Before the Health Revolution

In his 1930s novel 'The Citadel,' miners' doctor A.J. Cronin depicted the shambles of the health care system before the creation of the NHS.

Amongst the most prevalent illnesses in Britain throughout the twentieth century were the respiratory diseases caused by working in mines. Coal dust gradually builds in the lungs and can lead to persistent shortness of breath, fatigue, heart ailments, and pneumoconiosis. This was widely ignored until the 1930s. By writing on occupational illness and the medical practitioners who often failed to treat it, the Scottish novelist and doctor A. J. Cronin showed how depicting lives of the unwell can enact a change in the medical profession and society at large.

The scale of respiratory disease from working in mines was so great that two scholars of the disease, Arthur McIvor and Ronald Johnston, have described it as the “largest public health disaster in British history.” Even into the 1950s, the Labour MP Dr Barnett Stross estimated that around 2 million workers were suffering from respiratory disability. ‘Miner’s lung,’ ‘black spit,’ ‘the dust,’ or ‘diffug anal’ (Welsh for ‘shortness of breath’) was killing thousands each year.

In The Citadel, published in 1937, Cronin depicted the life of a working-class Scottish doctor, first in South Wales, and then London. Diligent, idealistic, and a gifted physician, Andrews Manson begins his career amongst the mining community of Drineffy. He treats patients in place of Dr Page, who has suffered a stroke. His political consciousness awakens. He meets a woman, Christine Barlow, a schoolteacher, with whom he falls in love and tells her, in their first meeting, what he thinks of the medical system then practiced in Britain:

“I’m finding out that some of them are all wrong. Take medicine, too. It seems to me that some of it does more harm than good. It’s the system. A patient comes into the surgery. He expects his ‘bottle of medicine’. And he gets it, even if it’s only burnt sugar, soda carb. and good old aqua. That’s why the prescription is written in Latin – so he won’t understand it… I do honestly think even from what I’ve seen that the text-books I was brought up on have too many old-fashioned conservative ideas in them. Remedies that are no use, symptoms that were shoved in by somebody in the Middle Age.”

In the inter-war period, the UK’s health services were falling behind those of comparable economies in Western Europe. From 1911 a National Health Insurance Act was initiated, which saw a deduction from employee’s wages to provide health care. This left many without support, particularly the unemployed and working-class women. In The Citadel Manson continues to treat people without insurance, as a model, perhaps, of how gaps in support can be filled. But the health provisions of the UK were unequal on another strata. There were public hospitals which were massively underfunded, and there were private hospitals for the elite. General practitioners (GPs) could be anywhere from on the brink of bankruptcy to mistreating the wealthy patrons of the West End for further business. These “jackals,” as Manson calls them, do pointless procedures and give drugs that patients don’t need.

The novel is closely aligned with author’s life. Born Archibald Joseph Cronin in 1896 in the Western Lowlands of Scotland, Cronin attended medical school in Glasgow before working in South Wales, including a three year stint in with the Tredegar Medical Aid Society – a service that provided free health care at the point of use and would later be Aneurin Bevan’s model for the National Health Service. Whilst in Wales, Cronin gathered information for his report on lung disease amongst miners, mirrored in Andrew Manson’s report in the novel. After a few years as a GP in London, Cronin turned to fiction and moved back to Scotland with his family. After three major novels, Cronin wrote excitedly to his agent: “Oh boy this is going to be a whale of a novel. Don’t flinch when I tell you it’s medical — it’s the best you’ve ever read. Also don’t forget it has a THESIS. There’s a purpose close behind me and it’s treading on my TALE.”

Though often thought of as a political novel, The Citadel might be better understood as social, in so much as it depicts the common needs and interests of a community rather than dealing with hierarchies or structures of power. Cronin saw that doctors and nurses work best as members a community: “GPs have all the opportunities to see things, and a better chance to observe the first symptoms of new disease than they have at any of the hospitals.” Rather than patients being whisked off to hospital and never seen by their local doctor again, Cronin realised that the opportunity to build relationships with patients and their families would allow the medical profession to notice patterns, such as miners presenting with breathing ailments.

Cronin envisioned that if the various tentacles of the health system were to work together, patients would be treated better and medical knowledge advanced, instead of “GPs fighting each other, not members of the same Medical Society with[out] wonderful opportunities for working together.” A universal health system would not only ensure that every citizen was covered, but that doctors could work in cooperation rather than competition.

In the final pages of the novel Manson comes up with his theory of a unified health system. Each member would specialise and then contribute to the whole by “pooling” knowledge. “It comes between State medicine and isolated, individual effort. The only reason we haven’t had it here is because the big men like keeping everything in their own hands. But oh! Wouldn’t it be wonderful, dear, if we could form a little front-line unit, scientifically and – yes, let me say it – spiritually intact, a kind of pioneer force to try and break down prejudice, knock out the old fetishes, maybe start a complete revolution in our whole medical system.”