Feature

A case of ‘tragic incoordination’?

Recent outbreaks of E.Coli offer an opportunity to examine the adequacy of our public health protection, says Charles Webster

Recent deaths in Scotland associated with E. coliare just the latest, tragic reminder that all is not well with public health. Within public health medicine such events trigger comparisons with the past, and there is a tendency to believe such disasters were avoided in the days of the Medical Officer of Health. Perhaps, but not entirely.

Now conveniently forgotten are events such as the Croydon typhoid outbreak in November 1937, which claimed 43 lives and caused 300 cases of serious illness. This followed hard on the heels of a typhoid outbreak in Bournemouth, where there were 718 cases recorded. The latter was castigated in a Timesleader as a case of ‘tragic inco-ordination’, an ‘indictment not of a faulty system but of a total absence of system’. (The Times, 15 February 1938).

Much the same could be said about the food poisoning incident in Scotland, which is the latest in a continuous series of embarrassing public health lapses. Among the worst features of the Croydon outbreak was the disinclination of the MOH to believe that contaminated water could be the source for the typhoid outbreak; the correct conclusion was immediately reached by a local layman, but was disputed by the MOH.

Even worse was the lack of communication between local health and engineering departments, which permitted laxity in working practices, so allowing the drinking water to be contaminated across a large area of Croydon.

The Croydon outbreak was a blow to the morale of public health medicine. It seemed that the legacy of John Snow and the Broad Street pump was not in safe hands after all. And it had widespread repercussions: apart from sparking off a round of recriminations between the rival medical organisations, its main effect was to concentrate attention on the lamentable absence of co-ordination in the nation’s health services, and the lack of leadership on this issue by the Conservative administration of the day.

The Croydon outbreak was the direct stimulus for a letter to The Times by Sir Kaye le Fleming and Lord Dawson of Penn, two of the leading members of the medical establishment (The Times, 22 November 1937). In fact the ideas contained in this letter reflected the views of Dawson, the author of the famous Dawson report of 1920, which was the first blueprint for a comprehensive health service. The letter regretted the failure of the government to advance medical administration. Indeed it claimed that rival medical services were tending to diverge.

In particular, there were ‘commonly two groups of hospitals, duplicating and even conflicting, without machinery in existence for co-ordinating their activities’. Bournemouth and Croydon demanded that there should be urgent reform of ‘evils of increasing divergence in the work of doctors in a community’ along the lines of Dawson’s proposals submitted to the Ministry of Health as far back as 1920.

The immediate product of this new mood of self-examination was the revival of the planning initiative within the BMA, which issued its own scheme for a comprehensive health service, A General Medical Service for the Nation, in November 1938. This sparked off a new wave of debate which continued without interruption until the NHS became established in 1948.

Croydon therefore deserves to be remembered as a significant catalyst to the reform of public health and medical services. Let us hope that the opportunity offered by the recent Lanarkshire incident to learn lessons about the state of our health services is also taken.