Another approach to assessing the validity of the Lewis/Webster reading is to set it against qualitative evidence of local experience. This section examines public health in a region of the South West of England containing two County Councils, Somerset and Gloucestershire, and three County Boroughs, Bristol, Bath, and Gloucester. Hitherto the detailed work on local government health services has concentrated on cities in the Midlands and North, to the neglect both of Southern cities and counties with sparsely settled rural populations, so this region provides a valuable counterpoint. Pastoral agriculture dominated in Somerset, with its celebrated dairy industry, along with tourism and coal production; Gloucestershire's economy was also agricultural with some coal mining and textiles. Bristol (interwar population c.400,000) was England's seventh largest city and the South-West's major outport, as well as a commercial, manufacturing and service centre. Gloucester (c.50,000) was a river port and cathedral city and Bath (c.70,000) a wealthy spa and leisure town.
Taking Lewis's criticism of the failure of diphtheria immunisation first, local sources suggest that action was inhibited by the legacy of popular antivaccinationism. Gloucestershire for example had long been associated with opposition to compulsory vaccination against smallpox, with public protests continuing up until the last epidemic of variola minor, in 1923. Meanwhile in Somerset MOH William Savage (who Lewis admires as a <<thoughtful commentator>>) moved slowly for fear that <<(...) the <<anti>> people will whip up a certain amount of opposition>>. In Bristol the MOH embraced the science of Schick testing and child immunisation on the American model by the early 1920s, but the political environment inclined the health committee to a voluntary scheme, with resulting low levels of take-up. Moreover in rural areas the powers of public vaccination were situated not with the county council, but with smaller subsidiary authorities, the urban and rural districts. Thus when Gloucestershire's MOH, Kenneth Cowan, initiated a county-wide immunisation scheme this foundered on local resistance. Some districts rejected the scheme, and in others its implementation was remitted to individual GPs who followed inconsistent practices with regard to the numbers of doses. These considerations suggest that it is unreasonable to attribute all blame for Britain's lag in adopting diphtheria immunisation to public health departments. Given the anti-vaccinationist past, it is arguable that only a strong lead from the state would have ensured success, but this was not forthcoming.
Nor is the charge that the relationship between poverty and ill health was ignored during the interwar depression borne out. A striking example is a long essay on the <<vicious circle>> of poverty in the 1934 report of Bristol's MOH, Robert Parry, in which he implicated lack of <<family means>> in leading to <<slumdom>> and poor public health. Nor was there neglect of new research on nutrition. Frustrated with the poor guidance from central government on the classification of malnutrition in school medical inspections, and consequent subjectivity in assessments, Parry initiated a panel study of local 9-year olds. Taking as baseline their classifications as <<well>> or <<poorly>> nourished at age 5, researchers conducted physical and mental tests on the children and interviewed their parents, concluding that <<we can unhesitatingly say that it is the economic state of the family>> which explained malnutrition. This hardly tallies with Lewis's assumption that the <<community watchdog>> role was neglected. One might also expect, if Lewis's judgement is correct, to find that Parry was an enthusiast for social medicine. But although he was a supporter of Ryle, he regarded social medicine as <<(m)ere change of name>>, and essentially similar to <<preventive medicine>> in which he held the university chair at Bristol.
Lewis's argument that the activities of public health doctors were becoming increasingly indistinct from those of general practitioners is also hard to validate. One obvious difference was that environmental health remained within the MOH's remit in the interwar period. Historians have hitherto neglected this, assuming that practical aspects of the work had been devolved to the sanitary inspector's teams, but the MOH still retained overall direction. Some issues were relatively minor. In Gloucester for example the health department fought a long-running battle in the 1920s to persuade a parsimonious council to provide metal dustbins for waste collection. Elsewhere though, the nineteenth-century struggle to provide constant supplies of fresh running water continued. In Somerset for example, MOH William Savage moved quickly to identify places which still lacked mains connections, after the County Council gained powers from district authorities in 1929. Levels of funding were raised and regional planning was introduced, though even in the 1940s some dairy farming areas still relied on springs and wells.
More generally, the MOsH in the five authorities regarded housing improvement as a major health priority. Again the sanitary inspectorate was the workforce, but it was the MOH who was: <<the centre of the stage, the author of the plot and "villain" of the piece, as the principal witness and the butt of cross-examination>>. In rural areas an active programme of visiting by the MOH and housing inspector preceded demolition of <<hovels and quite insanitary houses>>, while health officials advocated the building of low rent public housing and attacked overcrowding. In the cities the MOH was involved in inspection, slum clearance, the issuing of improvement and closure notices, and the planning of public building programmes. <<Of all the causes which tend to undermine the health of the people>>, stated Bath MOH, James Blackett, in his 1920 report to the council, <<a shortage of suitable housing accommodation is by far the greatest>>. His argument was that damp and overcrowding led to TB, the spread of infectious diseases and high infant mortality. Thus, even in prosperous Bath, health officials highlighted social determinants of morbidity, and used the housing sections of annual reports to encourage local politicians to initiate improvement. As to the scale of these initiatives, consider the example of Bristol. In the mid-1930s the health department conducted about 1,400 housing inspections annually, with a yearly average of 980 houses found unfit for habitation. Overall the interwar corporation built about 15,000 new houses, of which about 25% were for families removed through slum clearance.
By coincidence, one of Lewis's key witnesses for the argument that MOsH were losing their preventive role was based in the region. She notes the criticism which William Savage, MOH for Somerset, launched in 1935 of the administrative burdens imposed by the LGA, which he saw as <<not our proper business>>. Hospital work and responsibility for mental health, he argued, detracted from the development of new preventive strategies, and Lewis concludes from this that MOsH were failing to keep abreast of new practices and remained wedded to traditionalism. Was Savage's analysis reliable, and his perspective representative? Consideration of his long and distinguished career in Somerset (1909-1937) suggests not. Born in 1873 he was close to retirement by 1935, describing himself as <<an old timer bred in the old tradition>>. His public health textbook of 1941 demonstrates that his goal was not to reinvent preventive medicine, but to preserve for the MOH the time-honoured environmental duties increasingly devolved to sanitary inspectors. Indeed, a Ministry of Health surveyor in 1931 wrote that Savage was disinclined to delegate and was unusually committed to environmental health, functioning as a <<sort of super sanitary inspector>>. His substantial published output in the 1930s confirms this orientation, dealing predominantly with issues of milk and food safety and bovine tuberculosis (matters close to his heart in cheese-producing Somerset), while his textbook concentrated on water supply, disposal of sewage and effluent, river pollution and housing inspection. Savage may also have been singularly ill-disposed towards the post-LGA administrative duties because of difficulties peculiar to Somerset. His efforts to assert control over the transferred Poor Law institutions in order to <<depauperise sickness>> were unsuccessful, as was his recommendation that the county should build a new central hospital rather than developing existing stock. These observations point to a potential problem with Lewis's methodology, heavily reliant on articles in the professional journals, which when contextualised may have a different significance.
Claims of administrative <<overstretch>> are further contradicted by regional evidence that public health departments experimented with new preventive strategies. One example is the advance of health education, then termed <<health propaganda>>. To a limited extent this followed national leadership, with <<health weeks>> and distribution of journals and posters, but it emanated principally from local initiative. It is ironic in the light of Savage's complaints about bureaucratic distractions that Somerset County Council provides a prime illustration. A full-time worker gave talks to Women's Institutes, Mothers Unions, schools, district nursing associations, village communities, girl guides, boy scouts and so on. Films and a travelling exhibition accompanied these health education efforts, whose explicit rationale was to promote healthy living and counter the ignorance deemed to cause much ill health. Clearly innovative health promotion was not confined to better known <<progressive>> authorities like Bermondsey. Another example is the use of TB screening programmes which began during wartime. The first step was Bristol's purchase of a <<mass miniature radiography unit>> used to screen selected groups, such as cohorts of school leavers, council staff, civil servants and BBC radio employees. A van was then purchased, which made the equipment available for temporary loan to the neighbouring authorities, with Bath for example screening government employees in the city. Screening and health promotion assumed greater significance as an activity of local government public health departments under the NHS, but they were rooted in the earlier period.
Behind the critique which Lewis and Webster level is the assumption that interwar public health might have done more to further social justice during the economic recession. Certainly the case is well made with respect to the inadequacy of food supplements in the depressed areas and the failure of public housing adequately to address the needs of the very poor. However, if we turn from a narrow definition of preventive medicine to consider the activities of public health departments more broadly it is possible to discern a significant advance in equity. First, much local government health work was funded through local taxation based on property values, which, with some provisos (related to geographical variations and to exemptions), was increasingly progressive. And while user fees were introduced for some services, they did not loom large as a source of revenue and were not aggressively pursued. For example, in the five South West authorities on average only 8% of the SMS was funded by recoupments from parents.
Second, the growing range of personal health services meant more equitable access. After 1929 the appropriated municipal hospitals admitted patients for acute medical care on the basis of local citizenship and they added significantly to the volume of available provision. In Bristol for instance the ex-Poor Law Southmead Hospital rapidly developed from long-stay institution to acute care hospital: 75 per cent of patients stayed for less than four weeks by 1938, and the number of maternity confinements increased from 127 in 1928 to 3,131 in 1942. There were also experiments in bringing services to previously under-served rural areas. Gloucestershire initiated an <<Extension of Medical Services Scheme>>, creating a network of <<out-stations>> in remote places, with regular clinics linked to general hospitals through formal referral networks. In Somerset a different approach was tried, with a system of "flying clinics" (ie without a fixed location) for rural areas. This developed from a series of nurse-led <<Mothers and Babies Afternoons>> to include a doctor and the health propaganda officer. In the cities similar initiatives were underway. Bristol pioneered the building of health centres aimed principally at infants and children and intended to provide a nexus for MCW and SMS work, to ensure joined-up working and a referral system to underpin inspections. These were not health centres on the Peckham model, but considering the entrenched opposition of private practitioners to any such initiative, they too represented an important extension of access.
Finally, with respect to patient dignity, the removal of many services from the Poor Law lessened the shame of accessing public medical services, and eroded, though did not destroy, the historic division between a <<respectable>> voluntary sector for the self-supporting and a lesser public sector for the dependent poor. The appropriation of Bristol's Southmead explicitly aimed to <<remove the stigma of pauperism>> so that the poor would receive <<hospital treatment (...) under the same conditions as the rest of the citizens>>. Even in the public assistance institutions, oral history shows that management styles were becoming more compassionate, professional and progressive.