How soon is now? Public health and the BMJ

Dorothy Porter

In the BMJ on the eve of the Public Health Act 1875medicine's parliamentary champion, Lyon Playfair,honoured the contribution of physicians to securingthe public health, while bemoaning the thanklessnessof their task. "Each new confidence is bestowed underprotest and is yielded after much show of suspicion,"he complained, assuring his readers thatIf you were to believe the speeches which are made, medicalmen, instead of being the saviour of humanity, are theenemies of mankind. The country is determined not to beruled by them, and yet is continually bestowing upon themincreased powers. What does all this mean?'The answer was that the body politic was simply

acting like an individual patient resisting treatment:The public officer of health has to deal with the body politicjust as the private physician has to deal with the body of anindividual ... communities are acting like individual patients.They try to resist the admission that they are in a state whichrequires an abnegation of their own will, and a submission tothe orders of their medical advisers. They kick against theneed, but yield while they kick.

Eventually, however, Playfair confidently predicted,society would become a well behaved patient, therebymaking public health "a great field open to growingmedical men."Throughout the Victorian age the BMJ represented

public health as a high humanitarian calling but oneexperienced by medical men as a battleground. Thedoctor working in public health was portrayed as thevictim of vested interests, vulnerable to the whimsof central and local government and subjected tothe hostility and prejudices of his "patient," thecommunity. Early editors backed all measures thatfurthered the medical regulation of the community anddeplored politicians' failure to take rational profes-sional guidance-especially as urged by the BMA.Thus the BMJ became a vocal defender of the faith

in prevention of disease, a cause perceived from theoutset as the province of doctors rather than philan-thropists, engineers, or bureaucrats. On the settingup of the General Board of Health in 1848 thejournal echoed Henry Rumsey's outrage that thenation's health had been entrusted to "two lords and abarrister." When, by contrast, John Simon, a favouriteof the London hospital elite, was appointed thenation's spokesman for the public health the journalconsistently praised his reports, while agitating forfaster progress.

Department of History ofHealth Sciences,University of California,San Francisco, California94143, United StatesDorothy Porter, PHD,medical historian

BrMed7 1990;301:738-40

Defenders of the filthSimon's Sanitary Act 1866, judged the journal,

proved that in respect of the "reciprocal relations thatsubsist between dirt, disease, drunkenness, pauperismand crime," enlightenment was finally replacingapathy-"better late than never." But it was stilldissatisfied by the confusing sprawl of incoherentlegislation, which failed to clarify the responsibilitiesof respective local authorities for public health.2Editorials demanded a comprehensive system of com-pulsory rather than permissive legislation and helpedin the campaign that resulted in the establishment ofthe Royal Sanitary Commission in 1868. In an erabefore medical officers of health had gained theirown unified professional organisation the BMJremonstrated against their job insecurity and exposedrecalcitrant local authorities as reactionary "defendersof the filth."2

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Lyon Playfair (1818-98)

Nineteenth century public health legislationcontinued to disappoint. When provincial sanitaryauthorities were established in 1872 and appointmentsfor medical officers of health were made compulsorythe BMJ immediately pointed out critical weaknesses.The public health act failed to combine sanitaryauthorities into sufficiently large districts to be effec-tive and thereby enable them to appoint full timeofficers. Above all the journal audibly groaned as itslong time bete noire, James Stansfield, was appointedhead of the new Local Government Board in 1871 .

Misguided philanthropyStansfield had been a parliamentary spokesman for

both the Anti-Vaccination League and the NationalAssociation for the Repeal of the Contagious DiseasesAct. He was often depicted in the journal as theepitome of misguided philanthropy, leading societyastray from the path of scientific rationality. ErnestHart, the editor at the time, by contrast waged apersonal campaign in support of vaccination, publish-ing his own articles and statistics and ridiculing theopposition at every opportunity. Anti-vaccinationistswere dismissed as cranks and fanatical individualists.The journal expressed its regrets that Simon did

not join the campaign to extend the operation ofthe Contagious Diseases Act to non-military towns.It consistently advocated compulsory detention ofinfected prostitutes. William Acton's contributionsin the journal characterised repealers of the act asbenighted moralists determined to silence thoseattempting to end sexual ignorance. On the success ofthe repeal campaigns the BMJ uttered a long lament:when would the commonsense of medical scienceprevail politically?By the turn of the century, however, this question

was becoming complicated by the widening of theprofessional gap between preventive and curativemedicine. TheBMA had supported doctors working inpublic health, but after 1889 medical officers of healthhad their own professional organisation, the Society of

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Medical Officers of Health, and their own journal,Public Health. Traditional solidarities subsequentlyfractured.

Registering the fears of a clinical profession feelingthreatened by the dramatic expansion of public healthdepartments in local authorities, the BMJ was soonwarning that "a State medical service is at presentcoming into this country by stealth ... each time thestate sets up a new ad hoc salaried service it is loppingoff something from the responsibilities and duties ofthe private doctor."3 Not surprisingly, therefore, in1920 the journal wholly supported the Dawson report,hoping thereby to "stave off the demand made byacademic people and others to nationalise the medicalprofession."3 Dawson proposed a unification of pre-ventive and curative services designed to give inde-pendent general practitioners who were contracted,not salaried, the central role within a system ofprimaryand secondary health centres.

Social medicineA generation later, in the in-fighting over the setting

up of the NHS, the journal likewise championed "thestrong individualism which is characteristic of Britishmedicine and is responsible for its finest achieve-ments," backing medicine's battle against the "moderndogma" of the "worship of the State."4 In 1948 theclinical profession secured its freedom, and the publichealth profession utterly failed to influence events.This failure resulted, in part, from loss of intellectualauthority in the face of the rise of the new academicdiscipline of social medicine.The BM7 published some of the earliest definitive

statements by John Ryle, the first professor of socialmedicine at Oxford. Ryle described the new disciplineas clinical medicine applied to aetiology through ananalysis of social pathology. But the journal remainedunimpressed:The broad idea of "social medicine" is of course not new, andit may be interesting to recall here the proposal made in 1908that the B.M.A. should form a Section of Medical Sociologyas one of the Sections of its Annual Meetings.The new specialism was just another sign of the

times: "there is a regrettable tendency nowadays tobelittle the clinician."

Such problems raised themselves decisively whenthe NHS faced a major reorganisation at the end of the1960s. From the 1950s public health doctors and socialworkers had become locked in battle over the "socialcomponent of health." In 1968 the Seebohm Com-mittee on local authority services and the Ministry of

Health's green paper on the future of the NHS, bothendorsed the demand for raising the professional statusof social work into a separate sphere.The BMJ warned of the grave implications of

autonomous social services departments, not merelyfor those public health doctors most directly under-mined but for the role ofthe doctor in family health as awhole. The issue, it noted, "goes far beyond simplydepriving medical officers of a function." For the"transfer to lay staff... ofmedical and social functionsnow carried out by doctors raises questions ofprinciplewhich are of concern to all doctors."5 What was thisprinciple?Whatever social scientists may believe, when in troublepatients turn first to their doctor; and they look to him to sortthings out. The report (Seebohm) is apparently horrified thatthe doctor should be expected to lead the team coping withpersonal problems. Doctors believe that this is their responsi-bility, and ask only for the chance to have the staff to get onwith the job. The public would almost certainly agree withthem.6

Evidently, the journal had taken to heart themessage that Playfair had issued back in 1875:Perhaps even more than the priest, the medical attendantbecomes a confidant of the inner circle a physician shouldlook upon medicine as a sort of religion, and on himself as apriest of humanity, bound to spread his'sphere of usefulnessto all within range.'The "lay staff," or the social workers, within public

health departments did not share this view, and the1974 NHS reorganisation redefined the role of thecommunity physician as a specialist health strategist inthe integration of services. As early as 1976, however,the BMJ was publishing a series of articles by com-munity physicians who were discovering that their newspecialty was a fiction. Having abandoned environ-mental prevention community physicians were leftwith no legislative authority; personal preventivemedicine had been taken over by general practitioners,and the execution of service management in an era ofsevere financial cuts simply alienated assistant medicalofficers, district community physicians, and statecertified midwives from their clinical colleagues.Hence by 1980 the BMJ was. pointing out that

the objectives of community medicine had not been

John Ryle, FRCP (1889-1950). First professor of social medicine atOxford

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achieved. Instead of formulating policies for the pro-motion of health community physicians had becomeenmeshed in managing health service delivery.Boundaries had become blurred. "Where does the

The Convalescent (1919)Gwen John (1876-1939; British)

Gwen John was living in Paris at the the turn ofthe century, yet she was unaffected by theartistic revolution around her. Throughout her life her work remainedfigurativeyet highlyoriginal. It owed much to her training at the Slade with Henry Tonks, who taughi her to draw,and in Paris with James McNeill Whistler, who showed her the importance oftonal values.Lacking her brother AugustusJohn'sflamboyance, Gwen's painting nevertheless has astrength that derives not onlyfrom the underlying structure but alsofrom the subtle handling ofpaint and muted colour. "The Convalescent," ofwhich she made several versions, illustratesthese strengths well, with a characteristic inner quality and stillness.

.

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CLASSIC OF THE DECADE1914: Casimiir Funk's Die Vitamine, Ihre Bedeutung fur die Physiologie und

P-athologie, mit Besonderer Bericksichtigung der Avitaminosen.Wiesbaden: J F Bergmann.

function of the community physician end and thatof his colleagues on the district management teambegin?"7 The opportunity for implementing specialistknowledge of disease prevention and health promotionhad been lost, especially after the introduction in1984-5 of general management after the 1982 Griffithsreport.Outbreaks of salmonella infection in Wakefield and

legionnaires' disease in Stafford in 1984-5 exposeddisturbing disarray in disease prevention. AIDS hasfurther concentrated the public imagination on that olddiscipline that the World Health Organisaticin hasdecided to restyle the "new public health." The recentAcheson report also reflects- the current eagerness forrevitalising public health, though John Ashton, in hiseditorial, has pronounced it a "missed opportunity."8

The new public healthThere is a consensus for abolishing community

physicians and bringing back public health doctorswith a remit for surveying the state of health in adistrict; coordinating preventive medical functions,especially those concerned with infectious disease; andtelling local authorities and the health services what isto be done. The BM7's hearty enthusiast for the newpublic health believes that the participation of thosenon-statutory bodies that have provided most of thestimulus in recent times must also be a priority in thepursuit of health for all. Ashton further claims that theAcheson proposals would gag directors ofpublic healthby relegating advocacy of health to "the annualreport." Rather public health doctors should be per-mitted to speak out freely and represent communityinterests in all health controversies. All in all, theBMJ's spokesman is disappointed:We need a new type of practitioner for the new public health.The new public health is about giving away knowledge,power, and skills; it is enabling individuals and communitiesto take control of their own health.8Thus today'sBM7 offers a radically new representa-

tion of public health. Gone are the belittled cliniciansreaching out to become Playfairian "priests ofhumanity" under the moral mantle of public health as apreventive medical specialty. Now the BMJ is tellingits readers, right between the eyes, that "we need tostart again on neutral territory with a genuinelyinterdisciplinary and intersectoral directorate." Mostimportantly, technicians of all varieties, includingmedical people, must rethink their role because "in thenew public health, professionals should be on tap noton top."

Echoing its nineteenth century editors, the journalcontinues to ask: when will it be time for "health now?"

1 Playfair L. An address on the relation of medical men to the state. Br MedI1875;i:735-6.

2 Anonymous. The pursuit of health under difficulties. BrMedj 1866;i:311-2.3 Anonymous. Future provision of medical services. BrMedj 1920;i:800-20.4 Anonymous. The Health Service Bill. BrMedj 1946;i:489-91.5 Anonymous. A new structure. BrMed J 1968;iii: 197-8.6 Anonymous. Doctor or social worker? BrMedj 1968;iii:265-6.7 Anonymous. Community medicine: a second chance?BrMedj 1980;281:826.8 Ashton J. A missed opportunity for the new public health. Br Med J

1988;296:231-2.

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