On Social Medicine

Writings on social medicine by John Ryle

John Ryle described social medicine as an activity in which everyday clinical work should include the systematic observation of the circumstances in which the diseases confronted by doctors arose. They would record their observations so that they could be collected, analysed, and used to inform social policies and medical methods for preventing disease in the first place. and encouraging improvements in the general level of health—both physical and mental. In his own definition he emphasised research into the origins of disease, looking not only at their organic sources in individual bodies and transmission between them, but on predisposing factors in the human community:

Social medicine is clinical medicine activated in its aetiological inquiries by social conscience as well as scientific intent, and having as its main purpose the education of professional and lay thought and the direction of legislation on behalf of national health and efficiency. … Preoccupied with the teaching of the symptoms and signs of disease and ill-health, we have not sufficiently stressed the importance of pursuing their causes to their source, and in this we have somewhat failed as teachers, scientists, and humanists. … it is salutary to remind ourselves that aetiology is the most important but the most neglected branch of medicine, and that social medicine (which is applied aetiology) might immediately engage the more active attention of all teachers, students, and practitioners of medicine, and will eventually require the co-operation of all citizens.

The war was a strong stimulus to people to think about how best to improve the strength and health of the people, their resilience in both physical and psychological aspects, and their productive capacity, and so it was quite natural that attention turned to the kind of thinking about society which focused on these issues. Since social medicine was particularly concerned with collective well-being as a guarantor of individual health, it was relevant both to organisation for war and to the plans for post-war reconstruction which were intended to give the British war effort a long-term sense of purpose beyond mere survival. John Ryle saw the war and the post war world together. When complaints appeared in the press that war production was flagging for want of planning, he pointed out that proper consideration for the welfare of workers was the basic need for productivity at any time.

Experience and experiment in times of peace and during the last War have clearly shown that during prolonged periods of pressure industrial fatigue results in falling output, and that output again increases when hours are shortened, proper rest periods are instituted, and a sufficiency of holiday is allowed.  … the rising tempo of the war has continued to demand a rising tempo of production. Long hours and overtime, the monotony of repeti­tive work, noise, journeys from and to the factory, private and public anxieties, and rationing, not to mention patriotic zeal itself, have begun to have their anticipated effect on muscle and nerve and mind …

His remarks are also a reminder that, as a veteran of the previous world war, he had been through the arguments about the long-term value of a war effort, and the planning for its aftermath, before. He told his students that ‘there will be tasks of human reconstruction and repair, discoveries to make, educational reforms and reforms in our body politic, and a reorganization of medicine in the service of the State … for many years to come’.

This war is but the first chapter of a revolution in which you will of necessity be among the actors. You cannot afford to school yourselves in science alone. You must know something of men and movements, too; you must qualify for citizenship as well as for your baccalaureate or doctorate in medicine. Whatever form our future State may take the doctor will always be a key-man in its organization. He must earn his freedom to think and to advise …

John Ryle’s approach to social medicine was based on his own personal experience, and the interest he took in the people who came to him for treatment. A doctor’s everyday work should contribute to the general understanding of disease and health throughout the population. The treatment of disease and the active improvement of the living conditions of the people were inseparable in his view. ‘I regard social medicine  … as a logical development from and a direct expansion of clinical medicine …’ As a consequence, he insisted on the need, very apparent in war, for a sense of community, and a willingness to serve it through the organising power of the state. He believed also that in the medical profession it was essential to ‘develop the social conscience’, and that the profession’s ethics should include a commitment to the bettering of the social conditions which might lead to illness, rather than merely curing individuals’ illnesses. This was to be social medicine’s particular contribution.

…  it has seemed to me that medical students and doctors as a body, excusing themselves on the ground of their many preoccupations with the curriculum or the anxieties of practice, have held themselves too much aloof from the larger social problems. … I do not ask you necessarily to ally yourself with any particular political creed, but I do ask you to be seriously interested in man’s environment and the possibilities of its improvement.

It may properly be argued that many of the social evils, so widely manifest by disease … call not for medical action but for drastic social and economic reform. For these the electorate through their representatives, and not the doctors (as doctors), must become responsible. But who unearths and exposes the evils and their secondary effects? The factual evidence, the socio-medical experience, the statistical data—all of which must be carefully and laboriously collected and analyzed must continue to be provided by the doctors and their scientific associates and field workers and particularly by those whose concern is rather with the social than with the individual aspects of disease. Whether in this basic manner, or more immediately as an educator of opinion, or incidentally in the course of his daily professional activities, we have reached a time in which “the physician  … must assume leadership in the struggle for the improvement of conditions.” Without research and teaching in social medicine to guide him he cannot faithfully fulfil his mission.

An important reason to keep the idea of social medicine distinct from the idea of a state medical service was that the latter could, just as much as fragmented commercial practice, simply focus on treating the instances of illness and contribute nothing to dealing with the circumstances which prompted it. Of a state service he wrote:

For the most part it must be allowed that … neither the profession nor the public have advanced as yet beyond the idea of a service to cope with disease. The majority of doctors have been compelled by circumstance to the belief that their first function is the treatment of disease or injury, and not the maintenance of or education for health. … The public for the most part think of the doctor as someone to consult in times of sickness only. For most of them the glamour of medicine is connected with the saving of life or limb by medical or surgical skill. And yet the totality of lives or limbs saved by this means, great though it is, is infinitesimal in comparison with that saved by preventive methods. … The State, the profession, and the public have still to be educated to a wider understanding of the difference between “no disease” and “health”.

Too little attention, he felt, had been paid to health as a positive goal, and too little research devoted to what might promote it, rather than simply what might remove the causes or symptoms of disease. Health was something that could be encouraged to develop, and it could be studied in its own right as part of medical practice. As the circumstances encouraging health would be generally applicable to all, in contrast to disease which had to be approached case by individual case, it was an inescapably social matter.

A good definition of health in the individual should convey the idea of competence to perform and enjoy the tasks and functions appropriate to his or her age and sex. It should convey the idea of well-coordinated function, of life vigorous, well balanced, and attuned to its environment. It should certainly mean something more than a state of “no disease.” … it should really be our first pride and purpose—remembering the features and phenomena of health —to detect the earliest departures from it, to recognize morbid conditions when they are more susceptible of arrest or cure, to be more familiar with those multitudinous shades and varieties of unfitness which might have been altogether avoided.

… what a nation we could become again if we would but accept and act upon the fundamental principle that, for the individual and the community, health of body and mind and the things that secure them are the most important of all economies and the surest shield against adversity and discontent and conflict!

Regardless of arguments about the form of a future health service, there was a side to social medicine which led logically to a serious concern with politics, in whatever way might be suitable, in order to further the purpose of making communities healthier. John Ryle was emphatically neither a nationalist nor an imperialist. His stress on the need for social and political awareness amongst doctors, and a willingness to help develop and to act through state institutions, was intended primarily in the interests of the local community which the doctor served, especially its disadvantaged members. He defended political commitment and the principle of state-run services against charges from other senior doctors that they would politicise the relation between doctor and patient, restrict research, and censor the expression of opinion and criticism.

… it is an assumption that State medicine must necessarily impose controls on the professional thought and actions of the doctor and spoil his age-long human relationships with his patients. There is no reason why “free speech on medical matters, free criticism of medical affairs, and free publication of scientific work” should not be preserved under a national system …  

One cannot develop one’s functions fully as a doctor and a citizen without being interested in policies affecting the welfare of the community, and this is only another way of saying without ” being political.” Let us agree that it would be quite improper to mix politics with practice: and that it would be equally improper in the teaching of social medicine (which, like clinical medicine, has its scientific disciplines as well as its humanistic motives) to discuss political programmes for the solution of problems which can, and should, be as critically and dispassionately studied as bedside or laboratory problems. But it is surely wholly proper that doctors, when fitted and able to do so, should play a part in local government; that they should support parties which seem to them to work best in the national interest  …

(The quotations above are from lectures, articles and letters by John Ryle which appeared in the British Medical Journal on 16 Nov. 1940, 27 June and 26 Dec. 1942, 20 Nov. 1943 and 31 Mar. 1945; and in the Times on 24 July 1943.)