If we win the fight for a real national health system, a single-payer program, in the United States, it will signal the beginning of something even more significant than just the way we pay for or allocate health services. It will signify a step toward the reinventing of medicine in this country, of restoring its proper role as a healing art, as a way to achieve social justice. There are a significant number of doctors who already see this as the ultimate goal and they are deeply engaged in the struggle for health-care reform precisely because they want to practice medicine in that way, to fulfill a basic human need, not to make a profit. It works. I’ve been fortunate to have lived in Britain for 12 years, to have collaborated with doctors, midwives and public health workers –people like Peter Draper, David Player, Alex Scott-Samuel, names that will mean little in the United States, but that I need to mention– to have experienced this vision of medicine first hand and to have contributed to its embodiment in the watershed volume, Health Through Public Policy: The Greening of Public Health (1991). It is from this experience and engagement, as much as from principle, that I want to see it become the norm here.

Moving to Bayswater
Twenty-five years ago, at the height of British Prime Minister Margaret Thatcher’s brutal assault on her country’s working class, on trade unions, on basic social and political liberties, Barbara and I moved into a one-bedroom apartment in the central London district of Bayswater. It was an incredibly diverse area, both ethnically and economically. A few minutes to the east was St. Mary’s Hospital, in Paddington, where Alexander Fleming had discovered penicillin in 1928. Just to the west, down Westborne Grove, was Notting Hill, the site of the annual Carnival (initiated by the great Trinidadian communist, Claudia Jones, in the wake of the 1958 Notting Hill race riots) that, in time, has become the largest festival of its kind in Europe. (U.S. audiences are more apt to know the area from a 1999 film with Julia Roberts and Hugh Grant.)

When we moved to Bayswater, it was an area of immense social contradictions. There were the obvious signs of gentrification, as wealthy Arabs were buying up properties. But, the area also bore the brunt of Thatcherite policies that were affecting the entire city. London’s working-class, immigrant and native-born, was suffering from government efforts to restructure the economy, to make it more profitable for a few, that, in the process, drove the national unemployment rate up to past three million by 1982, triple what it had been a decade earlier. Equal to almost two-thirds of the population of Finland, the poor in Britain were literally a country within a country. London’s poor found it increasingly difficult, not just to find work, but to find shelter.

According to Frances X. Clines, writing in the New York Times in late October, 1987, “Homelessness and street squatters are on the rise…as the construction of housing for the London poor has fallen from an average of more than 20,000 units a year in the 1970’s to little more than 1,000 lately because of the Thatcher Government’s cutting local capital borrowing authority by two-thirds.” The response of many of the city’s boroughs was to lodge families temporarily –though this might last years– in bed-and-breakfast accommodation. As Clines explained:

“The housing of the poor in seemingly quaint B. and B.’s - a tucking away of desperation amid the faded antimacassars of an earlier age - is the fastest growing and most expensive new welfare development occurring in Britain.

In the last 15 months, the phenomenon has doubled, with 8,000 London hotel rooms now taken up by the poor and 10 more B. and B. rooms joining the welfare roll each day. Such social welfare leaders as Lord Scarman are warning that another ‘Fagin’s London’ will evolve as small children are idly pent up behind the hotel facades near railroad stations.”

By the time we arrived in Bayswater, the area’s bed-and-breakfasts had become one of the chief repositories for homeless families from other parts of London. As such, many of the people on the streets, in the buildings, around us, suffered from the health and educational problems that typically afflict people living in such conditions. Inevitably, this stirred political activists, among whom were socially conscious physicians who realized that there could be no normal medical solutions, no easy palliatives to be prescribed, for health problems created by national political and economic policies. As Wendy Farrant and Angela Taft of the Department of Community Medicine, St. Mary’s Hospital, wrote in Health Promotion International in 1988: “The major determinants of ill health (such as poverty, poor housing, homelessness and unemployment) lie outside the traditional remit of the health sector, and certainly cannot be solved at a purely local level. Many of these problems can be related to national policies that reinforce the health divide. They are exacerbated by local government policies that are damaging to the health of the more disadvantaged sections of the population.”

Writing specifically of the situation that had emerged in Bayswater, Stella Lowry wrote in 1990, in The British Medical Journal:

“Living in a bed and breakfast hotel is not an extended luxury holiday. It means keeping all of your belongings in one room, living out of suitcases, and giving no privacy. Children are born and brought up in one room, where they live with the rest of their family. There is no safe place to play. Washing and cooking facilities are shared with other families, and there may be nowhere to store food….

The adverse effects of these conditions on health have been well documented. Homeless women are twice as likely to have problems and three times as likely to need admission to hospital during pregnancy as other women. A quarter of babies born to mothers living in bed and breakfast accommodation are of low birth weight, compared with a national average of less than 1 in 10. The children are more likely to miss out on their immunisations, while poor sanitation and overcrowding encourage the spread of infections and diarrhoeal illnesses. Good nutrition is almost impossible because of the poor facilities for storing and cooking foods. Accidents are common among the children, and their parents often suffer from depression.”

It was in response to these health problems created by the Conservative Party’s political and economic strategies that the Bayswater Hotel Homeless Project was created, as Lowry wrote, “to cater specifically for homeless families but to ensure that they have all the benefits of registration with a local doctor. The project pays local general practitioners for sessions at a special surgery. When a family attends it is temporarily registered with the doctor on duty, and after three months permanent registration is arranged.” One of the leading figures in the Bayswater Hotel Homeless Project was Dr. Richard Stone.

Meeting Dr. Richard Stone
As it happened, one of the first things we had to do after moving in to the area was to register with a doctor. (Quite the contrary to what people in the States imagine about how the British National Health System worked, this was entirely our decision.) We walked around the area, visiting different practices, until we came across one that felt right. It was run by Richard Stone, along with four other doctors.

Stone, of Lithuanian Jewish background, was an exceptional physician, unencumbered by a narrow or reductionist sense of what health care required. What impressed me was that his views, consciously or not, owed so much to a tradition that had originated in the mid-nineteenth century, of which one of the most impressive and influential figures was a hero of mine, the German pathologist and anthropologist, Rudolf Carl Virchow, one of the giants of what is now called “social medicine.” As others developed the germ theory of disease, which, within the framework of capital-intensive, profit-driven 20th century medicine, would eventually become a profoundly reductionist approach, enhancing the primacy of a biomedical rather than a sociogenic model of disease, Virchow, up until his death in 1902, maintained that “Medicine is a social science and politics is nothing else but medicine on a large scale.”

As Western medicine during his momentous lifetime was steadily professionalized within the capitalist marketplace, Virchow’s view was increasingly discounted. But, it was never entirely silenced. It has always remained the view of a significant number of progressive physicians –certainly it was the view of the Argentine doctor, Che Guevara– who regarded that moral vision of medicine as a vital and necessary part of the process of progressive social change. In Britain, in the decades between the two world wars, it was a vision that was kept alive by doctors such as A. J. Cronin. The Scottish-born Cronin studied medicine at the University of Glasgow before and after the First World War. In the twenties, he briefly practiced in Tredegar, a mining town in South Wales that was the birth-place of Aneurin (Nye) Bevan who, two decades later, would be one of the chief architects of the National Health Service. As Bevan’s father, a coal miner, was dying from pneumoconiosis, Cronin served briefly as Inspector of Mines for Great Britain, until he moved to London, where he practiced in Harley Street, before eventually establishing a less lucrative surgery in Bayswater.

Given the prevailing realities of health in Western society, good doctors have often felt compelled to move beyond medicine in the conventional sense. So it was with Cronin. In the 1930s, he turned to writing novels that expressed his conviction that medicine should be an instrument of social justice. The most famous were The Stars Look Down (1935) and The Citadel (1937), one of the most popular British novels of that decade and one that has been credited as an inspiration for the NHS. As it was for Cronin, it was for Richard Stone. When he was in his office, he treated his patients with understanding and patience. He never regarded a pill as the ultimate answer to someone’s problems. So, we might see him on the evening news, filmed on a picket line, protesting the consequences of Thatcher’s policies. He was the embodiment of the ideas of Francis Fox Piven and Richard Cloward that I had taught in a class on the political economy of U.S. health care in Ann Arbor six years earlier. Yet, at the age of 54, Stone left medicine.

He became more deeply engaged in the volatile issue of race relations in London that increasingly preoccupied people of conscience as the eighties unfolded. By the late nineties, Stone was the Vice Chair of the Runnymede Trust, an independent policy research organization, founded in 1968, that seeks to advance equality and justice in a multi-ethnic society. As such, he was an adviser to the 1997-98 Inquiry led by Sir William Macpherson, a 72-year old retired High Court judge, into the death of Stephen Lawrence, a black British teenager of Jamaican parentage, who was stabbed to death on a bus stop on the night of April 22, 1993. The initial police investigation had named five suspects, who were never convicted. After examining the investigative work of the Metropolitan police, the MacPherson Inquiry concluded that the London police force was “institutionally racist,” a judgment that sent deserved shock-waves through the British system. Subsequently, Stone was a member of the NHS inquiry into the death of David Bennett, a Black patient in a medium secure psychiatric hospital in Norwich. Since then, he has focused on the twin issues of Islamophobia and Jewish-Arab relations.

I feel that we were deeply privileged. Sitting in the waiting-room of Richard Stone’s five-doctor practice a quarter century ago, what you immediately noticed were the large photographs on the walls. They were stills from the great 1938 film, The Citadel, based on the Cronin novel. Most of them featured one of my favorite actors, Robert Donat, as Dr. Andrew Manson. The book and the movie tell the story of a journey from his early practice in a Welsh mining village (much like Tredegar) to the point where he abandons a lucrative London practice to set up a multi-doctor clinic in a small town. Cronin, of course, established his practice in Bayswater and the pictures were hanging on the waiting-room walls because Stone’s practice was, in fact, the actual descendant of A. J. Cronin’s. We had somehow found our way into an important piece of the story of what is best in Western medicine and what I hope it will be like some day throughout the United States. Establishing a single-payer system is essential, but it is just the beginning. There will still be much to do.

[Cross-posted from The Porcupine, www.theporcupine.org]