- Email: [email protected]
In Response to the 2002, vol. 22, issue 4 article entitled “The Rise and Fall of Occupational Medicine in the United States” The rise and fall of occupational medicine in the United Kingdom
In Response to the 2002, Vol. 22, Issue 4 Article Entitled “The Rise and Fall of Occupational Medicine in the United States”
The Rise and Fall of Occupational Medicine in the United Kingdom To the Editor: he United Kingdom’s experience of occupational medicine over the past 2 centuries has many similarities with the account of its sorry plight in the United States.1 In the beginning, government intervention in conditions of employment was considered inexpedient in practice and wrong in principle. The Poor Law, which extended back 200 years to the time of Queen Elizabeth the First, still operated in the United Kingdom (UK), and under it, young paupers in the South, who otherwise would have been a charge on their local parishes, were transported to be so-called apprentices in the textile mills in the North of England. At the end of the 18th century, itinerant nonconformist busybodies investigated their state and published accounts of the deplorable conditions under which these young children worked, lived, were mutilated, and died. In response, an act was passed in 1802 purportedly to do something about the health and morals of the children. Talk, paper, and print are cheap enough, and in the absence of the appropriate level of enforcement, the whole exercise did not impose a burdensome charge on industry or the state. Local nonstipendary magistrates and clergy were designated to make regular factory inspections; it was their ignorance or complacency that was considered responsible for the worthlessness of the act. Notwithstanding its ineffectiveness in improving the lot of the child pauper-slaves, the act was extended to benefit “free” children working in factories. Following the expulsion of the Stuarts and the replacement of James II by William of Orange, there was a move to subordinate the Crown to Parliament and to empower the upper classes. After failed attempts by William Pitt and by John Russell, Earl Grey saw the successful passage of the Reform Bill of 1832. One of the first actions of the new Parliament was to set up a commission to report on the conditions in textile factories. The inquiry reported quickly and the Act to regulate the labor of children and young persons in Mills and Factories of the United Kingdom was promptly placed on the statute book on August 29, 1833. It regulated the minimum age and hours of work, and provided for continued education. As an enabling act, it allowed the King to appoint four persons to be inspectors of factories in places of labor for children and persons aged ⱕ18 years. The inspectors had powers of entry at all hours, of questioning people under oath, and of judging and sentencing. When one of the original four left because of the intolerable pressure he experienced from manufactur-
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ers, he was replaced by a Whig whose curriculum vitae before joining the inspectorate ran from demonstrating his loyalty by accidentally killing a political opponent in a duel (verdict of “death by misadventure”), flight to America for a few years to overcome financial embarrassment, and then a return to the UK as a newspaper editor. The other inspectors were men of substance and education, one of whom was elected as a Fellow of the Royal Society. Political will threw up inspectors of a caliber to institute a system of inspection and to enforce regulations. Initially, the role of physician was limited to certifying that young persons entering textile mills were at least aged 9 years. As any local general practitioner could be employed, the system was abused until 1844 when factory surgeons were appointed by the factory inspector. Later, physicians were to be used for initial and periodic examination of workers for an increasing number of hazardous agents. Although Dr. Thackrah published his book on occupational health in 1831, the Factories Inquiry Committee of 1833 had been aware that conditions in industry were prejudicial to health, and British physicians had investigated and reported on diseases in various industries (including cotton spinning and weaving, coal mining, and mining and quarrying), it was not until 1898 that Dr. Thomas Legge was recruited as the Factory Inspectorate’s first specialist medical inspector. As a result of his initiatives and those of the lay inspectorate, among whom the handful of recently appointed women inspectors were very active, by the end of 1900, the Factory Inspectorate had identified the main causes of industrial diseases produced by specific toxic substances known at that time. With the designation of a factory inspector as engineering specialist, the use of mechanical ventilation for the control of dust and fumes was extended. As a consequence, the period 1900 –1913 saw the medical and technical branches becoming progressively more effective in the prevention of disease. For example, in that period, reported cases of lead poisoning fell from 1058 in 1900 to 535 in 1913. For many years, Legge and his immediate successors composed occupational medicine in the UK.1 It was not until after the Second World War that it became an academic discipline under the aegis of a few universities and of the Medical Research Council. A series of committees studied the occupational health problem and made encouraging noises.2– 6 The Nuffield Foundation did more than talk and funded a number of initiatives, including the pump priming of local inde-
American Journal of Preventive Medicine, Volume 23, Number 4
pendent groups of occupational health services, and establishing a chair in occupational health at Manchester University, the first in the UK. By 1970, the 110,000 factories covered by the 1879 act had increased to 379,000 and the number of inspectors to 560, including 19 medical specialists, yet there had been little change to the organization and a large number of statutory instruments had accumulated.7 The inspectorate had grown into a remarkable band of scientific and engineering experts, but the problems had outgrown them. In 1970 a Labour government was in power, and the Trades Union Congress had been strengthened by a UK union membership of 10.6 million. Another commission (“Robens Commission”) was set up to review and remedy occupational health and safety in the UK,8 as a result of which The Health and Safety at Work Act came into being in 1974, which it was hoped would usher in a brave new world. The Health and Safety Commission (HSC), on which employers and employees each had three members, was established to formulate policy. To deal with the enlarged scope of occupations to be served, a number of inspectorates were merged into the Health and Safety Executive (HSE); in the process, the Employment Medical Advisory Service, which had earlier been brought into being, was transferred to it. To meet Robens’ recommendations for increased research into occupational health, and to replace the 1200 appointed factory doctors9 who conducted statutory examinations, additional employment medical advisors were recruited and trained. HSE acquired a large research budget to conduct and commission work in occupational health. At the peak of occupational health activity in the UK, there were four academic chairs in the specialty, and occupational health research was being actively conducted elsewhere—in Public Health departments, at the Institute of Occupational Medicine established by the nationalized coal industry, at the MRC Pneumoconiosis Research Unit, and in Cancer Research institutes. The Royal Society of Medicine established the Occupational Health Section, and the Faculty of Occupational Medicine was inaugurated in the Royal College of Physicians in London to supplement the existing Society of Occupational Medicine. To the existing diplomas in industrial health, academic institutions added the master’s of science, and the College of Physicians provided several levels of diploma, as well as maintaining a register of accredited doctors. Full-time and part-time courses and distant-learning programs were developed. With a change of government, a program of budgetary restraint was introduced under the guise of “increasing efficiency by removing fat from the system.” The severity of the cuts effectively put an end to occupational health as a thriving discipline. Deregulation, almost a regression to the Tudor ideology that consid-
ered government intervention in conditions of employment inexpedient in practice and wrong in principle, was instituted in the 1980s as a panacea to cope with economic recession.10,11 It was to contribute to the decline of occupational health, union representation on the HSC, and the change of government back to the party that instituted and implemented the Robens report notwithstanding. The UK has not regressed to Tudor Poor Law practice (the age for mandatory schooling is 16), but the appointed factory doctors are back in droves, and there has been a decline in union membership and power. Occupational medicine— whether academic, corporate, or freelance—is an uncertain career. The first three quarters of the 20th century, before the golden age of Robens, threw up a number of UK worthies of international stature in the field of occupational medicine, including Oliver, Thomas Legge, Collis, Henry, Middleton, Merewether, Hunter, Schilling, and Gilson. After 25 years of Robens, how many academics can anyone call to mind who can match them? For that matter, how many academics has anyone come across prepared to alert politicians to occupational health problems and to prick the consciences of the public? Morris Greenberg, MB, FRCP Former HM Inspector of Factories Former Senior Medical Officer of the Division of Toxicology and Environmental Health Department of Health London, UK E-mail: [email protected] PII S0795-3797(02)00507-X
References 1. LaDou J. The rise and fall of occupational medicine in the United States. Am J Prev Med 2002;22:285–95. 2. Kipling M. A brief history of HM Medical Inspectorate. London: Health and Safety Executive, 1979. 3. Committee of Inquiry into Health, Safety and Welfare in Non-Industrial Employment. Report of the Committee of Inquiry into Health, Safety and Welfare in Non-Industrial Employment. London: Her Majesty’s Stationery Office, 1949 (Cmnd 7664). 4. Committee of Inquiry on Industrial Health Services. Report of the Committee of Inquiry on Industrial Health Services. London: Her Majesty’s Stationery Office, 1951 (Cmnd 8170). 5. The future of the Occupational Health Services: A report of the Council of the British Medical Association. London: British Medical Association, 1961. 6. Medical Services Review Committee. A review of the Medical Services in Great Britain: report of the Medical Services Review Committee. London, Social Assay on behalf of the National Services Review Committee, 1962. 7. Bettenson AS. A brief history of HM Factory Inspectorate. London: Department of Employment, 1971. 8. Committee on Safety and health at work: report of the Committee 1970 –72. London: Her Majesty’s Stationery Office, 1972 (Cmnd 5034). 9. Ministry of Labor. The Appointed Factory Doctor Service: report by a sub-committee of the Industrial Health Advisory Committee. London: Her Majesty’s Stationery Office, 1966. 10. Department of Trade and Industry. Deregulation: cutting red tape. London: Her Majesty’s Stationery Office, 1994. 11. Health and Safety Commission. Review of regulation: final report. London: Her Majesty’s Stationery Office, 1994.
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The Rise and Fall of Occupational Medicine in the United Kingdom To the Editor: he United Kingdom’s experience of occupational medicine over the past 2 centuries has many similarities with the account of its sorry plight in the United States.1 In the beginning, government intervention in conditions of employment was considered inexpedient in practice and wrong in principle. The Poor Law, which extended back 200 years to the time of Queen Elizabeth the First, still operated in the United Kingdom (UK), and under it, young paupers in the South, who otherwise would have been a charge on their local parishes, were transported to be so-called apprentices in the textile mills in the North of England. At the end of the 18th century, itinerant nonconformist busybodies investigated their state and published accounts of the deplorable conditions under which these young children worked, lived, were mutilated, and died. In response, an act was passed in 1802 purportedly to do something about the health and morals of the children. Talk, paper, and print are cheap enough, and in the absence of the appropriate level of enforcement, the whole exercise did not impose a burdensome charge on industry or the state. Local nonstipendary magistrates and clergy were designated to make regular factory inspections; it was their ignorance or complacency that was considered responsible for the worthlessness of the act. Notwithstanding its ineffectiveness in improving the lot of the child pauper-slaves, the act was extended to benefit “free” children working in factories. Following the expulsion of the Stuarts and the replacement of James II by William of Orange, there was a move to subordinate the Crown to Parliament and to empower the upper classes. After failed attempts by William Pitt and by John Russell, Earl Grey saw the successful passage of the Reform Bill of 1832. One of the first actions of the new Parliament was to set up a commission to report on the conditions in textile factories. The inquiry reported quickly and the Act to regulate the labor of children and young persons in Mills and Factories of the United Kingdom was promptly placed on the statute book on August 29, 1833. It regulated the minimum age and hours of work, and provided for continued education. As an enabling act, it allowed the King to appoint four persons to be inspectors of factories in places of labor for children and persons aged ⱕ18 years. The inspectors had powers of entry at all hours, of questioning people under oath, and of judging and sentencing. When one of the original four left because of the intolerable pressure he experienced from manufactur-
T
310
ers, he was replaced by a Whig whose curriculum vitae before joining the inspectorate ran from demonstrating his loyalty by accidentally killing a political opponent in a duel (verdict of “death by misadventure”), flight to America for a few years to overcome financial embarrassment, and then a return to the UK as a newspaper editor. The other inspectors were men of substance and education, one of whom was elected as a Fellow of the Royal Society. Political will threw up inspectors of a caliber to institute a system of inspection and to enforce regulations. Initially, the role of physician was limited to certifying that young persons entering textile mills were at least aged 9 years. As any local general practitioner could be employed, the system was abused until 1844 when factory surgeons were appointed by the factory inspector. Later, physicians were to be used for initial and periodic examination of workers for an increasing number of hazardous agents. Although Dr. Thackrah published his book on occupational health in 1831, the Factories Inquiry Committee of 1833 had been aware that conditions in industry were prejudicial to health, and British physicians had investigated and reported on diseases in various industries (including cotton spinning and weaving, coal mining, and mining and quarrying), it was not until 1898 that Dr. Thomas Legge was recruited as the Factory Inspectorate’s first specialist medical inspector. As a result of his initiatives and those of the lay inspectorate, among whom the handful of recently appointed women inspectors were very active, by the end of 1900, the Factory Inspectorate had identified the main causes of industrial diseases produced by specific toxic substances known at that time. With the designation of a factory inspector as engineering specialist, the use of mechanical ventilation for the control of dust and fumes was extended. As a consequence, the period 1900 –1913 saw the medical and technical branches becoming progressively more effective in the prevention of disease. For example, in that period, reported cases of lead poisoning fell from 1058 in 1900 to 535 in 1913. For many years, Legge and his immediate successors composed occupational medicine in the UK.1 It was not until after the Second World War that it became an academic discipline under the aegis of a few universities and of the Medical Research Council. A series of committees studied the occupational health problem and made encouraging noises.2– 6 The Nuffield Foundation did more than talk and funded a number of initiatives, including the pump priming of local inde-
American Journal of Preventive Medicine, Volume 23, Number 4
pendent groups of occupational health services, and establishing a chair in occupational health at Manchester University, the first in the UK. By 1970, the 110,000 factories covered by the 1879 act had increased to 379,000 and the number of inspectors to 560, including 19 medical specialists, yet there had been little change to the organization and a large number of statutory instruments had accumulated.7 The inspectorate had grown into a remarkable band of scientific and engineering experts, but the problems had outgrown them. In 1970 a Labour government was in power, and the Trades Union Congress had been strengthened by a UK union membership of 10.6 million. Another commission (“Robens Commission”) was set up to review and remedy occupational health and safety in the UK,8 as a result of which The Health and Safety at Work Act came into being in 1974, which it was hoped would usher in a brave new world. The Health and Safety Commission (HSC), on which employers and employees each had three members, was established to formulate policy. To deal with the enlarged scope of occupations to be served, a number of inspectorates were merged into the Health and Safety Executive (HSE); in the process, the Employment Medical Advisory Service, which had earlier been brought into being, was transferred to it. To meet Robens’ recommendations for increased research into occupational health, and to replace the 1200 appointed factory doctors9 who conducted statutory examinations, additional employment medical advisors were recruited and trained. HSE acquired a large research budget to conduct and commission work in occupational health. At the peak of occupational health activity in the UK, there were four academic chairs in the specialty, and occupational health research was being actively conducted elsewhere—in Public Health departments, at the Institute of Occupational Medicine established by the nationalized coal industry, at the MRC Pneumoconiosis Research Unit, and in Cancer Research institutes. The Royal Society of Medicine established the Occupational Health Section, and the Faculty of Occupational Medicine was inaugurated in the Royal College of Physicians in London to supplement the existing Society of Occupational Medicine. To the existing diplomas in industrial health, academic institutions added the master’s of science, and the College of Physicians provided several levels of diploma, as well as maintaining a register of accredited doctors. Full-time and part-time courses and distant-learning programs were developed. With a change of government, a program of budgetary restraint was introduced under the guise of “increasing efficiency by removing fat from the system.” The severity of the cuts effectively put an end to occupational health as a thriving discipline. Deregulation, almost a regression to the Tudor ideology that consid-
ered government intervention in conditions of employment inexpedient in practice and wrong in principle, was instituted in the 1980s as a panacea to cope with economic recession.10,11 It was to contribute to the decline of occupational health, union representation on the HSC, and the change of government back to the party that instituted and implemented the Robens report notwithstanding. The UK has not regressed to Tudor Poor Law practice (the age for mandatory schooling is 16), but the appointed factory doctors are back in droves, and there has been a decline in union membership and power. Occupational medicine— whether academic, corporate, or freelance—is an uncertain career. The first three quarters of the 20th century, before the golden age of Robens, threw up a number of UK worthies of international stature in the field of occupational medicine, including Oliver, Thomas Legge, Collis, Henry, Middleton, Merewether, Hunter, Schilling, and Gilson. After 25 years of Robens, how many academics can anyone call to mind who can match them? For that matter, how many academics has anyone come across prepared to alert politicians to occupational health problems and to prick the consciences of the public? Morris Greenberg, MB, FRCP Former HM Inspector of Factories Former Senior Medical Officer of the Division of Toxicology and Environmental Health Department of Health London, UK E-mail: [email protected] PII S0795-3797(02)00507-X
References 1. LaDou J. The rise and fall of occupational medicine in the United States. Am J Prev Med 2002;22:285–95. 2. Kipling M. A brief history of HM Medical Inspectorate. London: Health and Safety Executive, 1979. 3. Committee of Inquiry into Health, Safety and Welfare in Non-Industrial Employment. Report of the Committee of Inquiry into Health, Safety and Welfare in Non-Industrial Employment. London: Her Majesty’s Stationery Office, 1949 (Cmnd 7664). 4. Committee of Inquiry on Industrial Health Services. Report of the Committee of Inquiry on Industrial Health Services. London: Her Majesty’s Stationery Office, 1951 (Cmnd 8170). 5. The future of the Occupational Health Services: A report of the Council of the British Medical Association. London: British Medical Association, 1961. 6. Medical Services Review Committee. A review of the Medical Services in Great Britain: report of the Medical Services Review Committee. London, Social Assay on behalf of the National Services Review Committee, 1962. 7. Bettenson AS. A brief history of HM Factory Inspectorate. London: Department of Employment, 1971. 8. Committee on Safety and health at work: report of the Committee 1970 –72. London: Her Majesty’s Stationery Office, 1972 (Cmnd 5034). 9. Ministry of Labor. The Appointed Factory Doctor Service: report by a sub-committee of the Industrial Health Advisory Committee. London: Her Majesty’s Stationery Office, 1966. 10. Department of Trade and Industry. Deregulation: cutting red tape. London: Her Majesty’s Stationery Office, 1994. 11. Health and Safety Commission. Review of regulation: final report. London: Her Majesty’s Stationery Office, 1994.
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