• By Laura Whybra
  • Posted on Thursday 13th March, 2014

Lessons in prevention from three pioneers of public health

strong>The recent death, aged 101, of Dr Andrew Semple, former Medical Officer of Health for Liverpool, has highlighted the great achievements of public health pioneers in the UK – and the continuing relevance of their work for prevention science today.In our own days of good public health, it is hard to imagine the fear that epidemics caused our predecessors and the enormous social effects they had. Indeed, it is entertaining to speculate how preventive care could have changed the course of history. The elimination of plague could have delayed the decline of great Greek and Byzantine civilisations, while better perinatal care for Tudor royalty might have made Edward VI a less sickly child - thereby keeping ‘Bloody’ Mary and then Elizabeth I from the throne. In the 19th century, clean water might have granted Queen Victoria’s beloved consort, Prince Albert, a longer lease of life.The Victorian era in Britain did, however, see demands for action on public health reaching a crescendo and witnessed the rise of forceful as well as far-sighted pioneers. Three leading figures – John Simon, James Niven and Andrew Semple – demonstrated over the next hundred years how crucial preventative reforms could be achieved.Before their time there had been instances of individual physicians taking preventive action. For example, John Snow dramatically ripped the handle off a water pump in central London that he had concluded was a source of cholera-infected water. But it was not until 1848 that the Public Health Act established national responsibility and official posts.As Medical Officer of Health for the City and the City of London Commission for Sewers, Sir John Simon (1816-1904) worked tirelessly to improve drinking water, sewage disposal, housing and access to hospital and other medical care. James Niven (1851-1925) became Medical Officer of Health for Manchester from 1894 until 1922, taking preventative measures against a lethal “Spanish ‘flu” epidemic that struck the city in 1918. He had previously worked in nearby Oldham where he led a campaign for tuberculosis (TB) to be classified as a notifiable disease. In this, he was influenced by his collaboration with Robert Koch, the Berlin-based doctor, who discovered the TB bacillus and demonstrated that this, not “bad air”, caused the deadly disease. Niven also had a passionate interest in child welfare and introduced strategies to make life safer for young people.When first appointed Medical Officer in Liverpool in 1948, Andrew Semple found a city riddled with infectious diseases, slum housing and toxic air pollution. Between then and 1974, he variously instigated a massive chest X-ray programme to identify asymptomatic TB, sought rehousing for TB patients, instigated mental welfare services and set up facilities for children with leaning difficulties. He also allocated money to family planning and health education.Lessons for the 21st centuryAll of these were remarkable achievements. But how can they inform our efforts to advance prevention science today?Health scientists can be said to enjoy an advantage over social reformers in that the cause of many illnesses is a single, preventable pathogen. Once identified, mass programs of inoculation and other preventative action can yield dramatic results. The global eradication of smallpox is a striking example. By contrast, those seeking to prevent psychosocial problems must often contend with multiple causes, risk factors and contextual variables.It is also clear that the science underlying the problem to be prevented must be sound. Our three pioneers in public health were eager to apply fresh knowledge and new methods. But when the science was wrong, disaster could strike. Thus, a well-meaning project to bring seemingly pure water from rural Croydon into central London faltered because it carried the cholera bacterium, triggering an epidemic. The three doctors were also tenacious and passionate about their cause. Each had a deep concern for the health of the poor and vulnerable, and was prepared to argue vigorously with those who challenged their use of taxpayers’ money. Semple’s allocation of public funds for family planning in Liverpool, for example, caused consternation among civic leaders from the city’s large Catholic community. All three were politically astute when challenging vested interests, although some of the compromises carried unwanted side effects. When Simon pressed for the creation of a hospital (St. Thomas’s) that could be easily accessed by the poor, he chose a site on the south side of the River Thames. His choice of an inner city location was opposed by the pioneer of modern nursing, Florence Nightingale, who believed in the benefits of fresh air. So while Simon got the hospital where he wanted, he was compelled to accept a design that allowed the prevailing south westerly winds to “purify” the atmosphere in its wards. Overcoming resistanceSemple, in the next century, encountered resistance to his mass chest radiography program from dockworkers who feared they would lose their jobs if the results of TB checks proved positive. To overcome this, he threw tea parties for dockers’ wives, held raffles and persuaded celebrities including the movie star Yul Brynner, comedian Ken Dodd and the ballet dancer, Dame Margot Fonteyn, to undergo high profile X-rays.Today’s prevention scientists might usefully note this willingness among those promoting better public health to embrace the mass media and take advantage of opportunities to promote their campaigns – even when presented by chance. Thus, in 1959, when there was a serious outbreak of the polio in the Midlands, parents were cautious about having their children inoculated with the two available vaccines. Initial take up was, worryingly low following claims that vaccination could cause as well as prevent the paralysing disease. However, in the midst of controversy, Jeff Hall, a footballer in England’s national soccer team, fell victim and died after his fight for life in an “iron lung” breathing machine had been widely reported in the press. As might still be expected today, the publicity involving a celebrity factor helped health campaigners to engineer a lasting shift in public opinion result that more orthodox methods had struggled to achieve.**************References:Lambert, R. (1963) Sir John Simon, 1816-1904, and English Social Administration. London: MacGibbon & Kee.Elwood, J.W. & Tuxford, A.F. (Eds.) (1984) Some Manchester Doctors: a biographical collection to mark the 150th anniversary of the Manchester Medical Society 1834-1984. Manchester: Manchester University Press.Sheard, S. (2006) The Nation’s Doctor. London: The Nuffield Trust.Sheard, S. (2013) Andrew Semple obituary, The Guardian, 18th December 2013.

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