Human Health this Millenium
For three-quarters of this millennium human beings lived in a relatively stable ecosystem centred on agriculture. It is difficult to be sure of the state of health of the people prior to the maintenance of official statistics, and so health under feudalism is to some extent a closed book. We know from literature and official records that many people lived to be old, but we also know of the existence of infectious diseases such as leprosy and scrofula.
The main disturbances to health under feudalism were war, pestilence and famine -the three horsemen of the Apocalypse.
The struggle between feudal barons, inherent in the feudal system and the value it placed on conquest, was bound to cause deaths. As with road accidents and industrial accidents today they would be deaths falling disproportionately on healthy young males.
As traders passed round the world they picked up the alien viruses and bacteria of the other isolated human communities through which they passed and transported them into environments where the population lacked the natural immunity which is the ultimate product of evolution of host and parasite towards coexistence.
In addition to these problems, from time to time the crops failed and famine resulted.
It was this last health problem which was to be the focus of the greatest single advance in health of this millennium, the Agricultural Revolution. New methods of farming made it possible to produce much more food with far fewer people. The banishment of famine produced the expected biological effect, a considerable increase in the population to match the increased capacity of the ecosystem to sustain the species.
This population increase led inevitably to one of the biggest social advances of the millennium, the industrial Revolution. Towns developed to accommodate the increased population, and the additional people, coupled with the declining need for labour in agriculture, made industrialisation inevitable.
The new towns were insanitary. The density of population had overwhelmed the capacity of the rivers to cleanse themselves of sewage, so that townspeople were literally drinking the sewage of towns upstream. Cholera and typhoid were the natural result.
The towns were overcrowded with poor housing. There was a consequent explosion of tuberculosis, a disease which is endemic in rural communities but which becomes epidemic in early urbanisation as a result of overcrowding and increased chances for spread, ultimately evolving into a state of natural herd immunity over several generations of natural selection.
Working conditions were poor and air pollution was widespread. So serious was the health damage caused by industry that throughout the nineteenth century recessions improved the health of the population. (Thomas Social Aspects of the Business Cycle, London 1925.)
The Public Health Movement
In these conditions the public-health movement was born. Launched by voluntary effort, as part of the social-reform movement, its development is often dated from the establishment of the Manchester Board of Health in 1796. The names of social reformers such as Chadwick figure prominently in the voluntary development of the early public-health movement. Chadwick is also credited with the idea for the Factory Inspectorate, and the various components of social reform were much less compartmentalised in those early days.
But by the last quarter of the nineteenth century, following the appointment of the first Medical Officer of Health in Liverpool in 1859, and the rapid expansion of such appointments in the following decade-and-a-half, the public-health movement had become professionalised and institutionalised in the persons of the public health doctors and the sanitary inspectors.
The achievements were massive. The water-borne diseases of typhoid and cholera were eliminated by providing efficient sewerage systems and clean drinking water, and developing food hygiene regulations. After the Boer War had demonstrated the poor physical fitness of many of the potential army recruits, child-health measures were developed at the start of the twentieth century which were to make rickets and childhood malnutrition a thing of the past. Smallpox was controlled by mass vaccination. Between the wars hospital services were developed by many local authorities, as were antenatal clinics and district nursing services. Diphtheria was wiped out by mass immunisation.
After the Second World War, attention turned to the root causes of respiratory diseases and the Clean Air Act protected the post-war generation from the bronchitis of their predecessors, as well as allowing people to see the bottom of a Lancashire or Yorkshire valley from the top of the nearby hills all year and not just during Wakes Weeks. In passing the problem of polio emerged and was solved, as a minor flu-like disease of infancy paradoxically became a major killer when improving living conditions reduced its incidence, but thereby caused it to strike more often at older children and adults in whom, lacking the protection of a harmless encounter in infancy, it was a serious disease. Vaccination wiped out the presumptuous blot on the optimism of social positivist thought.
In 1974 the public-health doctors were combined with doctors in medical administration and in the university departments of social medicine, to create the merged specialty of community medicine – defined as ‘that branch of medical practice which is concerned to improve the health of human communities’. Throughout the history of public health the specialty had never shrunk from political combat. Medical Officers of Health enjoyed statutory security of employment so that they could offend their employing council without being dismissed by it. The phrase ‘great campaigning Medical Officers of Health’ is instructive in the way it links ‘great’ and ‘campaigning’ in a single concept. Surely it is in these traditions that we find the section of the medical profession which is most intimately involved in tackling the political determinants of health, and in fearlessly allying itself with social reform movements where a health implication can be identified to create jurisdiction. Surely it is in community medicine that we are to find the heirs to these great traditions.
From Public Health to Community Medicine
The first decade of community medicine opened unpromisingly. The Medical Officers of Health had held sway over a great empire within the local authority. That empire had now been broken up. The Environmental Health Department was now independent, with its own Director, as was the Social Services Department, whilst the district nursing and health visiting services now fell under the control of the Health Authority’s Nursing Administration. The community physician remained the medical adviser to the local authority, but was no longer employed by it. (From the establishment of the NHS the local authority Health Departments were regarded as the third wing of the new service – the hospital service and general practice being the other two. The reorganisation of the NHS in 1974 supposedly integrated the three wings, and parts of the local authority health departments were transferred to the new health authorities. However social services departments had already split away from the health department, and environmental health was now also split away to remain with the local authority, so these simply ceased to be part of the NHS. Community nursing and the school health service were the main elements to be transferred. In addition public health doctors were transferred to the NHS to form the specialty of community medicine, along with administrative medical officers from the Regional Hospital Boards and academics from the University Depts. of Social Medicine. This left local authorities without medical advisers, and so a statutory obligation was laid on the NHS to supply local authorities with health professional advice. Under these arrangements community physicians, although employed by the NHS, continue to act as medical advisers to the local authority. Advice is usually provided to the environmental health, housing, social services and education departments. Provision of advice to other departments is much more patchy, and usually applies only where a local authority and an enthusiastic community physician are keen to keep alive the concept of the old Medical Officer of Health) The prime role of the community physician seemed to be the role of health-service manager.
Prevention of illness was moving into new fields. No longer, it seemed, could illness be prevented by engineering schemes, such as sewers, or by mass treatment programmes, like vaccination. The main killers were lifestyle diseases, such as the smoking-related diseases and the diseases of inappropriate nutrition. The largest single killer, coronary heart disease, was both smoking- and food-related, as well as being a disease of inadequate exercise. Health education was the cutting edge of prevention, and yet seemed markedly ineffective in changing people’s lifestyles. Beyond health education lay health promotion, with concepts of social engineering on a grand scale. The idea of food policy, whereby the production, pricing and distribution of food would be geared to the achievement of a healthier diet, or the idea of controls on the tobacco industry, or of healthy transport policy, were discussed in radical circles. In particular such ideas emerged from the Unit for the Study of Health Policy at Guy’s Hospital, associated with the name of Peter Draper. ( The Unit for the Study of Health Policy suffered severe difficulties in obtaining funding and ultimately collapsed, although it continues in a rather changed form as part of its local health authority.) To ordinary community physicians in their districts such ideas seemed remote from reality. There was no statutory relationship with the food industry or the tobacco industry and it seemed hard to make things happen outside the limited sphere of health and local government. Indeed, as the links with local authorities atrophied (naturally enough as new chief officers asserted their independence of their old imperial master) it seemed difficult to make anything happen outside the health authority.
The health authority was a cosy environment for a specialty disoriented by reorganisation and unsure of its new role. The community physician has much less in the way of direct management responsibilities than the other chief officers. This is justifiable because of the greater indirect responsibilities for health advice to other agencies, for strategic direction of health care and for education of the public.
But public health had outgrown indirect responsibility – the power of persuasion and campaign – half a century earlier. The former public-health doctors sought their statutory authority and found it only in the committees of the health service. Here they found also a reaffirmation of their medical status, as they sat alongside consultant physicians and surgeons, even, perhaps, dreamed of evaluating them.
I entered community medicine in 1979 and remember the fierce anger then directed at those of us who put forward the radical idea that it was beyond the health service, and beyond health care, that the determinants of health, and therefore the sphere of action of community medicine, lay.
In retrospect it can be seen that the anger was the anger of a specialty which was realising that it had lost its way. Health promotion and local authority work both began to be emphasized as the old community physicians began to examine the dead end they had shunted themselves into and the doctors fresh out of the training schemes simply began to put into practice the concepts they had learned in the academic departments of social medicine.
The first decade of community medicine opened in 1974 with the appearance that it might mark the death of public health, and ended in 1984 with the appearance that it might markets rebirth. (Paradoxically the rebirth of public health reflects the decline of the empire of the Medical Officer of Health. Throughout the twentieth century the growing size of the local authority health department turned Medical Officers of Health into local government administrators. The 1974 reorganisation of the NHS left community physicians with significant managerial power in the NHS. However most parts of this old empire have now gained their independence and this has left community physicians in an advisory role much more akin to that of the early Medical Officers of Health.)
Public Health and the Labour Movement
Public involvement in the prevention of illness pre-dates public involvement in general practice by half a century and the nationalisation of the hospitals by 90 years. Its roots lie deep in nineteenth-century social reform in the issues of poverty, housing and welfare services.
Social services departments, school meals, welfare milk, clean air, maternal and child welfare services, and the sewerage system are all products of the public health movement. The early Medical Officers of Health campaigned against poor housing. The forerunners of community medicine documented the systematic health deprivation associated with poverty, and hence lay the background for the Black Report, not one word of which was new to the practitioners of public health.
Today health promotion takes on new challenges. The old challenges of poverty and deprivation remain as powerful as ever, but the so-called diseases of affluence create new problems. It must be understood that the diseases of affluence, like the diseases of deprivation, fall predominantly on the poor. They are not diseases of affluent people, but rather diseases that affluent societies impose upon their poor. It is traditionally thought they are diseases of lifestyle. Indeed this explains why they fall upon the poor, for the rich respond to health education messages. So the poor suffer diseases of affluence because they are too rich, but the rich do not suffer from them because they are too intelligent!
It must be conceded that the poor are to blame for their poor health. They wilfully neglect to heat their homes, complaining that it costs too much, when all they would need to do is install double glazing and loft insulation. They allow their children to play in the street where they can be killed in road accidents instead of insisting that they play in the garden of their flat. They eat unhealthy food, pleading that healthy food costs too much, when all they would need to do would be to drive to the hypermarket, load up the boot and store fresh food in the freezer, spreading the cost with their credit card.
This victim-blaming concept of health must be replaced by a concept of diseases of economic activity, in which the promotion of health consists of changing the pattern of economic activity to one which produces better levels of health. The concept of food policy, whereby the production, distribution and pricing of food must be altered to improve the national diet is such an example. Changes in agricultural policy so that there are incentives to slaughter meat lean rather than fat, changes in food manufacture to produce healthier convenience foods, changes in food pricing so that healthy food is no longer expensive (a subsidy on brown bread for example) and planning of retailing so that cheap fresh food is readily available even to those without cars and freezers, are examples of such a food policy.
Other modern challenges to health are no different from those which have faced public health for generations – the challenges to control chemicals is the latest manifestation of traditional environmental health, whilst ideas such as cheap public transport to prevent road accidents follow the same model of health-oriented public services that was the mainstay of the health departments in the first half of this century.
Poverty, housing, welfare, development of public services, control of industry, planning of economic activity. Those are the issues in public health. They are issues that could have been plucked from the centrepiece of socialism. The health and well being of the people is the prime socialist value.
If the language of public health is the language of socialism it might be supposed that the labour movement would place public health to the fore of its policies. The reverse is true. Labour health policy rarely mentions environmental health. Labour councils allowed the role of the community physician to atrophy and the environmental health departments to slip into a sleepy backwater. (In early 1985 the MPU became concerned at the possibility that the Griffiths Report, which reorganised NHS management under a General Manager, might affect the freedom of community physicians to advise their local council. A letter was sent to the various associations of local authorities asking for their support. This letter cited the particular difficulties of Liverpool City Council which had been in conflict with Liverpool Health Authority over the refusal of the health authority to allow its community physicians to service the City Council’s Health Care Strategy Group. The Labour-controlled Association of Metropolitan Authorities sent an extremely negative reply, effectively denying that local authorities required medical advisers except in very limited spheres. The reply contrasted sharply with the response of the Tory-controlled Association of County Councils which said simply ‘We agree entirely with the view expressed by the MPU in this matter, and have so informed the DHSS.’) Health policy and industrial policy were allowed to slip into totally separate compartments, the latter uninfluenced by social policy and the former dominated by the problems of the curative system.
I find this a strange phenomenon for which I can offer only two explanations. One is the division of hard and soft issues, and the other is the reluctance of the labour movement to see doctors in anything but the traditional stereotype, which precludes alliance.
Public Health and the Medical Profession
If the labour movement finds it hard to see public health because it does not fit the stereotype images of medicine and of health politics, the medical profession draws its attitudes from the same stereotypes. Community medicine is not high in the pecking order of medical specialties. In the most recent of the regular surveys of medical students’ career preferences conducted by Professor Parkhouse, only 0.8 per cent of medical students give community medicine as a first choice of career, compared with 36 per cent for general practice, 15.9 per cent for surgery, 18.2 per cent for general medicine, 3.6 per cent for obstetrics and gynaecology, 3.4 per cent for psychiatry, 6.0 per cent of anaesthetics, 3.8 per cent for pathology and 2.3 per cent for radiology. Indeed community medicine attracts less than half the number of first preferences achieved by the ‘miscellaneous medical work’ category (1.9 per cent) and only twice as many as work outside medicine (0.4 per cent). Only 25 per cent of community physicians receive merit awards, as compared with an average of 36 per cent for all specialties, with 24 per cent for geriatrics and 61 per cent for neuro-surgery.
At the 1983 Annual Representative Meeting of the BMA community physicians were prominent in the debate about planning for nuclear war. This led a general practitioners’ leader to declaim from the rostrum, ‘Community physicians may have nothing to offer – I’d have thought we’d all have known that. Isn’t it almost the policy of the association?’
I doubt if such a statement could have been made about any other specialty with impunity. Doctors entering community medicine are invariably told by their colleagues that they are wasting their medical degree.
Community medicine, with its collective approach to the health problems of the community and the emphasis it places on prevention and on health, is as far as it is possible to be from the medical profession’s dominant ideology with its individualistic approach to the illnesses of individuals and the value it attaches to treatment and to sickness.
This has not always been so. In the nineteenth century public health had a much higher place in medical consciousness, and public-health campaigns were prominent in the early activities of the BMA. Virchow, remembered today entirely for his contributions to the clinical practice of medicine, combined that clinical distinction with the most radical of public-health perspectives – that politics was mainly medicine writ large, that capitalism was bad for people’s health and that only revolution would rid society of ill health.
(The same concept of politics as the ultimate expression of medicine also inspired Allende.) Sometime around the turn of the century the battle between the clinical and the public-health models of medicine was fought out. This duality of medicine is recognised in Greek mythology in the forms of Aesculapius and Hygiea, the two daughters of Apollo the physician, one of whom, Aesculapius, was concerned with healing and the other, Hygiea, with prevention. The symbol of medicine today is the staff of Aesculapius. At some stage Hygiea lost.
The Political Interventions of Organised Medicine
It is, of course, accepted that organised medicine will make political interventions in matters that affect medicine or health care, although some of the limitations on such interventions have been discussed in previous chapters.
It is a matter of much more intense debate as to the extent to which it should intervene in matters which affect health but not health care. As a result of the widespread acceptance of the clinical rather than the epidemiological/public-health paradigm, such matters are seen as only peripherally related to medicine and therefore vulnerable to the argument that the profession should take no political stance.
The BMA has, however, campaigned for legislation to compel the wearing of seat belts, and this campaign was merely part of a long tradition of BMA concern with issues of road safety. The BMA has recently launched a campaign for the banning of boxing. The Royal Colleges and the BMA have campaigned against smoking, calling for a ban on cigarette advertising and for measures to encourage diversification of the tobacco industry, and the BMA has now given this campaign a high priority.
On the other hand the 1983 ARM refused to pass a motion declaring unemployment to be an unacceptable health hazard, and extricated itself as deftly as it could from the situation it had been put into by the Board of Science report on nuclear war, widely interpreted as advocating disarmament.
What then determines whether an issue will be seen as a legitimate field for campaigning, or whether it will fall foul of the depoliticisation of the profession?
Smoking, seat belts and boxing have in common the fact that they emerge from the individual-behaviour model of health. Individuals are acting in a way which damages their health, and must be persuaded or constrained not to do so. Where commercial pressures are working to maintain the unhealthy behaviour they are fair game for the fearless opposition of the profession.
Unemployment and disarmament have in common the fact that they derive from the ‘capitalism is bad for your health’ model, and what is demanded in the name of health is fundamental social or political change.
Issues which derive from the individual behaviour model are often highly controversial, but rarely does this controversy follow party political lines. Michael Foot and Margaret Thatcher both voted against seat-belt legislation for libertarian reasons. In contrast, issues deriving from the ‘capitalism is bad for your health” model are bound to be issues of party controversy.
It seems that, at the moment, this is the point of transition from the area where the health ethic holds sway to the area where the depoliticised ideology of medicine declines to hear scientific evidence.
The task for the left in medicine is to understand this transition point and to shift it, whilst at the same time mobilising the profession as effectively as possible within the area in which it can currently be mobilised.
For the labour movement it is equally important to understand the transition point, for it shows where it can, at the moment, rely on organised medicine and even ally with it, and the areas where it must, for the moment at least, distrust orthodox medical opinion and seek its medical advice from within the movement.
As debate surges around that transition point the language of debate will be, on the left, the assertion of the health ethic, coupled with rigorous scientific justification of our position. Our opponents will respond by appealing to the profession’s distrust of politics.
One other lesson which can be learned from the nuclear war debate, and also from the issue of cuts in the NHS, is that it is possible to obtain patronage (in the sense of a resolution of support but no campaign) or legitimation (in the sense of a scientific statement but without the political lessons being drawn) when total support is not obtainable.
Thus in 1983 the BMA declined, with the eyes of the world upon it, to take any political stance on disarmament, but still endorsed a scientific report which could become an important source of information and rhetoric for the peace movement. In 1984 it went further and passed a resolution calling for worldwide disarmament and the reallocation of resources to health.
What had changed in 1984? For a start the second resolution was an apple-pie-and-motherhood resolution. Nobody can oppose the worldwide forging of swords into ploughshares. Secondly, health care had been drawn into the second resolution. Thirdly the issue had calmed down since the previous year, the world was no longer watching, and the resolution would no longer push the BMA into the forefront of the campaign.
Similar considerations seemed to influence the Hospital Junior Staffs Conference (rather more adventurous than the grown-up conference since a lot of delegates haven’t yet mellowed into the rules of the game) in its approach to the unemployment and health resolutions put before it by the MPU in 1983 and 1984. The 1983 resolution simply declared unemployment to be a health hazard. It was carried. This was scientific legitimation, the lowest level of BMA support. The 1984 resolution went further. It called for a political programme to combat unemployment. This would have been patronage – a point or two higher in the scale of support. It was firmly defeated. The 1983 ARM rejected a motion declaring unemployment to be a health hazard. But in 1985 the BMA set out to publicise scientifically the relationship of unemployment and poverty to health. Again the distinction is between patronage and legitimation. On this issue only legitimation is available.
The left must understand the difference between asking for legitimation, patronage and full campaigning support. They are expressed in different terms and represent carefully measured differences of response to the balance between the health ethic’s political correlates and the depoliticisation of the profession.