Comment
The changing role of the British state and its citizens
www.thelancet.com Vol 384 November 8, 2014
In 1898, Frederick Gowland Hopkins proposed the existence of accessory factors in foods and, along with the Dutch physician Christiaan Eijkman, would later be awarded the Nobel Prize for the discovery of several vitamins in foods. Some years earlier, Robert Koch and Louis Pasteur had shown the existence of germs: invisible but present everywhere. If the state was to improve the health of its population—whether to ensure a supply of soldiers, workers, or through simple altruism—it had to intrude into the daily lives of its citizens, especially women who, in the prevailing culture, were regarded as mainly responsible for reproduction, food preparation, and cleanliness. As the 20th century progressed, so did advances in clinical care. No longer was it the case, as Florence Nightingale had noted, that going into hospital increased one’s risk of death. Most patients could now expect to survive surgical procedures. However, there were substantial financial barriers to obtaining effective care. As casualties from bombing mounted on the home front in World War 2, the state was forced to make provision for the injured. The Emergency Medical Service became the basis for the post-war National Health Service.8 The attrition of merchant shipping in the Battle of the Atlantic forced the state to introduce rationing, but its policies were based on scientific advice about the composition of a healthy diet.9 Now, the government was telling its citizens what they could and could not eat. The government also took over some aspects of parenting, providing free
See Comment pages 1644, 1646, and 1651
Bettmann/Corbis
A J P Taylor, the British historian, noted that before World War 1, “a sensible, law-abiding Englishman could pass through life and hardly notice the existence of the state, beyond the post office and the policeman”.1 After the war, the life of a British citizen would be shaped by the state and its institutions in ways that could never previously have been imagined. Wars make states2 is perhaps the most famous phrase to describe the emergence of Europe’s nation states. States had to expand their role to ensure a regular supply of soldiers fit enough to fight.3 This expansion involved measures to improve public health, such as the 1902 Midwives Act, which was at least partly a response to the poor quality of recruits available for the Boer War.4 World War 1 was on a much greater scale than previous conflicts and would require a vastly expanded state role. Within days of the outbreak of war, the British Government passed the Defence of the Realm Act, which granted the state extraordinary powers, ranging from the right to seize land and property, to censorship.5 Some measures might have had consequences for health, such as the restriction of public houses’ opening hours and the content of alcoholic drinks; in some places it was even illegal to buy someone else a drink. However, for other measures, any link was tenuous or non-existent, such as prohibitions on feeding of scarce bread to birds and flying of kites. In 1916, conscription was introduced, allowing the state to determine who must fight. The war also ensured that some measures introduced earlier would continue, showing the wartime commitment to create a “fit country for heroes to live in”.6 After 1909, the few poor people who survived beyond the age of 70 years could receive a small pension, and, from 1911, the new national insurance scheme enabled specific types of workers who were ill or unemployed to receive compensation. At the same time, scientific advances in the understanding of origins of disease were creating a large role for the state in maintaining health. In the late 19th century, public health had focused on threats to health that could be seen or smelt, such as the socalled Great Stink of 1858, when the Thames was awash with human sewage.7 However, the new threats were invisible. Gregor Mendel’s work led to recognition of the underlying threat posed by some inherited genes.
1643
Comment
school meals and milk. The post-World War 2 period was one of further expansion of the role of the state, in health, education, housing, social care, and welfare. These policies showed a cross-party consensus, with substantial advances under Labour leaders, such as Clement Attlee, and Conservatives, such as Harold Macmillan. These developments were associated with sustained improvements in health; life expectancy at birth improved from 51 years for men and 55 years for women in 1914, to 71 years for men and 77 years for women in 1980. However, the political consensus then broke down. Before becoming Prime Minister, Margaret Thatcher had shown her commitment to reducing the role of the state when she withdrew free school milk for children older than 7 years. In government, she went further, radically reducing the role of the state in provision of social housing. However, subsequent Prime Ministers would go much further so that, a century after the outbreak of World War 1, the state seems to be in full retreat. Functions that, until even a decade ago, would have been seen as core responsibilities of government, such as defence and prisons, have been transferred to transnational corporations. Warnings that the 2012 Health and Social Care Act will lead to extensive privatisation of National Health Service provision can no longer be dismissed.10 Current Prime Minister David Cameron has placed only two areas, the security services and judiciary, beyond the scope of privatisation.11 However, history shows us that nothing is inevitable.
This policy is already fraying at the edges, as some corporations realise that they cannot make profits and safeguard their reputations.12 Could it be that the cycle of state expansion will soon start again? *Martin McKee, David Stuckler European Centre on Health of Societies in Transition, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK (MM); and Department of Sociology, University of Oxford, Oxford, UK (DS) [email protected] We declare no competing interests. 1 2 3
4 5
6 7 8 9 10 11
12
Taylor AJP. English history 1914–1945. Oxford: Oxford University Press, 1965. Tilly C. The formation of national states in western Europe. Princeton NJ: Princeton University Press, 1975. Downing BM. The military revolution and political change: origins of democracy and autocracy in early modern Europe. Princeton, NJ: Princeton University Press, 1993. Lewis J. The politics of motherhood: child and maternal welfare in England, 1900–1939. Montreal and Ontario: McGill-Queen’s University Press, 1980. Vorspan R. Law and war: individual rights, executive authority, and judicial power in England during World War I. Vand J Transnat’l L 2005; 38: 261–343. Partington A (ed). The Oxford Dictionary of Quotations. London: BCA, 1992. Halliday S. The great stink of London: Sir Joseph Bazalgette and the cleansing of the Victorian metropolis. Stroud: The History Press, 2001. Rivett G. The development of the London hospital system 1823–1982. London: King Edward’s Hospital Fund for London, 1986. Zweiniger-Bargielowska I. Austerity in Britain: rationing, controls, and consumption, 1939–1955. Oxford: Oxford University Press, 2000. Reynolds L, McKee M. Opening the oyster: the 2010–11 NHS reforms in England. Clin Med 2012; 12: 128–32. Cameron D. How we will release the grip of state control. Feb 20, 2011. The Telegraph http://www.telegraph.co.uk/comment/8337239/How-wewill-release-the-grip-of-state-control.html (accessed Oct 11, 2014). Illman J. Serco to withdraw from UK clinical services market. Aug 15, 2014. Health Service Journal http://www.hsj.co.uk/news/finance/serco-towithdraw-from-uk-clinical-services-market/5073892.article (accessed Oct 27, 2014).
Kami/arabianEye/Corbis
Refugees and health: lessons from World War 1
See Comment pages 1643, 1646, and 1651
1644
The vast territory and huge number of civilians affected by World War 1 caused an unprecedented displacement and forced migration of people in Europe and beyond.1 There is little consensus on the actual number displaced, but more than 9 million were internally displaced persons and more than 3 million were refugees.1–3 Although not comparable to the conflict in World War 1, today there are more than 51 million people worldwide who have been forcibly displaced; these include internally displaced persons, refugees, and asylum seekers, the largest number since World War 2.4 16·7 million of these people are refugees, 33·3 million are internally displaced persons, and 1·2 million are asylum seekers. More than half of all refugees come from just three countries:
Afghanistan, Syria, and Somalia. Lebanon hosts the largest number of refugees in relation to its population, with 178 refugees per 1000 inhabitants; this burden is the highest of any country since 1980.4 As in current conflicts such as those in the Central African Republic, Iraq, Mali, and Syria, the ethnic and religious dimensions of World War 1 played an important part in displacement of people. The pogroms in Galicia and Bukovina (both formerly part of AustriaHungary) caused about 70 000 Jews to flee to Vienna, Austria; this number had increased to 173 000 in May, 1917.1 During the war many Armenians fled from Turkey to neighbouring countries and hundreds of thousands were killed in 1915.1 Current conflicts causing massive www.thelancet.com Vol 384 November 8, 2014
The changing role of the British state and its citizens
www.thelancet.com Vol 384 November 8, 2014
In 1898, Frederick Gowland Hopkins proposed the existence of accessory factors in foods and, along with the Dutch physician Christiaan Eijkman, would later be awarded the Nobel Prize for the discovery of several vitamins in foods. Some years earlier, Robert Koch and Louis Pasteur had shown the existence of germs: invisible but present everywhere. If the state was to improve the health of its population—whether to ensure a supply of soldiers, workers, or through simple altruism—it had to intrude into the daily lives of its citizens, especially women who, in the prevailing culture, were regarded as mainly responsible for reproduction, food preparation, and cleanliness. As the 20th century progressed, so did advances in clinical care. No longer was it the case, as Florence Nightingale had noted, that going into hospital increased one’s risk of death. Most patients could now expect to survive surgical procedures. However, there were substantial financial barriers to obtaining effective care. As casualties from bombing mounted on the home front in World War 2, the state was forced to make provision for the injured. The Emergency Medical Service became the basis for the post-war National Health Service.8 The attrition of merchant shipping in the Battle of the Atlantic forced the state to introduce rationing, but its policies were based on scientific advice about the composition of a healthy diet.9 Now, the government was telling its citizens what they could and could not eat. The government also took over some aspects of parenting, providing free
See Comment pages 1644, 1646, and 1651
Bettmann/Corbis
A J P Taylor, the British historian, noted that before World War 1, “a sensible, law-abiding Englishman could pass through life and hardly notice the existence of the state, beyond the post office and the policeman”.1 After the war, the life of a British citizen would be shaped by the state and its institutions in ways that could never previously have been imagined. Wars make states2 is perhaps the most famous phrase to describe the emergence of Europe’s nation states. States had to expand their role to ensure a regular supply of soldiers fit enough to fight.3 This expansion involved measures to improve public health, such as the 1902 Midwives Act, which was at least partly a response to the poor quality of recruits available for the Boer War.4 World War 1 was on a much greater scale than previous conflicts and would require a vastly expanded state role. Within days of the outbreak of war, the British Government passed the Defence of the Realm Act, which granted the state extraordinary powers, ranging from the right to seize land and property, to censorship.5 Some measures might have had consequences for health, such as the restriction of public houses’ opening hours and the content of alcoholic drinks; in some places it was even illegal to buy someone else a drink. However, for other measures, any link was tenuous or non-existent, such as prohibitions on feeding of scarce bread to birds and flying of kites. In 1916, conscription was introduced, allowing the state to determine who must fight. The war also ensured that some measures introduced earlier would continue, showing the wartime commitment to create a “fit country for heroes to live in”.6 After 1909, the few poor people who survived beyond the age of 70 years could receive a small pension, and, from 1911, the new national insurance scheme enabled specific types of workers who were ill or unemployed to receive compensation. At the same time, scientific advances in the understanding of origins of disease were creating a large role for the state in maintaining health. In the late 19th century, public health had focused on threats to health that could be seen or smelt, such as the socalled Great Stink of 1858, when the Thames was awash with human sewage.7 However, the new threats were invisible. Gregor Mendel’s work led to recognition of the underlying threat posed by some inherited genes.
1643
Comment
school meals and milk. The post-World War 2 period was one of further expansion of the role of the state, in health, education, housing, social care, and welfare. These policies showed a cross-party consensus, with substantial advances under Labour leaders, such as Clement Attlee, and Conservatives, such as Harold Macmillan. These developments were associated with sustained improvements in health; life expectancy at birth improved from 51 years for men and 55 years for women in 1914, to 71 years for men and 77 years for women in 1980. However, the political consensus then broke down. Before becoming Prime Minister, Margaret Thatcher had shown her commitment to reducing the role of the state when she withdrew free school milk for children older than 7 years. In government, she went further, radically reducing the role of the state in provision of social housing. However, subsequent Prime Ministers would go much further so that, a century after the outbreak of World War 1, the state seems to be in full retreat. Functions that, until even a decade ago, would have been seen as core responsibilities of government, such as defence and prisons, have been transferred to transnational corporations. Warnings that the 2012 Health and Social Care Act will lead to extensive privatisation of National Health Service provision can no longer be dismissed.10 Current Prime Minister David Cameron has placed only two areas, the security services and judiciary, beyond the scope of privatisation.11 However, history shows us that nothing is inevitable.
This policy is already fraying at the edges, as some corporations realise that they cannot make profits and safeguard their reputations.12 Could it be that the cycle of state expansion will soon start again? *Martin McKee, David Stuckler European Centre on Health of Societies in Transition, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK (MM); and Department of Sociology, University of Oxford, Oxford, UK (DS) [email protected] We declare no competing interests. 1 2 3
4 5
6 7 8 9 10 11
12
Taylor AJP. English history 1914–1945. Oxford: Oxford University Press, 1965. Tilly C. The formation of national states in western Europe. Princeton NJ: Princeton University Press, 1975. Downing BM. The military revolution and political change: origins of democracy and autocracy in early modern Europe. Princeton, NJ: Princeton University Press, 1993. Lewis J. The politics of motherhood: child and maternal welfare in England, 1900–1939. Montreal and Ontario: McGill-Queen’s University Press, 1980. Vorspan R. Law and war: individual rights, executive authority, and judicial power in England during World War I. Vand J Transnat’l L 2005; 38: 261–343. Partington A (ed). The Oxford Dictionary of Quotations. London: BCA, 1992. Halliday S. The great stink of London: Sir Joseph Bazalgette and the cleansing of the Victorian metropolis. Stroud: The History Press, 2001. Rivett G. The development of the London hospital system 1823–1982. London: King Edward’s Hospital Fund for London, 1986. Zweiniger-Bargielowska I. Austerity in Britain: rationing, controls, and consumption, 1939–1955. Oxford: Oxford University Press, 2000. Reynolds L, McKee M. Opening the oyster: the 2010–11 NHS reforms in England. Clin Med 2012; 12: 128–32. Cameron D. How we will release the grip of state control. Feb 20, 2011. The Telegraph http://www.telegraph.co.uk/comment/8337239/How-wewill-release-the-grip-of-state-control.html (accessed Oct 11, 2014). Illman J. Serco to withdraw from UK clinical services market. Aug 15, 2014. Health Service Journal http://www.hsj.co.uk/news/finance/serco-towithdraw-from-uk-clinical-services-market/5073892.article (accessed Oct 27, 2014).
Kami/arabianEye/Corbis
Refugees and health: lessons from World War 1
See Comment pages 1643, 1646, and 1651
1644
The vast territory and huge number of civilians affected by World War 1 caused an unprecedented displacement and forced migration of people in Europe and beyond.1 There is little consensus on the actual number displaced, but more than 9 million were internally displaced persons and more than 3 million were refugees.1–3 Although not comparable to the conflict in World War 1, today there are more than 51 million people worldwide who have been forcibly displaced; these include internally displaced persons, refugees, and asylum seekers, the largest number since World War 2.4 16·7 million of these people are refugees, 33·3 million are internally displaced persons, and 1·2 million are asylum seekers. More than half of all refugees come from just three countries:
Afghanistan, Syria, and Somalia. Lebanon hosts the largest number of refugees in relation to its population, with 178 refugees per 1000 inhabitants; this burden is the highest of any country since 1980.4 As in current conflicts such as those in the Central African Republic, Iraq, Mali, and Syria, the ethnic and religious dimensions of World War 1 played an important part in displacement of people. The pogroms in Galicia and Bukovina (both formerly part of AustriaHungary) caused about 70 000 Jews to flee to Vienna, Austria; this number had increased to 173 000 in May, 1917.1 During the war many Armenians fled from Turkey to neighbouring countries and hundreds of thousands were killed in 1915.1 Current conflicts causing massive www.thelancet.com Vol 384 November 8, 2014
