Skip to main content
Loading Explore guides…
Public Health History · Acedra
Home
Explore
Medicine
Public Health History
Sign in to save
Chat
If YouTube asks you to sign in, open the video on YouTube.
Watch on YouTube
Reload player
Transcript
89 segments
Copy
Hide video
0:00
[MUSIC PLAYING] [APPLAUSE] VIRGINIA BERRIDGE: Well, thank you very much for inviting me. I've been hearing about some of the other talks that you've had. And I think they probably all sound very much more interesting than public health. It can seem to be a bit of a dry topic, but it's also a very broad topic. And so I thought I'd start by asking you, what comes to your mind when somebody says "public health?" What sort of things do you think of? AUDIENCE: Flu injections.
0:40
VIRGINIA BERRIDGE: Flu injections? Yes. Yeah? AUDIENCE: Spread of dangerous diseases-- spread of communicable disease. VIRGINIA BERRIDGE: Yes, infectious diseases, communicable diseases. AUDIENCE: Education on the importance of exercise. VIRGINIA BERRIDGE: Education on the importance of exercise. Well, this is a very well-informed audience. These are all public health topics. And just to give you an idea of the breadth of the area, this is a diagram, which was done some years ago
1:07
by some public health academics.
1:12
It's called the Rainbow Diagram. They're talking about the determinants of health. And these are all the things which affect health-- lifestyle factors, social and community networks, general socioeconomic environmental conditions, with all sorts of subsets under that. So all of those potentially come under the topic of public health. So just to try and segment it a little bit more, it could be services, systems, institutions. So it could be in local government.
1:49
It could be in the National Health Service. It could be in a health education agency, advising you about what you should be doing. It could be a public health profession. Back in history, it was the medical officer of health. Nowadays, it might be the director of public health locally, or it might be, in this country, the Chief Medical Officer. Some of you will have heard of Dame Sally Davies who is often in the media. Well, she's our Chief Medical Officer in this country.
2:20
She's the public health supremo In the United States, it would be the Surgeon General. Then another way of thinking about public health, it can be a form of knowledge, a way of thinking. And so it could be focused on a topic, like nowadays, obesity or smoking. Or it can be broader, thinking about individual behavior and the individual's responsibility for their own health. Or even broader still, thinking about inequality in society and how to deal with that and the effects of that on health.
2:55
Or it can be thinking about things like the environment and housing. So very many topics come under public health. And the point that I wanted to make today, being a historian, is that time also affects public health, because public health has not always been the same. The things that have been focused on within public health have changed over time. And that's what I want to primarily talk about today, because it is a very huge topic. And so I'm going to look at the development of public health
3:32
in the past, how we've got to where we are in the present day, and I'm going to very briefly look at the past from the 19th century onwards. But I'm going to focus on four stages, really since the Second World War-- the rise of a variant of public health called social and community medicine. Then in the '70s, the rise of lifestyle-- the focus on lifestyle and also on evidence, one way and the other, in public health. Then on different versions of public health-- health
4:07
promotion, new public health, primary health care. And then finally, I'll finish up by looking at some of the recent changes and directions and where we might be going. Well, going back to the 19th century and up until the 1940s, just very briefly to sketch in how public health changed in those years, if we'd been talking about public health in the 19th century, we would have been talking about housing, the environment, and in particular, about sanitation.
4:45
Public health meant drains, because for much of the 19th century, sanitation drains were really absent. You will have read or heard about the conditions as they applied in large cities-- cities like London, the new industrial cities like Manchester-- which were built without much by way of the provision of public facilities, so houses that had no sanitation whatsoever. So the key focus of public health in the 19th century was getting sanitary provision. It was an environmental movement.
5:24
But then by the end of the 19th century, change came. There was the Bacteriological Revolution-- the discovery that specific agents caused disease. And so disease could be dealt with not by changing the environment, but by dealing with the individual who was diseased. So lots of treatments came in for different diseases-- for cholera, for typhoid, and so on. Then in the early 20th century, public health changed again. There was a big focus at that time on the hereditary nature of diseases.
6:05
People were thinking about disease as being inherited. And they were focusing on topics like alcohol. Alcoholism was seen as something that was inherited from one generation to the next. They were focusing on sexually transmitted disease, which was also seen as transmitted through the generations. And so the focus of public health came to be on women as mothers and what was called, in the terminology of the time, the future of the race. That seems to be a very rather eugenic sort
6:39
of terminology nowadays. But that was the language at the turn of the 19th, the early 20th century. And then finally, in the interval years-- the 1920s and the 1930s-- public health really expanded its remit. And the public health practitioners, the medical officer of health would be running not just preventive services and health education services, but also running hospitals and running health services more generally. They took over running health services, in particular in London.
7:16
The London County Council was very well-known for its public health services. So I want to focus on what happened next. And what happened next was a big change for public health. And it developed a new terminology. It became called social medicine or community medicine. Now why was this? It was because new challenges developed for public health after the Second World War. It had confidently been expected when people were talking about the need for a national health
7:52
service that that national health service would be focused on public health. It was intended to be, originally, a local government-focused service run by public health practitioners-- the medical officer of health. Well, that didn't happen. We had the service that we've got today in this country-- the National Health Service-- which is a much more centralized service not founded on public health. And so there was a need for a new role for public health.
8:25
And that caused a certain amount of concern. Now another reason why there was a new role for public health was that the whole pattern of disease, morbidity, and mortality in the population was changing. So just have a look at this graph here. And you can see some of the changes that were taking place. This is a graph from 1917 onwards up to 2007. So it's a 90-year period. But I think you can see broadly the changes that are taking place. The green line at the bottom, which is infectious disease,
9:06
is declining very rapidly. Just before and after the Second World War and into the 1950s, it's almost gone nowhere, really, from being quite important. And the other diseases-- cancer, which is the dotted, black line-- and circulatory diseases also becoming proportionately more important. So this was the change which was happening just before and after the Second World War. It was what was called the epidemiological transition, which was basically, the old infectious diseases were in decline.
9:54
The role of public health had been to deal with some of those diseases. And what was becoming much more important were the chronic diseases-- the sort of diseases that we think about nowadays-- cancer, heart disease, and so on. And across Europe-- and in particular, in this country-- there had been this establishment after the war of new health systems, but systems which were very much focused on hospitals and focused on sickness. People always said about the National Health Service,
10:27
it was a sickness service rather than a health service. And public health, which had been much more than that-- it had been about preventing sickness, as well as dealing with it-- seemed to have lost its role. And so people started to talk about what role it could have in the future. And one of those roles, which still, I think, echoes down to the present today, was something called social medicine. And this was a very broad vision amongst some public health
10:57
practitioners just before and after the Second World War. This is a quote here from one of the main practitioners of social medicine-- a man called John Ryle-- who was professor of social science at Oxford University in the 1940s. And he said social medicine was the "whole economic, nutritional, occupational educational and psychological opportunity or experience of the individual or the community." So you can see that's a very broad vision. It's not just talking about people's
11:32
economic circumstances, but it's talking about their mental health, too. It's talking about psychology. And it's not just talking about the individual. It's talking about the individual in relation to the community where they live. Very broad vision indeed-- so it was very much health seen as a positive condition and also an attempt to try and bring greater academic credibility to public health as well. So that was one vision which people hoped, in the public health field, might
12:06
form the basis of the way health was conceived and the way health services were oriented in the post-war period. But what happened instead was something which was a slightly more limited vision-- something called community medicine. And one of the key proponents was a man called Jerry Morris, who was one of my colleagues at the London School of Hygiene and Tropical Medicine. He lived until the age of 99. And he was still coming into work two or three days a week.
12:40
So he only died about six or seven years ago. But Jerry was one of the key proponents of community medicine. He wrote in the late 1950s a book called "Uses of Epidemiology," which talked about public health doctors-- and they all were doctors at this stage-- moving into the National Health Service as consultant community physicians. And in the Health Service, they would undertake something which he called community diagnosis. So they would be the people who looked to the population, who
13:21
worked out what the needs of that population were, in terms of sickness and prevention and healthy living, and they would help formulate the way in which health services were structured and provided. And the key discipline in all of that was going to be risk factor-- epidemiology. So this variant of epidemiology was the new science of this new style of public health. So that's, in effect, what happened to public health in this country. It moved into the National Health Service.
13:56
And only recently, as we'll hear later on, has it come out of the National Health Service. And this was all part of a changing focus within public health towards lifestyle and also towards using evidence in a consistent sort of way. So the move was away from infectious disease-- something causing a mass pandemic or epidemic-- towards individual behavior and lifestyle choices as the cause of ill health. And the key research, which I think set the tone for all of that, was the research
14:39
about the relationship between smoking and lung cancer, which was done by an epidemiologist and a statistician, Richard Doll and Sir Austin Bradford Hill. Both of them, just by chance, working at my own institution-- London School of Hygiene and Tropical Medicine. But I did know Richard Doll, because he also lived a very long time. I didn't know Bradford Hill. But they did this research in the late 1940s, early 1950s. And originally, interestingly, they hadn't thought that smoking was the cause
15:16
of the rise in lung cancer. They thought it might have been something to do with the roads being tarred and the fumes that were given off by that happening. So they were quite surprised when they discovered that there seemed to be an association between smoking and the rise in lung cancer. And this was carried forward by a very important report, which was published by the Royal College of Physicians in 1962-- picture up there, Smoking and Health. And again, that committee which produced
15:51
this report of the Royal College of Physicians had originally been a committee on smoking and air pollution. But they decided that smoking was a much easier issue to deal with than air pollution. And so they decided to focus their report on smoking. And of course, air pollution has now come back to haunt us. So epidemiology lay behind all of this-- the element of risk in populations. But what also developed-- and I'll be showing you an example of this in a little while--
16:25
was a completely different style of public health using mass media campaigns to try and change behaviors, speaking to the whole population, and trying to make the population change their lifestyle and change their behavior. Well, another offshoot of this change in public health in the post-war period was a focus on health services research and the role of evidence. And this was another offshoot from social medicine. Some of the social medicine pioneers moved off in a different direction,
17:03
trying to make health services more effective and more efficient. And a key person in that area was a man called Archie Cochrane. Some of you may have heard of something called the Cochrane Collaboration, which still is very active in the public health and the health field. Archie Cochrane was a social medicine advocate who undertook random-- he was a prisoner of war during the Second World War. He was in Japanese prisoner of war camp.
17:35
And he occupied himself by doing randomized controlled trials of diet amongst the prisoners in his prisoner of war camp. And after the war, he was a great proponent of using evidence in a more effective way to try and get the right outcomes in health. And he gave a very famous lecture-- the "Rock Carling Lecture"-- in the early 1970s. And this led to a book which is still cited today, "Effectiveness and Efficiency-- Random Reflections on Health Services,"
18:08
which was trying to move away from individual clinical impressions as the basis for treatment and the basis for action in health towards a much greater use of a considered evidence. And of course, the gold standard of that evidence was the randomized controlled trial, which is still very much central to public health and health services more generally. But meanwhile, public health was adopting this new style of mass media campaign. And I'm just showing this as an example of a campaign which
18:49
was run in the early 1970s by a new agency called the Health Education Council. Now I don't know if you've got ideas of what might be different about this. I've given you a little clue earlier on. Some things are rather different about this sort of campaign. But some things are similar to things in the past of public health. Can you think of anything that's different here? I know this is hard, because you're not history students.
19:25
AUDIENCE: Very graphic. VIRGINIA BERRIDGE: It's very graphic, yeah. It's using shock, isn't it? Maybe you're not shocked now. We're used to nudity. But certainly in the early 1970s, I think this was unusual for a health campaign. So it's using shock to attract your attention, to try and change your behavior. AUDIENCE: Nowadays, we wouldn't put so many words on the poster. VIRGINIA BERRIDGE: Sorry? AUDIENCE: Nowadays, we wouldn't put so many words on the poster. VIRGINIA BERRIDGE: That's true.
19:56
Yeah. But then it was quite limited in terms of words. AUDIENCE: It's very accusative as well. I feel nowadays, it would be more soft and advisory, rather than straight-on aggressive. VIRGINIA BERRIDGE: Yeah. It's pointing the finger and saying, you're to blame. Isn't it? Yeah. Yeah, it's true. Yeah? AUDIENCE: The text is less legible in the essential parts. Today's cigarette packets have big, big, red letters-- VIRGINIA BERRIDGE: Yes. Yeah, that's true.
20:30
AUDIENCE: It doesn't highlight the "smoking kills" part. VIRGINIA BERRIDGE: No, that's true. Well, it's a different subject for a public health poster. Before the war, it might have been things like, well, cleanliness or preventing infection or something like that. So having a smoking-focused ad-- I know nowadays this is nothing new-- but in the 1970s, it was quite new to have this sort of campaign around smoking. And the Health Education Council was spending a huge amount
21:06
of money in the '70s just on smoking and using the mass media. The other interesting thing about-- well, many interesting things about this ad-- but it was produced for the Health Education Council by an agency, Saatchi and Saatchi, who obviously went on to greater things after this. But Saatchi and Saatchi first made their name in the health education field. And they're bringing those advertising techniques-- American advertising techniques, really--
21:38
and the art of persuasion into the public health field. But interestingly-- and I don't expect you to pick up on this-- they are using a very old-fashioned topic, aren't they, because they're using women as the ones who are at fault, and they're using women as mothers. So women are the people who are producing babies who are going to be affected by their smoking. So women are being blamed. Now I have to say, this is a very common theme within public health. And it certainly goes back to the turn
22:15
of the 19th, 20th century when we had that theme of women as mothers. So there are some new things here, but also, there are some very old things, too. And that has continued, I think. But public health also continued to redefine itself. And I want to talk about just three other definitions-- health promotion, new public health, and primary health care. And this came out of a period in the 1970s, 1980s of an attack on mainstream medicine. I mentioned that after the Second World War,
23:00
there was a great focus on health services, on high tech medicine. Public health seemed to have lost its role. Well, by the time of the 1970s, that enthusiasm for high tech medicine had gone, and it had gone for a number of reasons, I think. Firstly, because of the rising costs of health care after the oil crisis in the early 1970s. And people began to think, do we really need all these expensive centralized health services? Should we be trying to think of lower cost
23:35
ways of preventing ill health in the population rather than dealing with poor health when it gets to a crisis situation? So that was one strand. But the other strand was a critique of medicine itself, saying, did it actually do any good? And this is something that all sorts of disciplines joined in. The sociologists were there and also, the social medicine people. A key leader in this was a man called Thomas McEwen, who was professor of social medicine at Birmingham University.
24:10
And he wrote this book, which I've got up here, "The Role of Medicine-- Dream, Mirage, or Nemesis?" and basically argued that official medicine-- orthodox medicine, high tech interventions-- did much less good than improving the general health of the population. And so this was obviously leading right into a renewed role for public health. And three variants of public health came on the agenda in the '70s, '80s, '90s. The first was primary health care, which was given its seal of approval
24:54
through the declaration of Alma Ata in 1978, which was a desire to move out of the hospital into the provision of primary health care services-- services at the community level. And then that got mired into debates between, was it best to have horizontal primary health care, which was basically a broad vision of health services and systems, or was it better to have vertical primary health care, which would be primary health care focused on a few conditions?
25:28
And that was something which obviously appealed much more to international donors who became important in this area. Then there was a variant called health promotion. And that came through a number of documents-- the WHO's "Health for All" and also, the "Ottawa Charter for Health Promotion" in the 1980s. And I think that's a point to make about this initiative. There was a very strong Canadian influence in health promotion. And I've got off on the slide there a report which came from
26:02
the Canadian Minister of Health, Marc Lalonde, in the '70s-- "A New Perspective on the Health of Canadians"-- which was very much focused on a whole person, whole environment and community approach to health. And then there was something called new public health, which was a kind of medical version of health promotion. And that attracted a certain amount of criticism, because people felt that public health should be a multi-disciplinary initiative. And so there was a push internationally,
26:37
but in particular, in this country, to try and get something called multi-disciplinary public health. So nowadays, if you want to undertake public health as a career, you don't have to be medically qualified anymore. So they were quite successful in that initiative. Well, what's happened recently? Let's finish off by talking about some of the things which are now on the agenda. Well, one of the interesting things that's happened-- and it's very much visible.
27:13
There's stuff in the papers today about the EU is going to prosecute I think the British government, number of cities across Europe, well exceeding the EU's air pollution levels. And London, I think, exceeded them in the-- limits for the whole year, exceeded in the first five days of the new year of 2017. So the environment, which has really been out of public health for a while-- it's been very much lifestyle and behavior-- has come back into public health with a bang.
27:57
And that's happened in a number of different ways. There was the issue of acid rain. Everyone was talking about acid rain for a while. Then there was concern about nuclear fall-out-- fall-out from nuclear tests. Then, of course, climate change has come on the agenda. And now people are talking very much about cities and air pollution. And even the behavioral public health issues have now got their environmental emphasis and think of smoking and passive smoking and the way in which
28:35
we've now got controls on smoking in public, smoking in restaurants, and even, I think, smoking in cars now, although I'm not sure that that gets enforced-- smoking in cars when you've got a child with you. So air pollution, which I think people thought had been dealt with by the Clean Air Act in the 1950s, has come back onto the agenda in a big way in the 21st century.
29:09
And I think other things have come back onto the agenda, too. Everyone confidently expected that infectious disease had gone away. But from the 1980s onwards, I think it's been very obvious that infectious disease hasn't gone away. We still have HIV/AIDS. Then there was BSE. There was SARS, flu of various types-- swine flu, avian flu-- and then more recently, Ebola and Zika. And I think those last two draw our attention to something that's very obvious in present-day public health--
29:48
that it's very much of a global health enterprise. Obviously, people still operate at the national level. But there's a whole global arena of public health there which is increasingly important. And there have been attempts to try and achieve things at a global level. You may have read about the Millennium Development Goals which were promulgated at the time of the millennium in 2000, and they just came to an end in 2015. And some of those goals were achieved.
30:25
I think the one on malaria was achieved. But other ones weren't. And so people in the public health field are always optimistic. They're not discouraged. And so now we've got a new set of goals-- the Sustainable Development Goals-- and a further period during which some of those goals may be achieved. And one of the concomitance of those goals and that global set-up is the very important role played by international donors and donor agencies and organizations in the global health field.
30:59
Now historically, that was the case with the Rockefeller Foundation. But now Rockefeller has been joined by a whole host of other organizations like Gates, Gavi Initiative, the PEPFAR, and so on. So these are very important players in the global public health field. Another trend to bear in mind is an increased role for the pharmaceutical industry in public health and medication as a form of public health intervention. I said that public health was a kind of reaction against sickness services.
31:42
But in a sense, the sickness idea has come back into public health. It was there in terms of interventions like vaccination to prevent disease. But now we have medication as prevention in a whole host of areas. For example, think of statins to prevent heart disease, or think of methadone to deal with drug addiction, or nicotine to deal with tobacco smoking. And now, of course, we've got PrEP, which has been controversial, to prevent HIV/AIDS. So medication as prevention is a whole new area
32:18
within public health. And finally, of course, public health doesn't stay in the same location. In this country recently, it's moved out of the National Health Service and back into local government. And a lot of people in the public health field saw that as public health coming home. And they looked back to the history of public health and thought that this was going to be a golden age for public health. Well, with all the cuts that are going on in local government,
32:45
that hasn't quite proved to be the case. So I'll just finish with a few thoughts. I think we can finish by saying, well, what really is public health? It's still a very broad arena. And it's one that does, as I said at the beginning, change over time, in terms of its focus. We can ask, is it shaped by the challenges it faces, or is it shaped by the needs of the professions that operate within the public health field? What exactly does it cover? Some people have argued that public health likes
33:22
technical fixes and single issues, because they're easier to deal with. And the Gates Foundation, for example, has been criticized for focusing on vaccination immunization, rather than broader programs dealing with social inequality. And that leads onto, where should public health focus its efforts? Should it focus on health services, or should it focus on the community at large and activity and action within the community? And finally-- and I think this is probably very much the case now--
33:55
is there a convergence between issues at the national, international, and the global level? Because many of those issues-- for example, chronic disease, non-communicable disease, antibiotic resistance, climate change, and air pollution-- are not just issues for this country or other countries, but they are issues which are being taken up on the global stage, and they affect people globally. We were just in China before Christmas in Beijing, Shanghai, and other cities.
34:29
And the one thing that struck us there was how polluted the air was. So air pollution, I think, is very much of a global issue. So I'll finish at that point. As a historian, I cannot predict the future. So I have a cop-out there. But I think undoubtedly one thing you can say about public health is that it will continue to change over time. And the global impetus behind public health, I think will continue to become increasingly important. Anyway, thanks very much.
35:05
And I'm pleased to take questions if you've got them. [APPLAUSE]
35:14
SPEAKER: Thank you very much. We do have time for questions. So please. AUDIENCE: You touched on mental health with the Ryle quote. Could you maybe say a little bit more about where approaches to mental health fit in? VIRGINIA BERRIDGE: Yeah. It's interesting mental health figured so strongly at that stage in the 1940s and the 1950s. And looking at some of the surveys which people did from the School of Hygiene in the 1950s, mental health was very much a key area within public health.
35:47
And I think it became less prominent. I suppose with the focus on lifestyle and behavior, public health moved in different directions, and only recently has mental health started to come back into the public health agenda. In this country, still, I think it's not really defined as a public health issue, not quite so centrally. But certainly some of my colleagues-- particularly one person, Vikram Patel, who works in India-- is very much taking up mental health as a public health issue.
36:23
So I think it's coming back from the global level, rather than perhaps the national level. AUDIENCE: Thanks.
36:35
AUDIENCE: What can we learn from the past, in terms of educating the public about the importance of vaccines, because there is an anti-vaccine narrative that some people are trying to run with? And then perhaps parallel to that, you see people questioning whether we should put fluoride in the water. Or today, the BMJ, vitamin D meta-study came out showing we should all be taking vitamin D, whereas in the US they add that to milk and bread quite often. So as a historian, how would you perhaps
37:03
look at what we've tackled issues like that in the past? VIRGINIA BERRIDGE: Well, first of all, I think the broad issue is the nanny state idea, isn't it-- that is public health advocating a nanny state where everything is being dealt with by the state? And certainly, there's been opposition to public health initiatives on that basis.
37:33
And there's a constant tension there, I think, between the rights of the individual and the rights of the population at large, which is very much encompassed by vaccination, isn't it, where you're developing herd immunity by having larger numbers of people vaccinated. So I think that's an ongoing debate within public health and within the community more generally. I think to some extent that's not as strong as it was. There used to be very strong opposition to public health
38:09
as being busybody do-gooders who wanted everyone to behave and live in the same sort of way. But as public health has broadened out recently and then started to encompass, again, areas like air pollution and global issues, I think maybe that debate has become less fraught than it was. In terms of vaccination, I think there is some interesting history to bring into that, because there was a very strong anti-vaccination movement in the 19th century, people very opposed to vaccination.
38:44
And this was a popular movement. It was a working class movement, because vaccination was seen as something which people who were better off could get out of. It was seen as an unsafe procedure that often lead to side effects. And there were also cultural beliefs about where vaccination was coming from, what it was doing to the body, and so on, which were not understood really at the time. And I think often, sometimes the anti-vaccination impetus at the moment needs to be understood, in a way,
39:23
rather than just condemned. And very often in the public health field, I think people have tended to argue that these people are being duped, or it's false science, or something like that, whereas I think there are probably deeper cultural motives and ideas which could be teased out a little bit. And that's something which has also come up in the response to the Ebola virus and in Africa where people said, if we'd understood a little bit more about the cultural beliefs
39:56
from disease and so on, we might have dealt with Ebola more effectively initially.
40:12
AUDIENCE: Thank you. I know you said you're a historian. But what role do you see for technology in public health going forward? Can you see any ideas where technology can play a role? VIRGINIA BERRIDGE: Yeah. I think it's an interesting area. It depends how you define technology. There's the technology of pills and medicines and so on, which is very much part of public health. But there's also the technology of self-monitoring and monitoring your steps and your heart
40:46
beat and your blood pressure and so on. And that has been discussed very much in the public health field, not just in terms of the way those technologies operate, but also differential access to technology. So are you going to be getting levels of the population who are constantly self-monitoring and able to do that and then other populations or other parts of the population have no access to that sort of technology or have no cultural desire to access that technology.
41:18
So yeah, I think there certainly is a lot of debate about the role of technology in public health.
41:34
AUDIENCE: It might be slightly off your field. But is the funding crisis in the NHS new, or have we had things like that in the past?
41:46
VIRGINIA BERRIDGE: Well, it's not entirely off my field.
41:52
One of the interesting things about the changes I talked about between public health expected to run a national health service and then not running a national health service was that nobody really costed out what the National Health Service was going to cost, because all the debates before the Second World War and during the Second World War had made the assumption that public health was going to be funded out of local rates or taxation with a minimal input from--
42:25
well, not such a big input, anyway-- from central government. So that was one thing. There was never any real costing of what a national health service would cost. And I think the other point was that people expected that the National Health Service would deal with ill health in the population and that costs would go down after a few years. And they were really surprised when costs actually went up. So it wasn't until probably nearly 10 years after the NHS
42:58
was established that a committee was set up called the Guillebaud Committee, looking at the costs of the National Health Service. And this has, more or less, been an ongoing issue ever since. Certainly it came to a crisis point in the early 1970s with the oil crisis, which created a different situation across the Western economies. And so rationing health services, the cost of health services were very much on the agenda then. And really, they've been on the agenda ever
43:36
since, because I think as long as you've got a centrally tax-funded service, costs are going to be a political and a central policy issue. If you go to other countries, they're not talking about their health services in quite the same way that we talk about ours, because it is such a political policy issue.
44:00
AUDIENCE: What do you think of the legalization of controlled substances, particularly marijuana? There was a big debate in the US on that recently. Does that go against the direction of public health, or does that make it easier to change people's behavior or something? VIRGINIA BERRIDGE: Oh, that's a big topic. Well, interestingly, drugs and alcohol were really outside the public health area for a long while-- alcohol, because it was so affected by the temperance movement.
44:33
So alcohol was a temperance topic for a long while rather than a public health topic. And drugs-- and alcohol, too, in some respects-- was seen as within the mental health psychiatric area rather than being a public health topic. But that came out of that area a bit and moved into public health in the 1980s when I think HIV/AIDS and injecting drug use made it much more of a public health topic. And then onto the agenda at that stage came something which we still talk about called harm
45:08
reduction so that instead of having a war on drugs, you should have a preventive attitude towards drugs to try and prevent harmful use, but not necessarily to prevent all use whatsoever. So that, broadly speaking, has been the policy aim certainly in this country, I think less so in the United States, and obviously even less so in countries like Russia which don't have harm reduction at all, in relation to drug use. So a few years ago, we would have said that issues of legalization are very far
45:52
from practical possibility. But what's happened in the States has rather tended to disprove that, hasn't it, where the local state governments, the referenda have been producing majorities in favor of the availability of cannabis, either for medical purposes or for more general use. And that's a very interesting situation. How it will develop under the current presidency, I don't know.
46:31
It has been argued that America, historically, has been the key global power arguing for a war on drugs. It's been the leading proponent of that war on drugs approach across the globe. And yet, within its own boundaries, it's actually contravening the international drug conventions. And that's been a very interesting situation, which Obama didn't tangle with really. But it will be interesting to see what happens under Trump. I'm afraid I have no inside knowledge on that point. [LAUGHS]
47:11
AUDIENCE: I have a question. So you have worked a lot with policymakers, I think. Can you say something about how it is different to do the actual signs and to derive policies from that? VIRGINIA BERRIDGE: Well, there's been a big move amongst historians in the last 10, 15 years, I guess, to have more impact on policy. Now historians used to be, they couldn't care less about policy. They just wanted to do their own thing basically-- expand the boundaries of knowledge.
47:46
But recently, I think there's been a greater move towards that. A lot of discussion in the historical field about how you go about that. And different modes have been tried. Some of my colleagues are working with different government departments. And they advise civil servants in those departments. Tony Blair, when he was the prime minister, used to get little discussion groups together at number 10. And in some of those discussion groups, there would be historians.
48:23
Well, obviously didn't always take their advice. And I think recently-- I was just talking to somebody about this yesterday, actually-- those sorts of discussions go on. There are connections and lectures by historians at number 10 right up to the present day. But it is quite a difficult relationship, because policymakers and politicians are very much of the moment. They don't have that long-term view. And in a sense, they disregard the long-term view, really,
48:58
because they have to take decisions here and now. I shouldn't think the long-term history of Europe and the European history, more generally, is having much influence on the Brexit negotiations. But I may be wrong. So I think historians have to be careful about their relationships with policy, because it's easy to have one's work taken and used in a way which one didn't necessarily intend. But that's part of the nature of policymaking, I think. You have to be there at the right moment
49:34
with the right message at the right time. And so it can be a difficult relationship. SPEAKER: Time for one more question. No question left? Then please join me in thanking Professor Virginia Berridge. [APPLAUSE]
Here to help you learn
Sign in to keep a private conversation with your course tutor.
Ask me anything about the material…
Sign in to chat