Changing social and medical attitudes affect ill health

Health was defined by The World Health Organisation in 1948 as, ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’.

Varying definitions of health can be found depending on an individual’s perspective. Medics will focus on biological cause while sociologists argue that health is a product of social and environmental factors. (Naidoo & Wills, 2009a: chapters 1&2)

In the early 19th Century there was focus on the elimination of diseases such as plague, smallpox and cholera. With industrialization and rapid urbanization, as the 19th century progressed, health issues became focused on environmental issues such as clean water supplies, disposal of waste and better housing. (Naidoo & Wills, 2009b:p3)

Health inequalities have been recognised in the UK since William Farr first published statistics in 1837. It remains the case today that health is directly influenced by social class and the effects of poverty and associated behaviour factors. (Ewles, 2005: pp243-245)

Urbanisation is the process of population concentration. The 19th century saw the massive growth of cities and the migration of the population from the country and into cities on a scale never seen before. Houses became over crowded with entire families living in one room. The process caused huge problems for public health.

(Pathfinder pack on Urbanisation – the move to the city in the 19th century, n.d.)

(Urbanisation in the nineteenth and twentieth centuries, n.d.)

Urbanisation was the most profound effect of the Industrial Revolution which developed at a pace in Britain between 1800 and 1850. Cities grew rapidly and lacked sanitation, accumulated sewage, had high rates of crime and poverty and consequently high rates of disease. Heavy use of coal led to an accumulation of dirt and grime.

(Urbanisation, n.d.)

Larger cities were a necessity of industrial growth but the conditions they brought were in many ways regressive. (Lee, 1995:p48)

The Growth of Cities 1801-1901 in thousands.

City

1801

1851

1901

Birmingham

71

233

523

Bradford

13

105

280

Leeds

53

172

429

Liverpool

82

376

704

Manchester

70

303

645

Newcastle

33

88

247

Nottingham

29

57

240

Sheffield

46

135

407

(Reynoldson 1996:p10)

A part of London was described by Thomas Southwood-Smith in 1838 as follows, ‘Beckwith Row has an open drain. The houses have common, open privies (toilets) which are in the most offensive condition. In one house I found six persons living in a very small room, two in bed, ill with fever’. (Reynoldson, 1996: p110)

http://t2.gstatic.com/images?q=tbn:HcwSJOrT5lACaM:http://www.makingthemodernworld.org.uk/stories/the_industrial_town/06.ST.02/img/IM.1064_zp.jpg Slums in 1872 London [Making the modern world, n.d.)

There were no controls on the standard of housing and the Government maintained a laissez-faire attitude. That is they believed there should be no central government intervention. Local efforts were haphazard and insufficient. (Todd, 2002:p31)

Smallpox was the greatest killer at the beginning of the 19th century. Jenner observed that milkmaids who caught a mild form of the disease or cowpox didn’t develop smallpox. From this study, Jenner discovered a method of vaccination against smallpox. He faced much opposition to his discovery as some people simply didn’t like anything new while others described his theory as bizarre. Jenner wasn’t a fashionable London Doctor and he couldn’t explain how or why vaccination worked so he wasn’t taken seriously. Some people called it an interference with nature. (Lee 1995:p44) (Todd, 2002:p32)

Success of the vaccine was put down to coincidence by some Doctors who made money through an older practice of inoculation. (Lee, 1995:p44)

A smallpox epidemic, during which 40,000 people died, resulted in the government making the smallpox vaccination compulsory in 1840 even though some continued to argue that this measure was against human rights. Smallpox declined, until by 1900 it had almost disappeared. This was the first example of the government accepting responsibility for an area of public health. (Lee, 1995:p44)

Cartwright in ‘A social History of Medicine’ (1977) describes Jenner’s discovery as ‘one of the most beneficial changes in the history of social medicine….his work is recognised as the starting point of attempts to combat infection by immunization’. (adapted from Lee, 1995:p45)

‘Jenner’s work and the train of events that followed affected a social revolution. Individual choice was sacrificed for the interests of the community.’ (Cartwright, 1977:p92)

At the same time, two other diseases also presented a challenge. TB & cholera were more difficult to tackle as both diseases spread as a result of poor living conditions. TB or consumption took hold as towns grew and took over from smallpox as the greatest killer disease. Cholera epidemics struck several times during the first half of the 19th century. In 1854 John Snow proved that cholera was connected with polluted water. He was able to show that a water pump in the Broadgate area of London was the origin of 500 cases. People using another pump nearby did not catch the disease. Once the Broadgate pump was put out of action, no further cases were reported in the area. (Lee, 1995:p51)

http://t3.gstatic.com/images?q=tbn:dkmPPVrjlaE3NM:http://historyday.coldray.com/wp-content/uploads/2008/12/john-snow.jpg John Snow (1813-1858) http://t2.gstatic.com/images?q=tbn:fd12xpKjN8GveM:http://thedoublethink.com/wp-content/uploads/2009/04/450px-john_snow_memorial_and_pub.jpg Replica Broadgate pump

(www.health.eku.edu/ehs/faculty/darryl_barnett.htm)

A fierce debate raged about responsibility for public health with strong views about the role of the government. Several arguments for non-intervention were put forward including that government intervention would interfere with people’s basic rights – or the freedom to be dirty. Some people believed that if the state acted to improve housing the moral courage of the poor would be reduced. (Lee 1953: p53)

A letter to The Times in 1854 read, ‘We prefer to take our chance with cholera than be bullied into health. Many people have died from a good washing’. (Quoted in Lee, 1995:p53)

But several important people put the case for action by the state including William Farr and Thomas Southwood-Smith who both recommended government intervention. Tonge in ‘Challenging History 1700-1914’ says, ‘Of all the campaigners for improved public health, Edwin Chadwick stands monumentally above the rest’. Chadwick stressed the connection between public health and disease and how such factors needed to be addressed by government intervention. Chadwick’s report ‘The sanitary conditions of the Labouring Population of Great Britain’ was published in 1842 and recommended that the government take steps to improve drainage, remove rubbish from the streets and improve the water supply. (Wilkes: 2007: p 92) (Reynoldson: 1996, p 113)

http://t0.gstatic.com/images?q=tbn:iK4kyWJkVFmbWM:http://wpcontent.answers.com/wikipedia/commons/thumb/9/9e/SirEdwinChadwick.jpg/200px-SirEdwinChadwick.jpg Edwin Chadwick (www.answers.com/topic/edwin-chadwick)

The government distanced itself from Chadwick’s report largely because of the influential figures he has discredited and the laissez-faire debate lasted for much of the 19th century. Loosely translated this means ‘do not interfere’. Some members of parliament were making money from rent on the slums and refused to tear them down. Eventually, however, the social effects of economic growth were so severe that gradually the state became more involved in issues of public health. The ‘great stink’ in 1858 (when a heat wave caused the Thames to smell worse than ever) inspired the government into action. (Wilkes 2007).

In 1861, Prince Albert’s death from typhoid was attributed to contaminated water from the Thames and put further pressure on the government to do something. (Cartwright, 1977, p95)

In 1867, working class men were given the right to vote. Political parties realised that by promising to improve living conditions, they could secure the working class vote. When the Conservatives won the 1874 election, they introduced many public health reforms. Aaron Wilkes (Medicine through Time) sees this as ‘the most important reason why politicians began to make improvements’.

Some cities including Birmingham and Liverpool started some clearance of slums, built sewers, improved refuse collection services and opened public baths. Some private companies such as Lever, Cadbury and Rowntree saw the benefits of providing good housing for their workers. It was, however, not until after the First World War that extensive slum clearance was commenced. (Lee 1995:p57)

Miasma or ‘the infectious mist’ given off by rotting animals, rubbish and human waste was thought to be the cause of many of the epidemics in the 19th Century. Scientists identified germs using a microscope but believed that the disease caused germs rather than the other way round. This was known as ‘spontaneous generation’. Louis Pasteur questioned this theory and was able to prove that germs caused disease but many Doctors wouldn’t entertain his ideas. It took the German Doctor, Koch, to apply Pasteur’s theory to human disease. Koch was able to prove that germs caused TB, cholera and anthrax. (Mantin & Pulley, 1988:p49)

http://t2.gstatic.com/images?q=tbn:OdyqTCWJiq49tM:http://web.ukonline.co.uk/b.gardner/pasteur.jpg Louis Pasteur (web.ukonline.co.uk/b.gardner/pasteur.htm)

Pasteur built on Koch’s work and developed a vaccine for rabies. Soon the germs responsible for typhus, tetanus, typhoid, pneumonia, meningitis, plague, septicaemia and dysentery were identified. Once germs were discovered vaccines could be made. ‘Scientists now had a powerful new weapon to fight disease’. (Wilkes, 2007:p88)

Vaccination is one of the greatest success stories of modern medicine. Smallpox has been wiped out and tuberculosis and polio have been significantly reduced. Children are now regularly vaccinated against a number if diseases. (Lee, 1995:82) The smallpox vaccine was given free in 1840 but it was another 100 years before vaccination against TB was provided. This was followed by vaccines for diphtheria, whooping cough and tetanus (1954), polio (1955), measles (1964) and rubella (1969). (Lee, 1995:p82)

Progress continues today as a new vaccine has been introduced this year which protects girls against the virus that causes cervical cancer.

The 19th Century also saw developments in surgery. The problems were pain and infection. The breakthrough came with the development of anaesthetics and antiseptics. (Lee, 1995: pp59&61)

William Moston experimented with ether and James Simpson tried chloroform. As with most medical discoveries, the first reaction of surgeons was criticism. Some argued that the long term effects were unknown and others objected on religious grounds. In some cases patients still died if the anaesthetic wasn’t correctly administered. Some people thought that surgeons would cut off ‘whatever they liked’ while the patient was unconscious and army Doctors thought the use of anaesthetic was ‘soft’. (Reynoldson, 1996:97). Others said that it was ‘unnatural’ to ease a woman’s pain during childbirth. The breakthrough came when Queen Victoria used chloroform during the birth of her eighth baby and use of anaesthetics then became common practice. (Wikes, 1988: p101)

The use of anaesthetics was a great step forward but it didn’t stop deaths from infection after the operation. In the 19th Century hospitals were dirty places. Patients with disease were herded together, the same instruments were used on many patients and Doctors didn’t change their blood stained coats between operations. Doctor Joseph Lister was influenced by Pasteur and believed it important to kill the bacteria in the operating theatre. He did this by spraying carbolic acid (although his theory wasn’t quite accurate as the bacteria was really on the instruments not in the air, but the incidence of infection was reduced by some of the antiseptic also landing on the instruments in use). Lister encountered much opposition as nurses and doctors complained about the smell and the amount of time taken to clean the theatre. Lister didn’t communicate well and surgeons who didn’t work with him were not convinced. (Lee.1995: p64)

Eventually antiseptics and cleanliness came together to form the modern approach to surgery or asepsis. By the beginning of the 20th century Doctors were operating in a germ free environment, using sterilised equipment and wearing gowns & masks. Death rates reduced massively; at Newcastle Infirmary before 1873, 59.2% of patients died after an operation (pre antisepsis), after 1873 only 4% died (post antisepsis). (Figures from The Lancet in 1878 in Lee, 1995:p65).

Use of a carbolic spray during an operation circa. 1880 and the sterile environment of a modern operating department.

http://t0.gstatic.com/images?q=tbn:476AON2yuy0EGM:http://www.answersingenesis.org/assets/images/articles/aid/v4/antiseptic-surgery.jpg http://t0.gstatic.com/images?q=tbn:sgiACWjAMvVpNM:http://www.workingmats.com/images/Operating_Theatre_115313_08.jpg

(www.history.langtreeshout.org/tag/lister/)

(www.workingmats.com/images/Operating_Theatre)

During the Crimean war (1854/56) Florence Nightingale’s influence saw death rates reduce as she was responsible for organising better water supplies and food and keeping the wards clean. Fiona Reynoldson in ‘Medicine Through Time’ says the death rate of wounded soldiers in hospital reduced by 40% under Nightingale’s influence.

In 1899 a recruitment campaign for men to fight in the Boar War highlighted the fact that around 40% of those volunteering were unfit for military duty. In 1904 a government report concluded that there needed to be more government intervention to improve the health of children. When the Liberal government was elected in 1905, a large number of reforms were introduced including free school meals for poor children, a free school medical service and women were taught about hygiene and childcare. Pensions for over 70s and basic sick and unemployment pay were also introduced. Over the next 30 years successive governments took measures to improve the health of children and mortality rates dropped. (Wilkes, 2007:p114)

During the 1st World War, Prime Minister Lloyd George promised soldiers returning ‘homes fit for heroes’. The government set itself a target of building half a million decent homes by 1933. ‘The war revolutionized society and made us move in a new and different direction’. (Fenwick-Baines, 2009)

When Britain was plunged into the First World War the need for a way to combat staphylococcus, a highly resistant bacteria, was urgently needed. Many soldiers died, not from the bullets, but from the infection caused by the bullets deep in the body. Conditions in the trenches were appalling and wounds quickly turned septic. Alexander Fleming worked on wounds and infections during the war and made an important discovery that the penicillin mould would attack and kill certain bacteria. Fleming is credited with its discovery but other scientists went on to develop the drug for human use. Initially, money wasn’t available for its manufacture but The Second World War was vital in progressing its mass production. The American government recognised its value and agreed to pay drug companies to manufacture vast quantities to treat injured soldiers. Penicillin is still the most widely used antibiotic and is used to treat many bacterial infections, many other antibiotics followed . By the end of the war, drug companies made it available for general use. (Wilkes, 2007: p118) (Board works, 2003)

The problem of blood shortage baffled Doctors for centuries but hundreds of wounded soldiers provided the strongest possible reason for expediting the establishment of the new blood transfusion service. This is another typical example of war acting as a catalyst for change.

The 2nd World War actually saw the health of the nation improve as rationing meant that fatty & sugary foods were in short supply. The government urged people to ‘dig for victory’ and grow their own vegetables. The government promoted healthy living including basic hygiene and immunisation against diphtheria – all part of a campaign to have a healthy nation able to stand up to Hitler.(Board works, 2003)

Dig For Victory http://www.5aday.nhs.uk/images/top_tips_2/pic_carrot_eyes.jpg

The ‘Dig for Victory’ campaign during the 2nd World War is remarkably similar to today’s ‘Try 5’ message.

(www.bbc.co.uk/dna/h2g :2009) (www.5aday.nhs.uk: )

Birth rates reduced with the availability of contraception and with fewer mouths to feed, better food was provided for children.

Between the wars little changed as the economy experienced difficulties (the 1930s depression) but during and after the Second World War there was a further huge development. In 1942 The Beveridge Report recommended a welfare state and that the government should help people from ‘the cradle to the grave’. After the war people wanted change and a social revolution. The war was over and it was time to look to the future. Some people did not like the new ideas and said everyone should be independent, the rich objected to paying heavier taxes to fund the welfare state. (Cartwright 1977: p173)

The suggestions made by Beveridge were not immediately put into force as the cost was questioned but when Labour took power in 1945, the NHS was born. From the introduction of the NHS in 1948, everyone was entitled to free medical treatment. The welfare state and the NHS in particular met with opposition. Churchill and the conservative party felt the cost was too much for the economy to bear. Critics suggested the health service was wasteful and that people were getting things they didn’t need. The service was also free to overseas visitors and some argued that this was over-generous. The BMA objected, initially fearing Doctors would lose their independence and that their income would reduce as an employee of the NHS. Compromise was only reached when agreement was given that Doctors would still be able to take on private, fee-paying patients. (Lee 1995:95) (Reynoldson, 1996:118) (Lloyd T. 1986:289) (Wilkes, 2007:123)

The dawn of the NHS was a huge change in the way people accessed healthcare.

After the war New Towns were built to replace the inner city slums. The 1947 Town and Country Planning Act identified green belts where houses would not be allowed to swallow up the countryside. In 1954 the clean air act reduced smoke and smog in cities.

In 1980, The Black Report stated that although health had improved since the introduction of the welfare state, huge inequalities in still existed between the rich and the poor. It concluded the reason for the disparity to be poverty. (BBC History, 2009)

1992 saw the publication of ‘The Health of the Nation’. This was the first ever strategy for healthcare improvement setting out objectives and measurable targets in four key areas: heart disease & stroke, cancers, mental health, HIV/AIDS and accidents. The areas were selected because they were either a major cause of premature death or avoidable, interventions were possible and achievements could be monitored. (Childs, 1996)

In 2000 health authorities became more autonomous and the establishment of a ‘healthy competition’ between them. However, postcode can now determine the quality of healthcare provided and whether the hospital can afford or is willing to pay for the specific drugs and treatments, Press reports in recent months have highlighted how some patients been declined expensive cancer drugs by a particular hospital while it is provided to patients of a neighbouring authority. This contradicts the ethos of the NHS & its position of ‘equality of provision for all’.

Massive changes took place throughout the 19th and 20th centuries in terms of public health provision and scientific and medical discoveries. The NHS didn’t stay completely free. It is rarely out of the news as waiting lists get longer because people are living longer. The main problem is funding as modern drugs and treatments are expensive.Most Infections and diseases can be prevented or cured but Doctors still struggle with heart disease and cancer. Viral infections like the common cold and AIDS cannot be cured and emphasis is now placed on educating people about how to avoid diseases like AIDS and lung cancer through lifestyle changes. (Wilkes A. 2007:p124)

Two aspects of modern living which can have a detrimental effect on the health of the population are; smoking and diet.

Although initially promoted as ‘cleansing the lungs’ by tobacco manufacturers, the detrimental effects of smoking have been know for half a century. Naidoo & Willis in ‘Public Health and Health Promotion: developing practice’ highlight smoking as the ‘single most preventable cause of ill health and premature death.’ A third of cancer deaths are linked to smoking and it is also linked to heart and lung disease. Smoking is estimated to cost the NHS £1.7billion each year (Dept of Health 1998 & Royal College of Physicians 1992 in Naidoo & Willis 2009)

Marlboros for Mummy Examples of early cigarette advertising.

http://news.bbc.co.uk/nol/shared/spl/hi/pop_ups/03/uk_goodbye_tobacco_ads/img/2.jpg

(news.bbc.co.uk/…/html/2.stm) (news.bbc.co.uk/…/html/2.stm, 2009)

Early Cigarette advertising actually promoted the health benefits claiming relief from asthma, wheezing and hay fever. Craven called itself the ‘Doctors Choice’. Marlbroro promoted the benefits of smoking to Mothers.

In 1998 the government banned tobacco advertising and targeted an anti-smoking campaign at children, pregnant women and disadvantaged adults. Demand is controlled by taxation and a ban on smoking in a public places including pubs.

Obesity is a growing problem and has trebled since 1980. It is linked to social disadvantage and the way children’s lifestyles have changed over the last 50 years (more TV/computer time, less physical activity, convenience foods, working Mothers with less time). There is mounting pressure to ban the advertising of junk food. A high fat diet has been linked to heart disease and some cancers. NHS spending on sickness attributed to obesity has been estimated to exceed £3.6billion. (Joint Health Surveys Unit, 2002 & Mulvihill & Quigley, 2003 Naidoo & Willis 2009:p239).

Last year the government launched the ‘change4life’ education campaign to promote the message ‘eat well, move more, live longer’ which encourages parents to make sure their children have a minimum of one hour exercise each day and reduce the amount of fat in their diet.

http://t2.gstatic.com/images?q=tbn:lg0Gy-_B7JmSnM:http://www.sunseaandcycling.com/Files/Images/C4L_master-logo-rgb.jpg http://t1.gstatic.com/images?q=tbn:n39JMfcD3UH9DM:http://images.teamsugar.com/files/upl2/1/15111/11_2009/cb3240a4f35793dc_uk-change-4-life-ad.jpg

(www.nhs.uk/Change4life, 2009)

Public Health interventions have evolved as the government have taken responsibility for living conditions and health service provision, mass vaccination and immunization programmes.

The epidemiological transition in the 20th Century saw the main causes of death and illness shift from infections to illness such as heart disease and cancer where lifestyle is a huge factor. (Naidoo & Wills 2005:4)

Current public health measures include mass screening programmes for example for breast and cervical cancers, extensive vaccination programmes as well as education and advice delivered by practitioners and the media campaigns.

Examples of recent/current health media campaigns.

http://t1.gstatic.com/images?q=tbn:vS8pq7HettyShM:http://www2.glos.ac.uk/offload/staff/news/swineflu.jpg http://t3.gstatic.com/images?q=tbn:qNfrnzs-ahQTYM:http://draust.files.wordpress.com/2009/01/nhs-measles-poster.jpg http://t0.gstatic.com/images?q=tbn:gslEVyv3VyG7SM:http://www.elements4health.com/images/stories/conditions/breast-cancer-ribbon-2.jpg

(www.chesterfield.gov.uk/lowgraphic)..

(draust.wordpress.com)

(www.elements4health.com/report-highlights-ser)

The political agenda is dominated by social responsibility and recognition of the links between poverty and ill health. Acheson defines health promotion as ‘the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society’. (Acheson 1988 in Naidoo & Wills, 2005:4)