A Survey of The English Disease and A Programme for Action

Published by The Socialist Medical Association, 13 Prince of Wales Terrace, London, W. 8. undated, probably 1966

In the early years of the 19th century, when evidence on the conditions of workers in the new factories was being sought, a doctor was asked about the effects of working environment on the health of metal workers and metal grinders.  At that time, the dust was so intense and so harmful that the average expectation of life for these workers was less than 30 years. “A little expectoration is a good thing” the doctor replied “It helps to clear the lungs.”

The “English” Disease

“Nowadays, millions of people have a chronic cough, shortness of breath, and are incapacitated by attacks of bronchitis every winter. No doctor feels anything but a sense of’ frustration at the inability to treat adequately or to prevent what is recognised as a disease, for a chronic cough is no longer accepted as a “good thing”.  Yet in a recent medical symposium on chronic bronchitis there was no contribution on its relation to occupations and no practical proposal for the social action required to end what is known as the “English Disease,”  so prevalent is it in this country,  (it is 40 times more common here than in Denmark which has a comparable climate.)

Community Responsibility

Disease continues to be understood in terms of individual reactions to injury, despite the existence of social medicine as a discipline. Although the National Health Service accepts the principle of   community responsibility in care, there is no clear understanding of the nature of health as a disruption, of the functioning of human beings whose lives are made up of social relations with each other. These social relations are dominated in our society by inequality inequality based on the division of wealth and on the relationship to the means of producing wealth, that is to say, on workers and owners.   These social relations determine the health of society, the actions which can be taken to remedy illness, and the attitudes of people to health and to medical services.

A critical view of these social relations can only lead to the assertion of the collective nature of health or of illness and a “determination to transform these divisions; in other words, a determination to assert socialism as the necessary pre-condition for solving problems such as bad housing, poor nutrition, filthy air, dusty working conditions, problems which we know to be bound up with the causation of bronchitis.  There are many ways in which “socialism is health” can be interpreted, and this is one.

Clinical Description

Bronchitis means, inflammation of the bronchi, the breathing tubes which carry the air from the windpipe, dividing like branches of trees into progressively narrower sections till the lung tissue is reached where the alveoli (tiny chambers) are clustered like grapes across whose thin membranes the oxygen and carbon dioxide are exchanged with the blood.  The bronchi have a lining with cells which secrete a sticky liquid (or mucus) and others with little tails which can move (cilia). These have the function of trapping foreign matter and then removing it, in the opposite direction of flow to the airs towards the mouth.

In an attack of acute bronchitis (which could be due to any noxious substance like a poisonous gas but which is usually an infection by a germ), this, lining becomes inflamed and more mucus is produced which can only be removed by a cough or violent forced expiration and which appears visibly as phlegm or sputum. The cough in this way has a positive value in removing the infective matter in the sputum.

Normally, as in children, acute bronchitis, settles and the bronchi return to their healthy state.  For reasons which are not fully understood, this may not occur, and some chronic prolonged state of irritation results.  It is this which constitutes the basis of, chronic bronchitis and is characterised by permanent production of sputum from the irritated lining of the bronchus, at first as a morning cough (well known to smokers) and then constantly.  The sufferer is now liable to more frequent and more severe attacks of acute bronchitis and progressive lung damage by scarring and by damage to the elastic tissue which surrounds the bronchi and enables the lung to expand and contract with breathing.  The latter process, emphysema seen on certificates, as “bronchitis and emphysema” results in shortness of breath. Finally, the blood circulation through the lungs is affected, leading to heart failure. This, with the chronic state of infection, leads to death.

Behind this clinical description lies prolonged years of suffering in each patient – white faced, racked by coughs, unemployed for months every winter, dreading “romantic” fogs which can prove fatal in a few days (thousands died in London in the smog of 1952), unable to lie down to sleep, losing appetite for food and any savour for life.

Each year depending on the severity of the winter 30,000 to 40,000 people die in this, way, and 37 million working days are lost. One man in three, over the age of 60 is a sufferer. The cost approaches £100 millions annually.

 Asthma

Two other aspects need mention. The walls of the bronchi contain muscle fibres, and if these are irritated by infection, dust, pollens or anything to which they are sensitive, they go into spasm, the contraction narrowing the bronchus severely and demonstrating itself as asthma (wheezing).

Asthma is common in chronic bronchitis and intensifies shortness of breath.  Certain dusts penetrate the alveoli into the lung tissue and there set up a state of irritation resulting in scarring.  Thus silica leads to pneumoconiosis (e .g. in miners, quarry workers, grinders, potters), asbestos to asbestosis, cotton dust to byssinosis, spores to “farmer’s lung”.  This irritation will also involve the bronchi and, the general environment being conducive to chronic bronchitis, these recognised industrial lung diseases are generally found in combination with bronchitis. The effects, so far as the
patient is concerned, are inextricable.

Treatment

Because the development of this chronic irritative state by the bronchial lining is so slow and the response of patients so individual, the induction period for chronic bronchitis takes many years, and the diagnosis of the disease and its study are made difficult, particularly in the early stages.

If the important contributory causes are environmental, individual prevention becomes impossible, and it is not much use telling a   foundry worker to winter in the South of France. Nevertheless, certain measures are valuable – to stop smoking, not to sleep in icy cold bedrooms in winter, to avoid going out in fog, to learn breathing exercises, to obtain prompt treatment with antibiotics and anti-wheezing drugs for the acute exacerbations.   Now that free treatment is available, a helpless, passive attitude is impermissible.

Social factors

The; relation between cigarette smoking and lung cancer which accounts for 26,000 deaths a year is now beyond dispute.  The influence in bronchitis is less well known but equally clear.  Those smoking 25 cigarettes a day have a death rate six times that of non-smokers.   (Cigar and pipe smoking is less dangerous).   In a study of men by the College of General Practitioners, the overall prevalence rate for Great Britain was 2 per cent in non-smokers, 7 per cent in ex-smokers, and 9 per cent in present smokers.      The problem of why people begin smoking is complex.    Most admit that it is a social habit related to the assertion of adult status, acquired by teenagers in the company of others “because they all do it”, resorted to in situations of stress and social uncertainty, and powerfully enhanced by advertising (on which millions of pounds are spent yearly)   suggesting that a successful sex life is impossible without the seductive powers of a cigarette.  In contrast the Government spends only a few thousands a year on posters which emphasize the dangers of cigarette smoking but which are hardly likely to influence young people and on a motor van to tour the schools .with no effect on smoking habits as follow-up studies have shown..

Air Pollution

The clearest evidence of the effect of air pollution is found in fogs. Taking one area of London, the death rate rose from 73 on. November 29th, 1952 (an ordinary day) to 704 on December 13th, 1952, at the height of the fog.   Of 100 known bronchitics interviewed after the fog, 33 were off work as a consequence, many for months.   Bronchitis rates in a National Insurance study rose from 105 in moderate winter smoke towns to 125 in high winter smoke towns.

Pollution is part of the geographical variation so notable in bronchitis.    Death rates per million rise from 512 in rural Hampshire to 1266 in industrial Lancashire.   London, South Wales, Newcastle are other black spots.  A detailed map of Greater London shows a rate which trebles from the outer suburbs to the industrial East End.

Pollution is a combination of Wastes.  Every year one million, tons of smoke come from domestic chimneys, 500,000 from industry, 100,000 from railways.    The figures for grit are 100,000 tons from domestic hearths and 800,000 tons from industry. For SO2 (Sulphur dioxide which forms acid with water vapour) the annual figure is 5 ½ million tons.

The Clean Air Act of 1956, which set out to establish smokeless zones, is far from being successful.  A large number of local authorities have done nothing, and in 1962 they indicated an average of 15 years before action would, be taken.   The law is to eliminate smoke where practicable, which permits many factories to claim that they cannot afford the appropriate measures. Compulsion cannot be applied as there are not nearly enough inspectors.  The supply of smokeless fuels is inadequate and they are more expensive.   The expense of tall chimneys and other equipment for removing sulphur has meant little progress in this respect.

There is also the increasing hazard of exhaust fumes from motor vehicles.

In highly urbanised areas the carbon monoxide in these fumes is great enough to be a menace, and there are possible dangers of cancer from chemicals of a tarry nature (benzpyrene, etc.) and from lead in anti­knock. The main problem, however, remains sulphur and its effect on bronchitis. As a World Health Organisation report put it: “Your Sky a Sewer”.

Class Incidence

For research and other purposes, the Registrar General divides the population into five-broad categories according to their occupation and other social and economic factors.  For example, Class 1 includes; managerial and professional people; Class 3, skilled workers; Class 5, unskilled workers, such as labourers.

The death rate in unskilled workers is six times as high as that in professional people.  In the Report on an Enquiry into the Incidence of Incapacity for Work, the number of Incidents of the disease, or inception rate, rose from 15.4 in Class 1  to 63.4 in Class 5; the  number of days off work from 354 per 1,000 men to 2,364.  The days lost were 417 in agricultural workers, 5,012 in miners, with similar high figures for other dusty trades – textile workers, boilermen, gas, coke and heavy chemical markers.  In company directors it was only 44.

The disease is twice as common in men than in women, and for each socio-economic class this difference is maintained. Furthermore, the wives of workers share the greater prevalence of bronchitis compared with wives in Class 1.  These class differences, are seen in the geographical variation noted before, and are due to many factors such as poor nutrition, bad housing and over-crowding, excessive work, more frequent illness throughout life (a poorer constitution and especially respiratory illness in childhood), dusty working conditions and so on.

South Wales and the Rhondda take pride of place, suffering 2 ½ times as much bronchitis as Great Britain as a whole.    98,000 people live in the Rhondda, 96,000 in Cambridge.  In 1963, 1,350 died in the Rhondda.  If the death rate (adjusted for age and sex) had been the same as that of Cambridge, 385 would not have died.  In the same year, 72 Rhondda babies were born dead or died within the first week of life. If the rate had been the same as that of Cambridge, 26 of these babies would have lived.

Occupational Factors

There is a marked variation in the incidence of bronchitis in different occupations.   The inception rates (attacks per 100 men) in the National insurance Survey were:

All occupations together (average) 3.69
Miners and quarrymen 7.24
Service: office 3.79
Labourers 5.59
Food and drink 3.46
Drivers 4.96
Woodworkers 3.27
Foundry workers 4.71
Farmers 2.25
Transport 4.11
Sales 2.11
Construction 4.10
Professional 1.89
Engineering 3.8

These broad categories conceal differences: for instance in the last category, draughtsmen have twice the rate of teachers.

The fact that wives have a similar variation has led some authorities,,e.g. a recent Medical Research. Council Committee, to state that there is no occupational factor in these differences but that they are due to general living conditions.  This is a convenient theory for employers who resist the installation of proper ventilation equipment and new machinery because it is more expensive.  Recently, new machinery with exhaust ventilation of a unique design for use in foundries went out of production because employers refused to take it up: despite the fact that it was unique in dust-laying qualities.

In a symposium on dust in factories (Department of Scientific and Industrial Research), an Inspector stressed:  “Housekeeping needed more attention.  One firm increased production by no less than 33% as a result of cleaning the place up. Moreover, the initiative had come from the workers.”

 M.R.C. Report Challenged

We should remember that, in 1934 a Medical Research Council report concluded that there was “no evidence that inhalation of coal dust by miners caused fibrosis of the lungs  The work of a Socialist doctor was responsible for instituting studies which show that this decision was quite wrong.  Knowing, as we do the nature of chronic bronchitis and the effect of dust in, say, atmospheric pollution is it conceivable that the vast amounts of dust consumed at work are innocuous?

The “known” prevalence and attack rates of industrial respiratory disease depends on the interest taken. The certification rates for pneumoconiosis in South Wales (where the first research was done) before 1946 were 40 times those of other mining areas.     Following nationalisation, the rates evened out.   In 1953 – 56 the first surveys of the Staffordshire potteries showed large numbers of “first diagnosed” cases – 85 per cent of workers had never been X-rayed.

Concerning Wives

To return to the occupational factors in bronchitis, the fact that both men and women show a class variation has led to the view that it is their poor environment, and not the dusty work, which causes the trouble.     But the wives of men in dusty jobs have a higher incidence than the wives of men in dust-free jobs in the same town and with the same income levels.    This suggests that even dust brought home on clothes etc, can cause disease, and that this may be so is born out by the finding of “asbestos bodies” from asbestos dust in the families (and even the postman) of those in the asbestos trade.

The rates for men in dusty trades and their wives are not necessarily in step. In Glamorgan, whilst miners have a high incidence of bronchitis and a high death rate, their wives have a higher incidence but a lower death rate.

A factory can be quoted where six months after production began all 200 workers developed varying degrees of bronchitis and even pneumonia.  As we know, individuals react to dust in varying degrees. The statistics can easily cover up differences, but in a careful study of flax workers, the “preparers” (in the dustiest job) had significantly more bronchitis than the other workers.

The Cost of Coal

Part of the uncounted cost of the coal we use is the health of the miners who produce it. The dust .of a coal mine contains silica, and silica in the lungs causes fibrosis (scarring) or pneumoconiosis, and pneumoconiosis can lead to death. In 1964, 1,213 new cases in miners were diagnosed by pneumoconiosis panels compared with 1,648 in industry as a whole.

Diagnosis, however, is an uncertain business for the Panels are not concerned with the workers’ health but with disablement benefit (under the Ministry of Pensions and National Insurance). If an X-ray shows little scarring (shadowing), then breathlessness is assumed to be due to bronchitis and clams are disallowed.  Different Panels have contrary views on assessment, may ignore clinical details, or have inadequate access to equipment.

There were 1,116 deaths in England and Wales in 1964, some in the age group 35-40. In a further 1,313 deaths, fibrosis was a contributory cause. The accumulated total of those in benefit was 55,110.

Although the figures of new cases have improved over the past years, we are a long way from ending the disease or from a position where any miner faced with even an early, mild case,  can be taken off the coal face for safer work at full pay.

Asbestosis

Finally, we can look at an industrial dust disease which, in all probability, is on the increase as asbestos is used in many new processes and for a wide range of purposes.  In the eight year period 1931-8 140 cases were diagnosed; in 1955-62 there were 323 cases. Asbestos dust entering the lungs results, over the years, in some cases as little as two or three years, in increasing shortness of breath till severe illness develops.

The only protection is most careful attention to dust control, and in the scheduled (asbestos manufacturing)   industries, the incidence has lessened.   But in others, such as slab and pipe making, lagging and spraying, it is still rising.  An affected worker has no choice but to leave the industry.  There is even a possible danger to the general public from the dust.

A further hazard lies in cancer of the lung, ten times the incidence in asbestos workers than in the general public.  Further, cases of a rare cancer, mesothelioma, which develops in the pleura or outer lining of the lung, have recently been reported in asbestos workers. There were nine such cases in 1964.    Between 1924 and 1964, of 428 men dying of asbestosis, 141had cancer, and of 200 women, 28 had cancer.

A Programme For Action

(l)      The Trades Union Congress and many Unions (notably the Miners, Foundry-workers, and The Confederation of Shipbuilding and

Engineering Unions)   have for many years pressed for chronic bronchitis and emphysema to be a notifiable industrial disease, with industrial injury benefit at a higher rate and compensation. In Australia, miners are allowed to claim for bronchitis. If such a change were brought about in this country it would encourage action by the authorities and be some compensation for workers,

(2)       A great deal more research is needed on the causes of lung diseases and their prevention.  More epidemiological surveys, encouragement by health education for patients to seek treatment, and a more aggressive attitude generally would pay dividends.

(3)      Dust control in industry should be strengthened. It is difficult to see how this can be done realistically without an Occupational Health Service with a larger and more effective inspectorate and statutory powers for workers safety delegates, as well as more training and interest by doctors.

(4)    A more effective Clean Air Act with wider powers and a speeded-up programme.

(5)      Since the general recognition some ten years ago of just how dangerous cigarette smoking is, much effort has been devoted to persuading people, as individuals, to give it up.  These efforts have met with very little success, which is hardly surprising: it is because they can’t give it up, even though they may vaguely feel they ought to, that smokers go on poisoning themselves. We must face up to the fact that only a social attitude, profoundly antagonistic to smoking, which finds it disgusting and dirty, will succeed.

The cigarette industry cannot be banned, but its advertising can, and society generally must not be afraid to ban smoking in all public places, to complain when people smoke that it fouls the atmosphere of a room (as it does, making the eyes and nose of non-smokers sore)  and that it is not a pardonable foible but a bad habit.

(6)    It would be of great value if every national trade union had a full-time health and safety officer on its Executive, to deal with the problems referred to in previous pages and with similar questions,  and to help the campaign for better working conditions.
Throughout industry new processes and methods are continually introducing new hazards, and the surest way to get preventive, measures instituted is to make the people  concerned – the workers on the job – aware of the possible dangers.

(7)     The Factory Acts in relation to ventilation should be strengthened. If the Law, instead of laying the onus on the plaintiff (the injured worker) to prove negligence, compelled the employer to provide safe working conditions, e.g., through a licencing
system, as with road haulage, we should begin to make progress.

 “It Isn’t The Cough That Carries Them Off

This survey of the origin of the English cough is enough to show that it is not a personal affliction but very much a social questions and that its cure depends on social, that is political, decisions.

One could widen the discussion by showing that facilities for advice and treatment also vary with social factors.  (The average list of General Practitioners in Bolton, where there is two to three times as much illness as in Bournemouth, is over 3000.    Doctors in Bournemouth on the other hand, have lists of under 2000.)

Hospital services are just as badly distributed, both in terms of buildings facilities and specialist staff.

The National Health .Service is in a state of permanent crisis compounded of financial starvation and inadequate organisation.

It may seem absurd, faced with this state of affairs, to call for an end to diseases like bronchitis which almost seem part of human nature, but in/order to change society we must understand it. Understanding its nowadays, means that not only experts but all of us being aware of the issues involved in health,  education and social life, as much as in economic and foreign policy issues.

If society is to change it is we collectively, and not some mysterious process or some organisation on our behalf, who must change it and in doing so change ourselves.    That is why the Socialist Medical Association has always had as its slogan:

The Health Of The People Is The Responsibility Of The People Themselves

S.M.A. PAMPHLETS

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