Professional nursing education in Bulgaria was started by the Bulgarian Red Cross Society in 1900, following several discussions in the 1890s. The Red Cross invited some nurses from Russia – from the Holy Trinity Society (Svetotroizka obshtina), led by Russian nurse Sister Efrosina. A Holy Trinity Society was set up in Sofia, affiliated to the Red Cross Society. It followed the Russian nursing practice of learning, working and living together, which was similar to the German “motherhouse” model. A small hospital with eight beds was opened for the practical training. The course lasted one year, followed by a year of hospital practice, during which the nurses’ skills, qualities and abilities were evaluated by the head doctors on an attestation form. Qualities like obedience, accuracy and diligence were evaluated. In 1904, a Public Health Law passed by the Bulgarian Parliament formulated the general obligations of nurses: caring for and consoling patients, encouraging their hopes for improvement, and other activities connected to their status of “sisters of mercy”.

About 100 nurses graduated from the courses before the Balkan Wars of 1912–1913. Almost all of them served in the hospitals during these conflicts and later in World War I (WWI). Another 1,500 or so voluntary nurses who were trained in short courses also worked as sanitary staff. Many of them served in the military hospital wards for cholera, typhus, dysentery, and other infectious diseases. Many of them became ill and some of the nurses died. [1] A large number of nurses took part in the struggle against cholera and typhus epidemics during the Balkan Wars and WWI. They were appointed to care for typhus cases in the military hospitals. Unfortunately, the scarce documents detailing their activities are insufficient to reconstruct the work and contribution of nurses during this wave of epidemics.

On the initiative of Queen Eleonore of Bulgaria (1908–1917), nursing education in the country was reorganized after 1913. Eleonore von Reuss zu Koestritz was a skilled nurse, who studied in Kaiserswerth in her youth, and managed a sanitary train in the Far East during the Russo-Japanese War (1904–1905). Afterwards, she had a leading position in the nursing institution in Luebben. [2] Eleonore intended to reform nursing education in Bulgaria in line with the American model: a longer course of study with more disciplines, introduction of regular working time and salaries, and more independence in their personal life. For this purpose, she contacted Jean Delano [3] in the USA. After the organizational troubles caused by the war, two American nurses, Helen Scott Hay [4] and Rachel Torrance [5], reached Sofia and the new School of Nursing was started at the Alexander Hospital, run by graduates of the American colleges in the Bulgarian towns of Lovech and Samokov.

After the death of Eleonore in September 1917, work on the new School of Nursing in Sofia was interrupted. Jean Delano also died during a trip to Europe in 1919. But in August 1920, the new National Director of the American Red Cross Nursing Service, Clara D. Noyes [6] visited Bulgaria with Helen Scott Hay to explore possibilities for restarting the school. In October 1922, Rachel Torrance, who assisted Helen Scott Hay in 1915–1916, was appointed Director of the School of Nursing in Sofia. She arrived in the Bulgarian capital accompanied by her assistant, Theodora LeGros [7]. In 1924, Rachel Torrance was replaced by a new Director, Hazel Avis Goff [8], who stayed until 1927. During the early years of the school, some Bulgarian nurses were trained at the Teachers College in New York to take up leading positions in Sofia. The first was Nevena Sendova [9], followed by Krustanka Pachedjieva [10] and many others. Another young nurse, Boyana Christova, participated in the first international course for public health in London. She returned as the first nurse in Bulgaria specialized in public health. [11] Maria Nikolova [12] also graduated from the Bedford School in London.

In her book, “Making the World Safe: The American Red Cross and a Nation’s Humanitarian Awakening“, Julia Irwin researches the politics of the American Red Cross in Europe after WWI. [13] This activity is embedded in the context of the “Progressive Era” in the USA – a time of major sociopolitical reforms in public health and education, the rise of feminism and the expansion of women’s public participation. Julia Irwin believes that this was the time when, on the one hand, the American government discovered the value of foreign aid as a means of influence and as part of diplomacy. On the other hand, however, it became part of the self -understanding of Americans during WWI and in its aftermath.

The reorganization in Bulgaria was similar to processes in other European countries after WWI (Czechoslovakia, Poland, Yugoslavia, France etc.). There too, American concepts of nursing education and work were introduced, as experts sought to convince the local authorities that the American standards of the profession were the highest in the world. [14] The profession was defined in a universalist way. [15]

Special attention was paid to the educational level and qualities of the individuals who entered the school. The educational qualifications of the applicants had to “connote sufficient maturity of years and mind to safeguard the school against the extremely youthful persons of unformed character and unstable ambitions.” “Nursing,” Clara Noyes wrote, “is one of the noblest of vocations and as such not to be entered into lightly or as a stopgap between school and marriage.” [16] The curriculum was enriched by the addition of more specialist subjects. Hazel Goff prepared some new textbooks. Boyana Christova prepared a course in public health, and Maria Nikolova taught the new subject of ethics, a topic that Krustanka Pachedjieva also lectured on.

Soon after the school relaunched, a Florence Nightingale Society of nursing was organized, which started taking part in international meetings and congresses of nurses. The Florence Nightingale Society joined the Bulgarian Women’s Union, which was the main such organization in the country and led the struggle for women’s rights. A newspaper called Sestra (“Nurse”) was also launched. It commented on professional topics as well as on the social and cultural life of nurses, and covered international news regarding the profession. Additionally, it described the activity of the School of Nursing.

As a result of the school’s reorganization by the American nurses and their Bulgarian students, a new type of nurse with a different professional habitus appeared. The new situation was described by Maria Nikolova, who later wrote a history of nursing in Bulgaria. She distinguished the “new nurse” from the “old type”, while also emphasizing continuities:

In the 1930s, vocational training for nurses became a more attractive profession and its status in Bulgarian society changed. The field still had to overcome the traditionalist attitudes of local Red Cross authorities and of officials at the Health Ministry. The Red Cross tried to keep the traditional image of nurses as symbolic figures of compassion and charity work. [18] This corresponded also to the traditionalistic and neo-patriarchal tendencies in Bulgaria. Only at the end of the decade did women win the right to vote.

The communication between American and Bulgarian nurses included collaboration in Sofia as well as regular correspondence between the Americans (Rachel Torrance, Hazel Goff, and Clara Noyes) and senior Bulgarian nurses Nevena Sendova and Krustanka Pachedjieva, both during the Bulgarians’ apprenticeships and when they became directors of the School of Nursing. Other regular letters maintained the social and professional network: between Clara Noyes in New York and the Americans in Sofia (Rachel Torrance and Hazel Goff), between students sent abroad and the directors etc. This exchange created a network of communication that helped establish and internalize personal contacts and loyalty, develop professional standards, and create female role models. The correspondence was very important in maintaining the women’s network of individuals who traveled a lot and often changed their place of work.

Power relationships were part of this communication and they were reflected in the letters. These differences were more obvious in the beginning because the Bulgarians were still students and the Americans were their teachers and leaders, and also decided on the future leadership of the School of Nursing. Writing letters to their American teachers in the initial period, Bulgarians became familiar with professional standards and learned to evaluate new situations and professional challenges according to these standards. The correspondence was also a way to maintain control over the school’s activities. In the second period, during the 1930s, once Bulgarians were in charge of the School of Nursing in Sofia, the communication with the American nurses continued and new forms of collaboration were found. [19] Bulgarian nurses stressed in their letters that the school was a “grandchild” of the American Red Cross. [20] Using the same kind of family metaphor, Clara Noyes regarded the Bulgarian school as “a daughter” of the American Red Cross. [21] She was proud “that the work that was done there by our American nurses has borne such good fruit.” [22] Such maternalistic discourse was typical of the relationship between “Western” and East European women in international communication in the women’s movement at that time, and was supported by both sides. In the correspondence with Clara Noyes, this metaphor continued throughout the years of Nevena Sendova’s directorship, which ended in 1934. Krustanka Pachedjieva deployed the same metaphor of “the American Red Cross’s daughter” when she took over as Director. [23]

The letters written by Nevena Sendova and Krustanka Pachedjieva to Clara Noyes contain reports on the school’s work. They also contain personal information, jokes, and memories of their shared past, meetings, friends and colleagues. The documents comprise a mix of institutional and private narratives that helped maintain not only professional but also personal ties between the Americans and the Bulgarians.

In September 1932, a typhoid epidemic broke out in the southern regions of the country. According to the Director of the Sofia School of Nursing, Nevena Sendova, the Red Cross Society in Bulgaria decided to send four third-year students, led by Todorina Petrova [24] (at that time head nurse at the Red Cross Hospital in Sofia), to help the patients in the small town of Bratsigovo, where they stayed and worked for 40 days. [25]

Typhoid fever was a widespread infectious disease in Bulgaria well into the 1940s.

Rates of the most widespread infections per 100,000 population in 1942 [26]

Between 1930 and 1934, typhoid epidemics exploded in Sofia, Plovdiv, Pazardjik, Kyustendil, Haskovo and other towns. The main causes of this situation were the lack of hygiene and especially the insufficient clean water supply for the population. [27] In some regions of Bulgaria, schools were closed. In the small town of Bratsigovo near Plovdiv, about 400 people fell ill in 1932, out of a population of 3,200. [28]

The situation remained critical in other towns too, despite the beginning of immunization campaigns.

Nurses played a key role in the struggle against typhoid fever: They cared for patients in hospitals and assisted with prevention measures as public health workers. [29] Their contribution was very important, especially in the case of sick children: Mary Walton and Cynthia Connolly wrote that “Research on nurses’ work at Children’s Hospital of Philadelphia in the late 19th and early 20th centuries shows that nurses were crucial in the treatment of pediatric victims of the typhoid fever epidemics.” [30]

The work of nurses during the epidemics in Bulgaria is underrepresented in historical sources as well as in the historiography. The correspondence between nurses is an important source that can break this invisibility of the past because it reflects the nurses’ experiences but also indicates the expectations of the recipients.

Nevena Sendova described the nurses’ work in her letters to Clara Noyes. She continued writing letters during the epidemics and was able to provide direct information to Clara Noyes as part of her reports on the work of the School of Nursing in 1932. She took the opportunity to present the growing importance of nurses in Bulgaria.

Nevena Sendova, as Director of the school, together with her colleague Maria Nikolova, joined the students to help and to observe the nurses’ work in Bratsigovo. They stayed for eight days. Maria Nikolova visited 40 homes of the sick. Home visits were not only needed to help the patients, but were also established as an important public health measure at that time. The aim was to study, control and advise people (primarily mothers) on how to improve the living conditions and the social situation of their families according to scientific hygienic standards. During their visits, the nurses were confronted not only with the health situation and bad hygiene conditions, but also with the poverty and the living conditions of the local people and with their habits, superstitions and prejudices. [31]

Nevena Sendova described for Clara Noyes the desperate situation that she found in Bratsigovo, where the schools had been turned into hospitals during the epidemic:

In this situation, the nurses from Sofia – Sendova, Nikolova and Petrova – organized work both to help the sick local people and to train their students. Their intervention therefore also had a pedagogical character. The letter emphasizes that some of the people’s household belongings – the infected objects – were publicly burned. This is presented as a necessary civilizing activity, and as something of which Clara Noyes is expected to approve. Nevena Sendova points out that people needed the nurses’ explanations and demonstrations because doctors did not discuss the situation properly with their patients.

At the same time, the nurses presented their work in a symbolical way, both to their patients and to their former American teachers:

Even when doing the most menial physical work, scrubbing the floor in the hospital, Nevena Sendova relied in her thoughts on the authority of two symbolic figures of nursing: Florence Nightingale, a symbolic figure for all nurses, and Helen Scott Hey, her personal teacher and educator for all Bulgarian nurses. Helen Scott Hey had recently died. Nevena Sendova wrote of her that she was “a friend, a good teacher and a hero nurse, the organizer of modern nursing in Bulgaria”. [34]

In her descriptions, Nevena Sendova maintained a cultural distance from the population of Bratsigovo. People were presented in their unhygienic conditions and their ignorance about the etiology of the typhoid epidemic. In contrast, nurses were able to explain the true reasons for their illness and teach them how to live in a more hygienic way. Their actions were enlightened and rational, in contrast to the irrational views of the population concerning the epidemic.

In Sendova’s account of the “Bratsigovo case”, Bulgarian nurses belonged to a symbolic professional community emulating its leading figures from the past. Those examples helped the Director of the Nursing School to do the work of cleaning without experiencing it as humiliating, and to burn people’s belongings in the school yard. Guided by their foreign teachers, nurses managed to “normalize” the situation in the town: the “faded red, green or brown” sheets were removed, the infectious pots were buried. Death rates in the town were minimized and Nevena Sendova hoped that in the future “the people will appreciate better the laws of personal hygiene.” [36]

The Bulgarian Nurses Association sought to use these achievements and “the psychological moment” of the struggle against the epidemic for public demonstrations and information about caring for typhoid patients. Their activity in Bratsigovo was also invoked at a meeting with the Bulgarian Women’s Council (of the Bulgarian Women’s Union) to enlighten its members about the profession. [37]

In this way, Nevena Sendova hoped to convince Clara Noyes that Bulgarian nurses were ready to fulfill their duty and serve society. She showed that they had reacted properly in the time of disaster and had managed to make the right decisions. Nurses had internalized the professional norms that they had been instructed in through their study of the American model. Doctors, nurses and midwives often described local hygienic habits as something strange, irrational and “dark”. This “othering” of their native people was a tool to strengthen their professional status. Nevena Sendova also observed this distance in her letters. She did not support the image of “the picturesque Bulgarian towns” that Clara Noyes knew from her short visits to Bulgaria, and did not hesitate to present Bratsigovo as an unhygienic place with citizens who believed in strange superstitions.

In 1933 and 1934, typhoid epidemics spread again in the southern regions of Bulgaria. Two of the most experienced nurses – Zafira Christova [38] and Maria Lazarova, who were lecturers at the school in Sofia – were sent by the Red Cross to the hospital in Haskovo to assist the struggling local medical staff of 12 doctors, two nurses and two unskilled nurses (Samaritan nurses).

Christova and Lazarova shared their experiences with the school Director, Nevena Sendova. In their letters to Nevena Sendova they described the hospital situation during the typhoid epidemic, their work there and their living conditions during their stay. [39] Power relationships with the doctor who was head of the hospital were also discussed in the letters. As Director of the School of Nursing in Sofia, Nevena Sendova was in a position to send reports about the activities during the typhoid epidemic in Bratsigovo in 1932 (to Clara Noyes) and in 1934 found herself receiving reports (from Zafira Christova) during the epidemic in Haskovo. In both situations, she was responsible for maintaining professional standards and the nurses’ personal networks.

The town of Haskovo had at that time a population of about 26,000 citizens. Like other towns in Southern Bulgaria, it had problems with its clean water supply. Doctors and other medical professionals considered the lack of clean water the main reason for the typhoid outbreak.

The hospital buildings in Haskovo had been destroyed by a strong earthquake that hit the region in 1928. In the following years, new buildings were erected and in 1936 the number of beds in the wards increased to 300. Because of the lack of financial support, furnishing the new buildings proved very difficult. According to the annual reports of the hospital, supplies of food and medicines for patients were also irregular in the 1930s. [40]

The two nurses, Christova and Lazarova, arrived in Haskovo by train on January 25, 1934, and were met at the train station by the hospital administrator and a local nurse. Without having the possibility to see the town, they were taken straight to the hospital. They wished to have a separate room to live in there, but there was no space and they were accommodated together with a midwife in a hospital room described by them as a store for physiotherapy devices. They could not rest properly because the room-mate’s shifts were different from theirs:

They also described the low quality of the food (“horror”, “indescribable”, “I bristle thinking about it”) and water.

In the beginning, there was some disagreement about the division of work with the hospital head doctor, who said that he “didn’t want generals in his hospital”. [42] The matter was resolved and the two parties reached an agreement on the organization of medical services. Discipline in the hospital was very strong: “The hospital is like a military zone,” they wrote. “Nobody is allowed to leave.” [43]

The two Sofia nurses were responsible for the severe cases ward with 45 children, and they alternated night and day shifts, each lasting 12 hours. The child morbidity and infant mortality rates in Bulgaria were still very high in the 1930s. The educational programs of the Sofia School of Nursing placed emphasis on measures for improving children’s health and the need to train public health nurses for the children’s wards.

When they arrived at the Haskovo hospital, the two nurses noted the poor conditions in the children’s ward. There were no sheets for the children’s beds and young patients were lying on “bare tarpaulin”. [44] The nurses asked the hospital at least for “short sheets” for the children’s beds so that they could be changed regularly but there were none available, so they asked Nevena Sendova and the Red Cross to send some old sheets for the Haskovo hospital.

Zafira Christova expressed in the letter her concerns about the hospital conditions for sick children: “It is poverty, poverty, a horror!” [45] The connection to the school in Sofia was very important to Christova and helped her solve many practical problems: She asked Sendova for nurses’ apron dresses and slippers. However, what she sought above all was professional understanding and support.

Like other letters in the communication with the School of Nursing, these letters were a mix of informal and professional information. Nevena Sendova (the Director), Maria Nikolova, Todorina Petrova, Zafira Christova, and Maria Lazarova were young women from the same generation; they were friends and colleagues, but their letters were primarily about the service they had been sent to perform.

Their aim was not only to help in the hospital, but to initiate improvements in the way the institution’s activities were organized. Zafira Christova wrote:

The nurses described the cleaning of the children’s mouths as especially exhausting. Typhoid disease caused changes in the digestive functions and system and was characterized by, among other symptoms, dry, cracked or swollen lips, with a brown or gray crust, which was painful for the patients, especially for children. This crust had to be regularly removed. Christova wrote: “When I am getting up from a child whose mouth I have cleaned, it is very hard to straighten my waist. And there are so many of them!” [47]

Fatigue was also part of the hospital work during the epidemic. The nurses were tired and suffered from headaches. But the hard work was something they found young nurses had to get used to. Lazarova and Christova missed their students who could learn to work in extraordinary situations: “How I regret that the probationary class is not here to see how to clean mouths, how to do dozens of injections.” [48]

During their service in Haskovo, both nurses demonstrated to their Director, Nevena Sendova, that they had not lost their optimism. Despite the 12 to 13-hour shifts, the lack of rest and sleep, and the poor living conditions, they expressed a positive attitude toward their stay. Zafira Christova summarized their everyday life in the hospital: “I and Sister Lazarova are healthy, we eat more bread, drink tasteless water and laugh from time to time.” [49] At the end of the letter she adds: “I repeat, for now we are healthy, we see only full days of work and even forgot that tomorrow is Sunday.” [50]

Laughing “from time to time”, the two nurses kept their distance from the troubles in the hospital.

The two letters present important moments in the nurses’ experience during the typhoid fever epidemics between 1932 and 1934, and give us the opportunity to hear their own voices. These are voices of elite nurses in leading positions at the Red Cross School in Sofia, who represented the “new type” of educated “intelligent nurse”. The documents provide information about the trends in the nursing profession in Bulgaria at that time. Nevena Sendova, Todorina Petrova, Maria Nikolova, Zafira Christova, and Maria Lazarova did their best to represent the Red Cross Society’s School of Nursing through their work. Their descriptions present hard work: how they scrubbed hospital floors, cleaned rooms, organized instruments, gave hundreds of injections, cleaned children’s mouths, changed bed sheets etc. without proper rest. They also exercised their power: visiting patient homes and checking hygiene conditions, instructing local people, and burning infected pots in the school yard. They did not see their service as “humiliating” them. They also defended their independence to take decisions and plan their work. Feeling that they were part of a wider nurses’ society was also an important source of their positive attitude.

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Irwin, Julia F.: Making the World Safe: The American Red Cross and a Nation’s Humanitarian Awakening. Oxford 2013.

Lapeyre, Jaime Patricia: The Idea of Better Nursing: The American Battle for Control over Standards of Nursing Education in Europe, 1918–1925, PhD thesis, University of Toronto, 2013, https://tspace.library.utoronto.ca/bitstream/1807/43635/1/Lapeyre_Jaime_P_201311_PhD_thesis.pdf, accessed December 15, 2022..

Nikolova, Maria: Short History of Nursing in Bulgaria, (in Bulgarian, unpublished, undated), Regional Archive – Jambol, F. 1161, p. 40. (after 1966)

Noyes, Clara D.: The School of Nursing at Sofia, Bulgaria. The American Red Cross, News Service. New York 1923.

Noyes, Roger L.: Clara D. Noyes, R. N., Life of a Global Nursing Leader. Market Harborough, Leicestershire 2017.

Popova, Kristina: “The Joy of Service”. Biopolitics and Biographies Between New York, Sofia and Gorna Dzhumaja in the First Half of the 20th Century”. In: CAS Working Paper Series 5 (2013), p. 1–58.

Walton, Mary K/Cynthia A. Connolly: A Look Back: Nursing Care of Typhoid Fever: The Pivotal Role of Nurses at the Children’s Hospital of Philadelphia between 1895 and 1910: How the Past Informs the Present, In: American Journal of Nursing 105 (2005), 4, p. 74-78.