The Health Committee of the Association of Municipal Corporations, a representative body for many of Britain’s towns and cities, expressed concerns about immigration to the Ministry of Health in a meeting in 1957. Immigrants, argued the deputation from the AMC, might be coming to the UK because of ‘the encouragement which a free health service could give to such people to come to this country with the object of seeking free treatment.’ In addition, public prejudice against immigrants was linked to ‘the problems they created and the demands they made on the Health Services.’ As Bivins notes: ‘Only a decade after the NHS opened, the fearful and possessive discourse of its exploitation by “medical tourists” was already emerging, hand in hand with redefinitions of British “identity” and “belonging”.’
This is not an academic journal, and I’m not going to try and replicate an academic book review of Bivins’ thought-provoking and hugely ambitious Contagious Communities here. What I’d like to do is offer some (not especially comprehensive) thoughts about what I found most important and interesting in this series of closely-researched, linked case studies, covering the period 1948-1991, that think about the NHS not through the lens of national policy and re-organisation, like many earlier histories, but by centring the shifting attitudes to migrant health, and the ways in which local, community-led pressure groups, the Ministry for Health, associations like the BMA, the media and other government departments interacted in both shaping, and quashing, concerns. Contagious Communities is clearly-organised. The first two chapters consider how official responses to TB changed both nationally and locally between 1948 and 1962. The third chapter rethinks smallpox along similar lines. The fourth chapter flips the language of analysis to consider discourses of ‘race relations’ between 1962 and 1971, arguing that ‘the language of race itself became increasingly tainted’ and that even ‘the appearance of racism’ was seen as harmful by politicians, civil servants and diplomats. However, as we shall see, this did not necessarily lead to more positive initiatives. The fifth chapter considers a disease that was environmental and easily addressed, yet embarrassingly, still prevalent in modern Britain: rickets. In contrast, the final chapter thinks about genetic diseases that were associated with ‘ethnic’ populations; sickle cell anaemia and thalassaemia.
In the 1950s, TB, rickets and smallpox were all diseases that had been all-too-familiar in Britain in the not-so-distant past. However, Bivins shows how popular and official memories of these once-endemic menaces were swiftly transformed. TB became ‘an imported illness’, despite its continued incidence among the native population. While smallpox outbreaks had occurred six times between 1951-60 in Britain – as Bivins puts it, smallpox in this period was ‘both spectacular and quotidian’ – it was the 1961-62 outbreak, framed by debates over the Commonwealth Immigrants Bill, that led to its reframing as ‘the killer that slipped through the net’ (Observer headline, 1962) or ‘the oriental killer’. Rickets, related to poor diet and a lack of sunshine, was relabelled as ‘Asian rickets’ due to its incidence within Asian communities, ignoring the internal diversity within this group. Evidence to associate these particular conditions strongly with immigrants was patchy, especially for TB. Bivins meticulously considers how figures on TB incidence were selectively used to support the favoured policies of the group in question. For example, a 1957 Ministry of Health survey on TB incidence in the UK presented a complicated picture: ‘Irish and Hungarian rates were among the highest, while rates from West Indian and African communities were very low… The highest rates of incidence… were found in the group from the Indian subcontinent.’ However, if Europe had been considered as a single category, rather than the Hungarians being categorised as a separate group, ‘it would have produced a significantly larger group of affected migrants.’ The Ministry of Health, seeking reasons to justify health controls for Indian and Pakistani migrants but not migrants from European countries with an equally high level of TB incidence, did not choose to present the survey results in this way.
Another important aspect of Bivins’s book, however, is the caution with which she handles the temptation to ascribe these actions to ‘simple racism’. Racist attitudes took varied forms, and much health policy was formulated in the context of promoting community integration to improve ‘race relations’. Furthermore, in the context of the Cold War and Britain’s waning international influence, Britain’s ties with the Commonwealth were becoming increasingly important, and government officials were reluctant to do anything that might be perceived as racist and exclusionary, especially in the earlier part of the period covered by this book, when Britain actively sought to attract foreign labour to assist in post-war reconstruction. However, the language of integration did not necessarily serve the interests of migrant communities. For a start, integration was assumed to be more difficult for non-white migrants, especially younger migrants who did not arrive in family groups, who were presumed to indulge in ‘non-British’ cultural practices that were detrimental to their health. In the early 1960s, for example, the British Medical Journal invoked such stereotypes about young South Asian male migrants, claiming that their living conditions were primitive and uncivilised. This kind of attitude affected public health interventions. Rejecting fortification of foodstuffs with Vitamin D to address the rickets problem in 1993, the Principal Medical Officer in the Nutrition Section of the Ministry of Health stated that immigrants needed ‘education rather than nutrition.’ The Department also rejected screening or counselling interventions for individuals affected by sickle cell anaemia because they believed this would be stigmatising for the populations they believed were at risk; Africans and West Indians. ‘There were no consultations with any affected community,’ Bivins notes, ‘simply a uniformity of internal opinion that ‘they’ would respond poorly.’ Here, a supposed sensitivity to racial issues actually led to othering and ignorance. Similar concerns arose in relation to thalassaemia. However, when the United Kingdom Thalassaemia Society was formed by parents of affected children in 1976, it swiftly told the Department that they wanted targeted screening and genetic counselling to help reduce rates of the disease.
Finally, Bivins considers what was meant by ‘public health’ in this period. Viewed as transient minorities, migrant communities were often excluded from public health considerations, and it was suggested that they should not be given special treatment, despite their different medical needs. The Stop Rickets campaign of 1981-2 proposed a three-year project to eradicate rickets that would cost £149,000 in its first year, and £100,000 for each of the next two years. ‘After all… the recent HEC [Health Education Council] Mother and Baby Campaign had cost £600,000. This comparison provoked a frosty but revealing reply [from the Department of Health and Social Services]: the latter was entirely different as it addressed “the entire population”.’ Bivins argues that as models of intervention changed from ideas of ‘social medicine’ to an assessment of how citizens could individually manage risk, the Department ‘increasingly sought to intervene in public health problems only if “the public” in question was co-terminous with the entire British population or some nationally distributed cross-section thereof (pregnant women, for example.’ Addressing problems that were particular to migrant communities were seen as incompatible with these priorities – a stance that was justified by appeals to the need to preserve good ‘race relations’ by not treating certain groups differently from the community as a whole.
Bivins’ monograph is an important read for historians of post-war Britain, intersecting with numerous themes in existing historiography; race, gender, medicine, the NHS and the welfare state. Inevitably, it presents a series of case studies, as covering this entire period in detail would be an impossible task. However, it presents us with a new way of looking at the history of the NHS – an angle that is especially relevant given how we talk about the NHS today.