When Does The Air Matter? by Janet Greenlees

Air Quality and the Working Environment

In this month's blog post Dr Janet Greenlees, Senior Lecturer at Glasgow Caledonian University, looks at  the history of industrial air quality and considers how it has variously been considered a worker's health, community health, and economic concern.

When Does Air Matter?

Men and women weaving at the White Oak Mill in Greensboro, NC, 1909.
Courtesy of the National Museum of American History.

When do people think about the air quality inside buildings? Similar to other health issues, the honest answer probably would be when either they or someone they care about is affected by the poor air they breathe on a regular basis. That being the case, the air quality in working environments could only then be of concern to a relatively small number of people with any improvements sought by labour and their representatives or employers seeking to increase productivity. However, sometimes public health concerns about air quality can apply to both the community and the working environment. How then, is the public health discourse negotiated when the needs of industry can be affected? And, why do certain health issues attract public or political interest and intervention, while others do not? A simple answer might be that the only health issues to attract widespread public interest are those which can affect large numbers of people, such as contagious diseases. However, a closer look suggests regional and national variations regarding responses to public health concerns, even when the same issues and industries cross special boundaries.

An Air Laden with Dust and Dirt

During the nineteenth and early twentieth centuries, cotton cloth manufacturing grew rapidly in New England, America and Lancashire, Great Britain. Both industries subsequently declined, albeit at different rates. Cotton manufacturing was also an industry where men and women worked alongside each other, performing the same tasks for the same rates of pay and experiencing the same workplace health hazards. The air these men, women and sometimes children breathed was laden with dust and dirt, factory ventilation was poor and concerns were raised about the spread of contagious diseases in such environments, particularly tuberculosis. In addition, the noise from the machines was horrendous, particularly in the weaving rooms, and could cause hearing loss and in some cases, deafness. While since the earliest cotton factories, workers had been aware that inhaling dust and dirt made them feel unwell and the noise was uncomfortably loud, it was the late nineteenth century before the workplace became entwined with public health reform, starting with fears about tuberculosis contagion. Public and much scientific belief held that the tubercle bacilli attached itself to dust and quickly spread disease throughout the mill. In the progressive state of Massachusetts, the leading cotton cloth manufacturing state, these fears about TB contagion secured both a legislative ban of a particular technology, the suction shuttle, and selective employer cooperation at improving ventilation. In contrast, and despite widespread belief that England led the way with factory regulation, the tuberculosis risk in the Lancashire mills was debated, but economic concerns prevented both regulation and industrial reform.

Worker Fatigue and Factory Ventilation

The Boott Cotton Mill of Lowells, Massachusetts.
Courtesy of the Lowell Museum Collection.

During the early twentieth century new health concerns arose, firstly surrounding the importance ventilation and following the Great War, fatigue. Fatigue was not simply related to long hours of labour but also to working in poorly ventilated factories. In Massachusetts cotton towns, ventilation became a public health campaign with improvements introduced in many public buildings, including schools and government buildings and extending into workplaces. Some (but not all) employers accepted the notion that a healthy worker was a more productive worker. Ventilation attracted considerable British debate and scientific interest, but while some communities sought to improve factory ventilation and legislation imposed air quality standards on the cotton mills, in reality, employers remained able to operate as they saw fit. Factory air quality was secondary to the needs of industry. The Great War turned scientific, political and medical interest to fatigue research, particularly in Britain. Textile workers were included in the research; however, industrial decline meant political and scientific interest in operative fatigue quickly faded. The same was true in New England. During the 1920s, most of the cotton manufacturing industry shifted to the southern states. Remaining northern firms were more concerned about economic survival than the air quality in the mill. Worker and community concern about mill air quality also declined as jobs took priority. Indeed, wider economic concerns were increasingly influencing the public health agendas of both countries.

Cotton Dust Inhalation

Nevertheless, scientific and medical interest about occupationally specific health concerns was growing, particularly surrounding cotton dust inhalation. However, the physical symptoms of respiratory damage caused by dust inhalation mirrored those of respiratory diseases common to many textile towns, including bronchitis and pneumonia, namely, tightness of the chest, dyspnea and coughing. Therefore, doctors found it very difficult to identify cases of byssinosis, the respiratory disease caused by prolonged cotton or flax dust inhalation. While public concern grew surrounding the widespread dust found in urban environments, such concerns were not transferred to factory dust. There, dust remained an occupationally specific hazard about which middle class social and political reformers had little interest. This was only reinforced by the ambiguity surrounding diagnosis. For workers, dust was an everyday reality that was simply part of the job and unions sought compensation rather than reform. Britain was first to introduce byssinosis compensation for selected male workers in 1941, although it was the 1970s before compensation was extended to all affected workers. By this time, cotton manufacturing had virtually disappeared from the country. Despite individual American doctors and scientists recognizing byssinosis cases, it was 1969 before the federal government introduced compensation for byssinosis sufferers. Instead, public health concerns about dust remained confined to the urban living environment and, when combined with the ambiguity surrounding diagnosis, many workers were left to suffer on their own.

Interior of a Lancashire Cotton Mill with Mill
Workers at their Machines, Lancashire, c. 1890.

Managing the Health Impact of the Working Environment 

Lastly, noise, but not internal industrial noise, briefly became a public concern. Community concerns about specific urban noises increased as the twentieth century progressed. Societies were formed to tackle ‘unnecessary noise.’ However, the continuous crashing of metal-tipped shuttles against metal loom frames in the mills which caused hearing loss in many workers was ignored. Instead, communities, medics and even operatives accepted that hearing loss was a risk attributable to certain jobs, including weaving. Weavers adopted coping strategies to manage the noise, including sign language and lip reading. Indeed, despite the fact that other air quality issues had attracted public interest and industrial reform, operatives regularly found themselves needing to adopt coping strategies to manage the health consequences caused by working in confined spaces with poor air quality. Other strategies included taking unpaid time off, patent medicines, cooperative strategies, switching firms to where conditions were better and exiting the industry. Air quality at work was important to workers, but managing the health impact from the working environment comprised only one part of their decision-making surrounding work, health and community. Similarly, at different times, certain aspects of air quality became community health concerns. Only at certain times did the two environments entwine.

Janet Greenlees

Dr Janet Greenlees

Janet Greenlees is a Senior Lecturer in History at Glasgow Caledonian University, based in the Centre for the Social History of Health andHealthcare. Her research interests include women and work, public health and the working environment and maternal health and she has published on all these topics. The intersection of health in the community and work environment described above is explored in greater detail in her book: When the Air became Important: A Social History of the Working Environment in New England and Lancashire, 1860-1960 (Rutgers: Rutgers University Press, forthcoming 2018). For more on gender and workers’ responses to poor air quality at work, see ‘Workplace Health and Gender among CottonWorkers in America and Britain, c. 1880s-1940s’, International Review of Social History, 61, 3 (2016), 459-83.

A Forgotten Episode of International Health by Dora Vargha

In this month's blog post, Dr Dora Vargha, University of Exeter, uncovers the neglected role of the Socialist Bloc and Eastern Europe in the history international public health. Dora argues that rectifying this omission is essential to capture a complete picture of international and global public health in the crucial era following the postwar settlement. 

The Establishment of the World Health Organization

The establishment of the World Health Organization is no doubt a crucial and fundamental moment in the history of international (and global) public health. The leadership, ideas and early decades in the unfolding Cold War can be assembled through biographies of Director-Generals, the Organizations own chronicle of its first decades and through histories of malaria eradication. However, certain equally important aspects of the early years of the WHO, like the sudden exit of the Soviet Union and Eastern Europe shortly after the establishment of the organization merit little more than a mention in these histories.

The Socialist Bloc and the Missing History of the WHO

Andrija Stampar (1888-1958), born in Drenovac, Croatia,
was a key figure in the history of twentieth-century public
health and  a leading figure in the League of Nations Health
Organisation. Commemorative Stamp of Anrija Stampar,
 issued 1970, Yugoslavia (Public Domain).

This omission from the historiography is not entirely surprising. The Socialist Bloc, and Eastern Europe in general has been, until recently, missing from international health narratives on the whole, despite foundational Eastern European figures in its history such as Andrija Stampar, key member of the League of Nations Health Organization (LNHO) and president of the First World Health Assembly, and Ludwik Rajchman, director of the LNHO and founder of UNICEF. Often seen as a politically homogeneous area under complete Soviet control in the postwar era, Eastern European countries have not been considered to have agency in international health during the Cold War.

But the history of international and global health has a lot to gain by including the Socialist Bloc in the picture. This unexplored history points to questions whether international health always happens within organizational structures of international agencies and through philanthropic entities such as the Rockefeller Foundation; what the stakes were in this Cold War divide in the formative years of the WHO; and the extent to which we can talk about a unified response within the Socialist Bloc to diplomatic and public health challenges in their time outside of the organization.

Socialist Networks and International Public Health

Considering alternative international public health, in this case socialist networks, is crucial in getting a complete picture of postwar international public health and its effect on modern global health. The historiography of internationalism has been going under a rapid change by including alternative internationalisms and focusing on socialist exchange in ideas, practices and knowledge. Much of this new research has addressed issues of development, culture and education. Many have called attention to Eastern Europe’s role in transcontinental collaboration and have placed contributions to postcolonial projects in focus. With some notable exceptions, such as Young-Sun Hong’s work on East German development projects, or Ana Antic’s research on transcultural psychiatry in Yugoslavia, health has mostly escaped the attention of these new histories.

Through the lens of Hungary, the last country to re-join the WHO in 1963, my research aims to put Eastern Europe in the focus of international health inside and out of the World Health Organization. I seek to explore what happened to international health in Eastern Europe, outside of the purview of the usual suspects: international agencies and non-governmental organizations, like the Rockefeller Foundation, how complete was the break with liberal internationalism and what, if anything, took its place.

It was not long after Eastern European states successfully joined that the Soviet Union decided to leave the WHO. The Russians were not very eloquent in their reasoning, they cited the mammoth bureaucracy, high member fees and the political influence of the United States in the WHO. The exit of the Soviet Union, followed by the whole Socialist Bloc challenged the proclaimed universality of the newly formed WHO and the centrality of technical expertise in opposition to political allegiance. The quick deterioration of the East’s relationship with the organization seems to fit neatly into a narrative of the escalating Cold War and increase of the Soviet Union’s hold on Eastern Europe. However, when inspected in detail, the reasons for the exit of these countries was more complex and had to do as much with expectations of what an international health agency should do, as with foreign policy.

Grievances towards the WHO

Dr Josepf Plojhar, (right), Minister for Health, Czechoslovakia.
Also pictured, Tadeusz Michejda (left), Minister for Health, Poland;
Luitpold Steidle (right), Minister for Health, GDR.
Berlin, 14 September 1950. Bundesarchiv. Bild 183-T00826
   

The grievances towards the WHO had been many and from an Eastern European perspective, were mostly justified. The overpowering American influence undoubtedly played a large role in this. Certain issues, such as Americans barring access to vital drugs, such as penicillin in Poland and Czechoslovakia, became especially sore points for Eastern European politicians and physicians. In his memoir from 1978, Tibor Bakács, Hungarian virologist and representative to the second World Health Assembly in 1949 gave a dramatic account of the appeal of Josef Plojhar, Czechoslovak health minister and roman catholic priest.

Socialist countries did not have their own penicillin plants back then, they had to import the needed amount for hard currency from the West. The Czechs, in order to become independent, purchased a whole penicillin plant from the Americans before the political turn of February 1948, which according to the contract the US had to deliver in two installments. The first one arrived, but the second one, which was to be delivered after the political turn, was held back by the Americans. Father Plojhar, wearing priest’s attire, asked the delegation of the United States in front of the Assembly, why they had not honored the contract. The American delegate, putting aside all civility (and with the knowledge of the subservient voting machines behind its back) just briefly said: "Contract, no contract, you turned socialist, you get nothing!" The president of the assembly then put the Czechoslovak question to vote, and apart from the 5 yes votes of the socialist countries present, the issue was overruled by the majority. The vassals "voted well" - it was a real American decision. I wouldn’t have thought that professional issues, what’s more, questions of health can be distorted so under political duress.¹  

While Plojhar’s speech does not appear in the minutes, the American delegate, Leonard A. Scheele Surgeon General referred to it and dismissed the claim by stating that the equipment in question is not necessary for the production.

Attributing Eastern European countries’ decision to leave solely to Cold War political alignments would be a mistake, however. Recent research on the years of communist takeover has shown that the relationship of the Soviet Union and Eastern European countries was a complex one and certain aspects of that relationship were very much open ended. We cannot readily assume a master plan from the Soviet side, with which Eastern European states quickly fell in line with. Moreover, while the overwhelming influence of the United States in the WHO and pressure from the Soviet Union no doubt playing an important part, countries like Hungary had other, substantial reasons for discontentment.

Second World Health Assembly

Second World Health Assembly, Rome,
13 June to 2 July 1949: Decisions and
resolutions: plenary meetings verbatim records:
committees minutes and reports: annexes.
Courtesy of WHO: IRIS

The Socialist Bloc did not immediately follow the Soviet Union in stepping out of the WHO. The minutes of the second World Health Assembly in 1949 give a glimpse of the short time when Eastern European countries took part in the WHO’s work without the presence of the Soviet Union in the organization. In their speeches, Eastern European delegates acknowledged the merits of the WHO and the overall significance of the organization.

However, there were problems: several Eastern European delegates criticised the WHO for its one size fits all approach. Apart from issues with access to penicillin, the Czechoslovak delegate called on the WHA to rethink the universality of certain public health issues and instead, consider health priorities on a national level. The Hungarian Health Minister, István Simonovits pointed to the fact that while Hungary considers fellowships to be crucial as a form of pursuing international public health, many of its fellows are regularly denied entry visas to WHO member states and are therefore unable to attend conferences they are invited to. Simonovits also considered visiting lecturers to be less useful for Hungarian public health: “Even the best lecturer was hardly more useful than a good article, because in many cases the lecturer had no knowledge of our special local problems.”

The criticism of several of the Eastern European delegates point to a different expectation of the tasks and responsibilities of international health organizations. In the late 1940s the countries in question were still in a horrid state, their hospitals bombed, medical equipment seized or destroyed, with extreme housing problems and crumbling infrastructure. In countries with extreme shortages of medication, physicians and buildings fit to house patients, and with no access to the Marshall Plan or other forms of aid, the policy of the WHO to give technical assistance instead of material aid seemed pointless, offensive even. As Plojhar, the Czechoslovak delegate put it: "It is more urgent for us to dispose of some public-health problems than to receive good advice."

The buildings of the Foreign Ministry and War Office in Budapest, 1949.
Photograph by Carl Lutz. Foto:Fortepan/Archiv Für
Zeitgeschichte Eth Zürich / Agnes Hirschi. Photo ID: 105808

Withdrawal from the WHO

The second World Health Assembly was the last one that Eastern European countries attended for almost a decade. Romania, Albania, Poland, Czechoslovakia and Hungary left the organization in 1950. Some of the delegates, like Plojhar warned of this possibility at the Second WHA in 1949. But perhaps the withdrawal was not a clear choice. Instead of issuing a warning, the Hungarian delegate used his speech to plead for the inclusion of socialist approaches to public health, and to remedy the situation that caused the Soviet Union to leave the organization.

The withdrawal of such a substantial number of countries from the WHO placed the question of membership into focus and pointed to broader questions of supranationality and state sovereignty. The WHO navigated its practice among two legal school of thoughts: one of which considers such an international organization to be supranational, making a unilateral withdrawal impossible once a member voluntarily joined, and another considering membership in the international organization to be dependent on its alignment with foreign policy. The United States favoured the latter interpretation, its Congress upholding the right to withdraw within a year of joining the WHO. The organization itself adopted a position of compromise between the two schools, introducing “inactive membership” for withdrawing states. This latter solution also helped save the international organization some embarrassment, when the Soviet Bloc exited the WHO.

Not only did the practice of international public health in Eastern Europe continue with the budding socialist internationalism within the Bloc, but countries like Hungary continued to participate through interaction and collaboration with the West. Being out of the WHO, divided by the Iron Curtain also did not mean that the region was isolated in terms of international health. If we shift our focus from viewing internationalism in public health from the perspective of international organizations and governments, and turn to the agents of internationalism themselves, we find that the sites of international collaboration in public health were as varied as the people acting as internationalists. Families and virologists, hospital directors and religious scholars were actively involved in shaping international collaboration in research, treatment and access to technology.

Decentering Narratives of Internationalism and Global Public Health

Geographically and conceptually de-centring narratives of internationalism and global public health, especially ones tied to the Cold War, is crucial for a nuanced understanding of this formative era. By bringing Eastern Europe into the focus and considering alternative internationalisms, new faces, practices and relationships become visible, which, in the end, can help us piece together a very messy and often confusing picture of international and global health in the 20th century.

Dora Vargha

Dr Dora Vargha

Dr Dora Vargha is a lecturer in the Medical Humanities at the University of Exeter. Previously, she has held research fellowship positions at the Max Planck Institute for the History of Science, Berlin and at Birkbeck, University of London. She is an acclaimed authority on the history of global health and biomedical research in the Cold War era with a particular focus on Eastern Europe. 

Dora's work has been widely published in leading peer-reviewed journals including Contemporary European History, and Bulletin of the History of Medicine. She has recently completed the manuscript for her forthcoming monograph Iron Curtain, Iron Lungs: Governing Polio in the Cold War which explores a series of polio epidemics in Hungary in the context of international Cold War politics. She has recently embarked upon a new research project, for which she received a Wellcome Trust Seed Award, titled, 'Socialist Medicine: An Alternative Global Health History'.

Dora is the recipient of many scholarly awards including the J Worth Estes Prize from the American Association for the History of Medicine and the Young Scholar Book Prize from the International Committee for the History of Technology. She is the founding editor of and a contributor to the Central and Eastern European History of Medicine Network Blog. Dora is also a collaborating member of the Reluctant Internationalist research group, a Wellcome-Trust funded project that is researching the history of public health and international organisations. 

---

1 Tibor Bakács, Egy Életrajz Ürügyén (Budapest: Kossuth Könyvkiadó, 1978).^↩

AIDS and History by David Kilgannon

In this month's blog post, David Kilgannon, a Wellcome Trust funded PhD candidate in the Department of History, NUI Galway, looks at the response of two voluntary organisations, Gay Health Action and the Irish Haemophilia Society, to the arrival of AIDS in 1980s Ireland. In 2015, David completed his Wellcome Trust funded MA on the history of AIDS activism in Ireland at the Centre for the History of Medicine in Ireland, University College Dublin.

First Reported Cases of Aids

Report on the appearance of Kaposi's 

Sarcoma and Pneumocystis Pneumonia 

among homosexual men in New York 

and California, Morbidity and Mortality

Weekly Report, 3 July 1981.  Published

by the Centers for Disease Control and 

Prevention. Public domain.

The first clinical observed cases of AIDS arose among a group of homosexual men in Los Angeles in 1981. All five men presented with Pneumocystis pneumonia, a rare form of pneumonia, which is usually successfully fought off by the human immune system. The increasing prevalence of gay men with impaired immune systems throughout 1981-82 led the US Centers for Disease Control in June 1982 to classify this new disease as Gay Related Immune Deficiency (GRID). However, this model was soon found to be inadequate when non-homosexual patients, including women and children, presented with GRID symptoms. This resulted in the reclassification of the condition as Acquired Immune Deficiency Syndrome, or AIDS, in August 1982.

AIDS: State Response & Policy Failure 

Yet, the initial appearance of AIDS among gay men and intravenous drug users, and its continuing association with these socially marginalised groups was incredibly influential in shaping what were often desultory state responses to the syndrome, with the reaction of national healthcare systems to the incipient epidemic often appearing apathetic and lethargic. For example, in the United States it took a full three years after the first identification of the condition for the Department of Health and Human Services to produce and distribute their first AIDS information booklet for the public. While state responses were often insufficient, the appearance of AIDS instigated a substantial response by voluntary and activists groups. Roy Porter identified this phenomenon as one of the seminal features of the response to the spread of AIDS from the 1980s onwards.

AIDS Activism in Ireland

Number of cases of Sero-positivity in Ireland, 1985-1990

The historical study of AIDS, and AIDS activism in particular, has received sustained historical analysis in the United States and the United Kingdom. However, it has yet to be examined in Ireland. This lacuna is striking, as Ireland arguably presents a distinctive national context relating to AIDS. Three features are particularly notable. The principal prophylactic advocated for AIDS prevention, the condom, had limited availability in Ireland until 1985. Under the Health (Family Planning) Act (1979), anyone wishing to purchase a condom required a doctor's prescription. Secondly, the largest constituent group affected by AIDS in the United States, the gay community, was effectively criminalised in Ireland until 1993. Thirdly, in the 1980s the Irish health service underwent a period of drastic reductions in capacity, losing over a third of hospital beds during this decade. Taken together, these factors make a study of AIDS activism in Ireland particularly worthy of analysis in relation to its counterparts in the broader Anglophone world. My research attempted to examine two such examples of this phenomenon in Ireland. Namely, the activist responses from the gay and haemophilia communities to AIDS, as exemplified through the work of Gay Health Action and the Irish Haemophilia Society. 

Gay Health Action

Number of AIDs cases in Ireland, 1983-1990

The work of Gay Health Action was explored through an examination of their records found in the Irish Queer Archive held at the National Library of Ireland. These sources indicate that Gay Health Action's activism was directly influenced by the international impact and context of AIDS. Articles from the National Gay Federation's magazine Out reveal a community that was quite aware of the devastation of the gay community in other countries. This awareness played a key role in instigating the foundation of Gay Health Action in January 1985 even though AIDS was not yet then a prominent public health threat in Ireland. At that point, only eleven deaths had been attributed to the syndrome in Ireland. Gay Health Action worked to raise awareness by disseminating information on the disorder, producing information leaflets and running education seminars. The group organised itself within the existing structures of the gay community, using already established methods of information dissemination within the community and establishing a telephone helpline that had clear antecedents to earlier forms of gay activism. This led Gay Health Action to take an increasingly prominent role in the management of all matters relating to AIDS in Ireland, speaking as experts on the condition to media and running an information service that superseded the role of the state's Health Education Bureau.

Irish Haemophilia Society

Number of AIDS related deaths in Ireland, 1982-1990

Yet, this form of activist response was not replicated among the varied voluntary groups representing communities that were directly impacted by the advent of AIDS in Ireland. The Irish Haemophilia Society, many of whose members became afflicted with AIDS due to the use of imported blood products which were infected with HIV,  took a quite different approach. As a reading of Lindsay Tribunal Report, the Irish Haemophilia Society's proceedings transcripts, and the society's newsletters reveals, they only began to seriously grapple with the challenge of AIDS following the infection of more than a third of their members. This fact meant that the preventative, public education role fulfilled by an organisation such as Gay Health Action was less relevant to the Irish Haemophilia Society and its members. Instead the organisation focused primarily on providing pastoral care to infected Irish haemophilia sufferers, including supports that assisted those dying from AIDS.

The Voluntary Sector and Epidemic Disease

By examining previously unstudied responses by voluntary groups to an epidemic disease in 1980s Ireland, this project aspires to add greater depth to our knowledge of Irish health policy and the role of the voluntary sector in addressing the challenges associated with an epidemic disease.

David Kilgannon is a PhD researcher in the Department of History in the National University of Ireland (Galway). His project, which is co-supervised by Dr Kevin O'Sullivan and Dr Sarah-Anne Buckley, examines the changing treatment of the disabled in twentieth century Ireland and is funded by the Wellcome Trust. His Master's dissertation, 'How to survive a plague': AIDS activism in Ireland, 1983-1989', examined voluntary sector efforts against the AIDS virus in 1980s Ireland. It was completed in the Centre for the History of Medicine in Ireland, School of History, University College Dublin under the supervision of Dr Catherine Cox.

Childhood illness in twentieth-century Ireland by Ida Milne

In this month's blog post, Dr Ida Milne,  Irish Research Council ELEVATE fellow co-funded by Marie Curie Actions, writes about her postdoctoral project on childhood illness in twentieth-century Ireland.

We live in an era where we expect our children to survive to adulthood without having their lives threatened by common infectious diseases of childhood.  The situation was rather different in the Ireland of the early part of the twentieth century. In 1911, more than 2,000 infants under the age of two died from diarrhoeal illnesses, almost double the number that died the previous year.  The increase was not helped by the hot summer, which exacerbated the hygiene difficulties in an era when many houses, even of the affluent, did not have running water or flush toilets. As a twenty first century mother, I find the idea of nursing a child suffering from diarrhoea in an overcrowded third floor  bathroomless tenement almost unimaginable. 

Child mortality in the early-twentieth century

Having healthy children who would survive to adulthood was not taken as the norm, as we do now. Statistics tabulated by the Registrar-General in 1911 show that one-fifth of the total 72,475 deaths in 1911 were children under 5; of these, 945 were caused by ‘convulsions’ and 1,370 by bronchitis. Scarlet fever claimed the lives of 260 children under fifteen; 460 under-fifteens died from measles, and 819 under tens from whooping cough.  

Slums in Dublin, c.1865-1914 (Image from NLI collection: L_ROY_07881)

Dublin tenements, poverty, and childhood illness

Few families, rich or poor, remained untouched by these deaths, but the over-crowded living conditions of the poor could bring extremes of ill health. Stella Larkin McConnon, trade unionist James Larkin’s granddaughter, told me that the poor health of the nation’s children was one reason he became so interested in improving living conditions for families.  The Larkins had good reason to be aware of the suffering.  Stella’s own mother was brought up in Marlborough Street in the heart of Dublin’s tenements, and was the only one of ten children to survive to adulthood.  Stella still remembers visiting the tenement, one room with only one metal bed, the only toilet downstairs in another part of the tenement, the cooking done on an open fire.

Improving child health

By 1981, the landscape of death in childhood had changed radically. There were no deaths in either Northern Ireland or the Republic from scarlet fever or whooping cough, and only two from measles.  Only 2.78 per cent of the total deaths, 916 of 32,929, were of children under five.

Many factors contributed to the improvements over the course of the twentieth century:  among them vaccination schemes and more effective medicines, public health education and increased state intervention in the health of children, better housing and diet and improved air quality. It didn’t happen by accident – throughout the century, there were individuals who identified areas to change and worked to effect that change.  Their number includes the first chief medical officer for Dublin, Sir Charles Cameron, trade unionists like James Larkin who worked to give families a decent wage, pioneering TB Dr Dorothy Stopford Price,  Department of Local Government and Public Health Chief Medical Officer James Deeny, Noel Browne and many others who played macro and micro roles in the significant reduction in deaths from disease in childhood.

Research project on childhood disease

In October, I began a three year  Irish ResearchElevate Fellowship in the National University of Ireland and Queen’s University, Belfast to research this dramatic changing landscape of childhood disease, which is in general a good news story for Irish society and Irish public health.  While statistical and documentary sources will be important to the project, a key feature will be a series of qualitative interviews with medical professionals, with people who worked in relevant Government and local authority roles, and with parents and sufferers. I intend that these interviews should, at the conclusion of the project, be available in an open access archive to other researchers. 

Mother (to District Visitor): "Lumme, miss! There ain't no danger

of infection. Them children wet's got the measles is at the 'ead of 

the bed, and them wet ain't is at the foot.

London Mail, 23 October 1913

Image courtesy of the Wellcome Library

The project builds on and was partly inspired by the RAMI Living Medical History project; Susan Mullaney, Mary O’Doherty and  Patrick Plunkett of the RAMI section on history of medicine devised this innovative project to interview retired medical doctors about their working lives, collecting memories on the changes in medical practice over the course of their careers. Several of the LMH interviewees had either suffered from diseases like diphtheria and tuberculosis themselves, or had family who did, and this really brought home to me how all-pervasive the effects of childhood disease were on Irish society, that they were not merely confined to the poor and the badly-housed, but could also invade better-off families.

Oral history of medical practitioners

Oral history interviews can add flesh to the dry bones of statistics. When working on my PhD on the effects of the 1918-19 influenza pandemic here,  the people who spoke to me about suffering this influenza as small children, or who told me about how their families coped with the tragic losses of children or parents to the 1918-19 flu, breathed life into its history, recreating the fear caused by the unpredictability of  this most awesome of influenza pandemics.

In the case of this new project, I am hoping to find people who can talk about the changing landscape of childhood illness in the twentieth century, from their own perspective, whether as medical workers, patients, parents or as Department of Health officials and politicians.

I’m curious about issues like knowledge transfer – how and what did parents learn about treating the illnesses their children caught?  As a child growing up in the 1960s, I recall my mother hanging blankets over the windows when we caught measles; the information she had been passed down by her mother was that children with measles could damage their eyesight if they read or were in daylight.

When I had my own children in the 1990s, I was struck by the efficiency and dedication of a district nurse in north Kildare who made sure we parents brought our children for vaccinations, and cajoled and informed those parents who had reservations about allowing their children to be vaccinated. Getting medical workers like her to talk about their work is one of the goals of this project. This district nurse was, it seems to me, a local hero, a micro role player who was a small but significant cog in the expanding machinery which managed and significantly improved the health of our children over the course of the twentieth century. 

Dr Ida Milne is a social historian based at NUI Maynooth and Queen's University Belfast. She holds an ELEVATE Irish Research Council International Career Development Fellowship co-funded by Marie Curie Actions. 

The Crusade to ‘Conquer Cancer’ in Ireland, 1950s-70s - Smoking and Lung Cancer: The Rise of the Visual by Jane Hand

In this month's blog post, Jane Hand, a PhD student at the Centre for the History of Medicine, University of Warwick, writes about public health initiatives in the campaign against lung cancer in Ireland, c.1958-78. This was the subject of her MA dissertation undertaken at CHOMI, UCD (2011).

Since the late 1950s the relationship between smoking and lung cancer gained increased national prominence in Ireland, becoming the focus for a variety of both public and voluntary health education campaigns. The visual component of these health campaigns was central to the formulation of health education strategies reflecting changing perceptions of disease. In addition, as health advertising became increasingly central to public health, aspects of medicine and media consumption became more closely allied. This facilitated the emergence of a lifestyle-orientated public health centred on behavioural modification in relation to chronic disease diminution.

Fig. 1 Anti-Smoking Leaflet aimed at children, 

Department of Health and Children (NAI S16659A)

The causal connection between smoking and lung cancer was the first major chronic disease model to be explicitly linked to lifestyle factors. Consequently, health education material attempted to incorporate models of behavioural change. The initial release of anti-smoking publicity material in 1958 consisted of two leaflets highlighting the connection between smoking and lung cancer. As shown in Fig. 1 and Fig. 2, the first leaflet targeted adults, whilst the second aimed at reducing the smoking uptake amongst the young. Both publications employed visual techniques centred upon simplistic imagery, eye-catching colour usage and the juxtaposition of upper and lower case text to emphasise particular aspects of its composition to the reader. By adopting a question/answer format these leaflets provided concise and precise health information whilst removing medical jargon from their explanatory texts. Their basic function was to establish a specific mode of behaviour and correct health conduct in relation to cigarette smoking. Minister for Health, Séan MacEntee made the rationale behind the publication of these leaflets by the Department of Health exceedingly clear: ‘The reports of investigations into the death rates from lung cancer have ensured that the results must be brought to the notice of the public’.¹

                                                 

Fig. 2 Anti-Smoking Leaflet aimed at adults,
Department of Health and Children (NAI S16659A)

Efforts to reduce tobacco consumption amongst younger age groups remained a central objective of state-led health promotion initiatives. Consequently the “Smoking Kills Your Taste for Life” campaign centred upon the mantra ‘If You Don’t Smoke - Don’t Start, If You Do Smoke – Stop Now!’ which represented the principal component of the Department’s health education strategy for much of the 1970s. A series of health educational films, including the “Smoking Kills Your Taste for Life” filmlets, were shown in primary schools throughout the country, with Irish-language voiceovers for those schools situated in Gaeltacht areas and some others that requested the Irish version.²

The dangers of smoking were compiled in a booklet The Facts about Smoking and Health, anti-smoking posters were widely circulated and a series of shorts were aired on RTÉ television.³ The establishment of a poster competition on a non-smoking theme proved particularly popular.⁴ The competition itself was widely advertised using press, radio and television. Entry forms had themselves acted as advertisements, comprising a strong anti-smoking message. As displayed in Fig. 3, these provided educative information concerning the dangers of smoking whilst appealing to the public-consciousness to elicit a positive response: ‘Deep down you must know that smoking is bad for your health – but let’s face it, at your age lung cancer seems a remote possibility’.⁵  The use of a direct-address style in the accompanying text to this pamphlet only served to further foster a perception that confidence in curative measures was maintained within the visual expression of disease and illness.

       

Fig. 3 ‘Smoking Kills Your Taste for Life’ poster competition entry form
Department of Health Files (INACT 428227)

During the 1970s an emphasis on the harmful effects of tobacco smoking on the lungs became more overt. The utilisation of various shock tactics, specific medical knowledge and biological explanations became increasingly standard practice. Science was becoming as much a part of the various promotion techniques employed, as were those pleas to health consciousness. Increased biological knowledge facilitated the emergence of a series of intellectually founded anti-tobacco smoking campaigns, particularly those instigated by the Irish Cancer Society, such as “How Smoking Affects Us” reproduced as Fig. 4.⁶ The caption serves to draw the reader’s attention to the integral message of the leaflet thus preventing any possible misinterpretation.⁷ By combining text and illustration the pamphlet successfully attempts to heighten its educative purpose. Ultimately the use of a diagram coupled with numbered explanations serves to convey an otherwise complicated medical message in a concise and understandable format.

           

Fig. 4 Anti-Smoking Leaflet produced by the Irish Cancer Society,
Department of Health Files (INACT 428227)

The 1970s represented the era when persuasion media as a method of health education became central to public health campaigns. Analogous to Britain, state expenditure on health promotion increased dramatically reaching £110,000 for the year 1970-1971, thereby facilitating the application of new-style advertising campaigns highlighting the tobacco and lung cancer risk.⁸ Campaigns developed a more scientific and biological character. The use of a series of precise anatomical diagrams designed to outline the effects of smoking on the body became evermore commonplace Whereas almost all anti-smoking propaganda produced during the late 1950s and 1960s had focused exclusively on the relationship between smoking and lung cancer, the 1970s was notable for widening the scope of the anti-smoking crusade. No longer was the lung perceived as the only body organ to be affected by the adverse effects of prolonged cigarette smoking, but rather its additional detrimental effects, as displayed in Fig. 5, Fig. 6 and Fig. 7, on the heart, brain, and nose and throat in particular were increasingly expounded.

Fig. 5, Fig. 6 and Fig. 7 The Better Health Pack Leaflets
on the bodily effects of smoking (NLI Ir614 h4)

Moreover, the focus altered somewhat with increased state interest in the effects of smoking on the pregnant woman. The dangers of smoking in pregnancy were highlighted in a special article entitled ‘You and Your Baby’ which was distributed nationally by the medical profession to expectant mothers.⁹ With the formation of the Health Education Bureau in 1975 and its greatly increased budget following the appointment of Charles Haughey as Minister for Health in 1977, state sponsored health campaigns adopted a more sophisticated composition.¹⁰ The tar and nicotine content of cigarettes was increasingly emphasised to create an anti-aesthetic surrounding the habit of smoking.¹¹ The promotion of anti-smoking material centred on the endorsement of behavioural change rather than on compulsion, with the media providing the key factor within a new style of health activism. 

The modification of individual behaviour through the initiation of highly stylised visual health campaigns became central to public and voluntary information programmes. As encapsulated by MacEntee, lifestyle choice and behavioural change became pivotal to the success of anti-smoking education campaigns centred upon the concept that ‘If you have never smoked, don’t take it up; if you are already a smoker, give it up, or at least do not smoke immoderately’.¹² By accepting the epidemiological argument for a connection between smoking and lung cancer both the state and voluntary organisations alike firmly aligned themselves to the implementation of a programme of preventative measures. This was achieved through the adoption of visual illustration as the main feature of health advertisement material. The promotion of anti-smoking material within Irish public health campaigns relied upon the efficacy of visual advertising in producing health responses on the part of the public. Ultimately this ‘visuality’ in promotion methods was key to the rise of a new health ideology based on individual responsibility for healthy lifestyles and behaviours.

Jane Hand is a doctoral student at the Centre for the History of Medicine, University of Warwick. Her PhD is entitled 'You Are What You Eat: Chronic Disease, Consumerism and Health Education in Britain since the Second World War' and she may be contacted at j "dot" hand "at" warwick "dot" ac "dot" uk

Author’s note:

The images reproduced in this post were sourced directly from the Department of Health with the permission of Fergal Flynn, Department of Health.

All other primary source material is held at the National Archives of Ireland.

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1. Department of An Taoiseach, ‘Cancer: Publicity Leaflets etc.,’ 11^th February 1958, National Archives of Ireland, TAOIS S16659A. [Italics added by author].↩
2. Anon, ‘Radio programme on cigarette smoking’, 1973, Department of Health and Children, INACT 461262.↩
3. Minister for Health (Erskine Hamilton Childers), ‘Radio Programme on Cigarette Smoking 19/06/1973 – Written Answers’, Department of Health and Children, INACT 461262.↩
4. Minister for Health (Erskine Hamilton Childers), ‘Radio Programme on Cigarette Smoking 19/06/1973 – Written Answers’, Department of Health and Children, INACT 461262.↩
5. Minister for Health (Erskine Hamilton Childers), 'Address by Mr Erskine Childers, T.D., Táinaiste and Minister for Health at the Prize-giving ceremony in the anti-smoking poster competition in the Metropole Ballroom, Dublin, 6 January, 1971’, Anti Smoking Poster Campaign for School Children and Television Campaign, Department of Health and Children, INACT 422036.↩
6. The Information Services of the Irish Cancer Society, Smoking Burns You Up: How Smoking Affects Us, Leaflet Department of Health and Children, INACT 428227.↩
7. Cooter and Stein, ‘Coming into focus’, p. 186.↩
8. Coiste no gConnartha Rialtas, ‘A meeting of the Government Contracts Committee’, 6 August 1970, Department of Health and Children, INACT 422036; Minster for Health (Erskine Hamilton Childers), ‘Ceisteanna – Questions. Oral Answers – Health Educational Programmes’, Dáil Debates, vol. 254, col. 2249-2250, 23 June 1971; Berridge and Loughlin, ‘Smoking and the New Health Education in Britain 1950s-1970s’, pp 960-961.↩
9. Anon, ‘Radio programme on cigarette smoking’, 1973, Department of Health and Children, INACT 461262; ‘ “You and Your Baby”: A Family Doctor Publication by the Irish Medical Association in conjunction with the British Medical Association’, Department of Health and Children, INACT 461262.↩
10. Dwyer, Short Fellow, p. 152. ↩
11. Berridge and Loughlin, ‘Smoking and the New Health Education in Britain 1950s-1970s’, p. 961.↩
12. Irish Times, 5 Dec. 1959.↩