their professional group or membership (Valle Calzado, 2016). It also ascertained their relationship with the government of the Republic, their services in the 1934 elections, their relationship with leftists, and even explored the elected positions that public employees might have reached (Mirón-González, 2013). The statement aimed to filter out the state-dependent workers, seeking a profile of a Catholic-traditionalist worker, of unquestionable obedience, deeply patriotic and a staunch enemy of Republican and left-wing ideas in general. The information that people provided through their sworn statement was opposed by the statements provided by influential people and of reference to the regime, such as mayors, local heads of the Falange, parish priest of the Church, police and civil guards, among others (São Francisco, 2006). Besides, testimonies were collected from people who knew the person making the statement, which meant that any neighbor with a desire for revenge could provide verbal reports motivated by personal enmity. This information led inexorably to the arrest of people under investigation as suspicious elements, circumstances that gave rise to unprecedented informant activity (Mirón-González, 2013). The deadline for submitting sworn statements ended in December 1939, considering that any person who had not submitted them previously would lose their job and would not be entitled to any claim (Díaz Díaz, 2016). The doctors most closely associated with the regime were those who formed the Purging Committees, bodies that investigated the conduct of officials and issued a proposal for admission or initiation. Any doctor could be reported to the committee, and the committee would only have eight days to present the statement of charges against him or her. Being agnostic, caring for or assisting their neighbors, sometimes considered by others as suspicious persons for not being related to the regime were on many occasions the only reasons given for arresting and exercising the repression of the dictatorship on nurses and midwives (São Francisco, 2006). Accusations against health workers could include issues such as leftist ideology, being a prison health worker during the war, seizure of buildings or goods to set up maternity clinics or makeshift blood hospitals during the war, among others. Thus, the sentence issued against public workers covered a wide range of punishments: forced transfer, definitive removal from his or her position, cessation of his or her professional practice, among others. Once charged by the Committee, they were arrested and detained to be judged in a military tribunal by summary court martial. Specifically, the files of the midwives who had been teaching at the Central University since the 1920s were analyzed by the examining magistrate who purged the teaching staff at the University of Madrid and ultimately by the Ministry of National Education (Mirón-González, 2013  The values of the new regime were instilled in the family environment, which if not converted, even entire families would go on to be judged and imprisoned. Some researches, such as those of Ruiz-Berdún and Gomis Blanco (2012), as well as of Mirón- González (2013), claim that public employees were punished during the post-war period, not for their own activities during the war, but for family reasons. Consequently, being the daughter, sister, or wife of a man with an ideology contrary to the regime became a reason for persecution at the end of the war (Ruiz-Berdún & Gomis Blanco, 2017). This may have contributed to the fact that many midwives who practiced their profession at the beginning of the Civil War did not request their reincorporation after the war, for various reasons: fear of being purged, as they had acquired a certain relevance during the government of the Second Republic, due to their trade union significance until the Civil War and their involvement in assisting relevant women during the war, among others. Therefore, it can be considered that some midwives may have died during the conflict, others may have been imprisoned, and for many others exile outside Spain was their only option (Ruiz-Berdún & Gomis Blanco, 2012). The census conducted by the French government in the summer of 1939 indicates that the final count of Spanish exiles was approximately 527,843, including doctors, dentists, pharmacists, nurses, and optometrists (Guerra, 2002).

Conclusion
The Spanish Civil War (1936)(1937)(1938)(1939) divided the country into two sides (Republican side and National side), leading to the cessation of peaceful coexistence among fellow citizens, the loss of midwives, nurses, and highly qualified practitioners. It even meant an institutional, social and economic setback, which resulted in a paralysis of the State Administration, frustrating the health model promoted by the government of the Second Republic.
With the surrender of the Republican side and the ceasefire came the purging of public employees who were against the regime: midwives, practitioners, or nurses who had been disqualified from practicing their profession, whose only crime was to protect the helpless during the conflict. These health professionals carried out their work in a com-mendable manner by caring for, assisting, and helping those in need, both civilian and military personnel during the hostilities of the war. Nevertheless, the post-war period only offered them purging, imprisonment, or exile. There is a real lack of knowledge about the number of professionals who, once the Spanish Civil War was over, did not return to their profession, either because they died at the front or because they were condemned to death, imprisoned, or exiled to other countries. Some people were even unable to return to their jobs because they had been taken over by another professional. Therefore, historical research should be carried out on the nursing profession during the Spanish Civil War and the post-war period to rescue from oblivion this group of illustrious and unrepeatable midwives, nurses, or practitioners who with the best of their being and knowledge laid the foundations of Community Care in Spain and reached the essence of Public Health Nursing, caring for the neediest in any corner of the country.