What do we mean by public and private?

In Britain there have been many recent debates in health policy and in other areas of policy about the issue of public/private relationships and about how partnerships can be formed to the benefit of both sides. The Private Finance Initiative (PFI) in relation to the building and running of hospitals has brought the matter to the fore for health. New hospitals are being built through private finance; the hospitals will be run by the National Health Service (NHS) on a lease, with services provided through private companies. For those who have visited London lately, the new University College Hospital looming over the intersection of Gower Street and Euston Road provides a visual illustration of these relationships. For London Underground Ltd. public/private means a new system where private companies will run the track and signalling, while the state concern provides the services.

This type of interaction between public service provision and private enterprise has been hugely controversial in both areas, but has been a way in which the zeal for complete privatization of public services under the previous Conservative government can be publicly abandoned, while maintaining relationships with the private sector. It became a mantra in some areas of policy, health in particular. My own institution, London School of Hygiene and Tropical Medicine (LSHTM), has recently funded a senior lecturer in public/private partnerships as an initiative in tune with the spirit of the time. These relationships have been visible outside the United Kingdom (UK) as well as in both developed and developing countries. These recent UK debates give a key to one area on which a plenary could focus – this is those relationships in the provision of services.

But the terms also have other meanings, too. Take public health, where the public can mean public space, the wider environment, even the role of the public, the good of the public and how this relates to the role of private family relationships or private individual behaviour.

This brings us to another dimension – the concept of the public sphere. This will be familiar to many in the audience. Hagerman’s The Structural Transformation of the Public Sphere provided the argument that the intrusion of public authority into private lives through the growth of the welfare services was to erode individual autonomy, turning active citizens into passive consumers of material and cultural goods. As a result genuinely independent and critical forms of public action and opinion, pursued by private individuals voluntarily associating as a public, were compromised, while the power of both private and statutory corporations was enhanced (Hagerman, 1989). Historians have now begun to test this thesis empirically (Sturdy, 2002). There is private and public too, in terms of the role of charity and voluntarism (Mohan and Gorsky, 2001), and the meaning of private as things which are secret and hidden and perhaps revealed to the public.

All these, and more, can be encompassed under my title. Surveying everything would be impossible for such an ambiguous area. What I plan to do therefore is to focus on three themes.

• 1. Some recent illuminating work on the public/private theme in relation to health services and to public health before 1945.

• 2. Then to focus on the post-1945 period in relation to the health of the public – a period which seems to be still relatively neglected. How does this reflect some of the issues I have raised?

• 3. And finally a future research agenda for public and private with and some comment on potential methods and sources.

Public health and health policy up to 1945

For public health, the key change at the turn of the nineteenth and twentieth centuries was from the focus on the public environment, cleansing public space, providing main drainage, water supplies and slum clearance to an emphasis on the role of the family and the modification of individual behaviour through hygiene and health education.

As with all such historical change, the sharpness of the change can be overemphasized. Recent work, for example, Hamlin on Chadwick and public health, has shown how the environmentalism of nineteenth century public health was a surrogate for more general social reform. Its public focus was muted (Hamlin, 1998).

Dorothy Porter has argued that the advent of bacteriology and germ theory, once seen as the motive force behind the ‘personalization’ of public health concerns in fact served to maintain an interest in the environment, although this time it was the role of the individual in the environment which became the focus (Porter, 1999). Mick Worboys’ work on the diffusion of these theories also draws our attention to the unevenness of the spread and to the interaction of environment and individual vector through the idea of ‘seed and soil’ (Worboys, 2000).

This more recent work on public health serves to modify the sharpness of the public/private change and to make it more. Anne Hardy and others have also drawn attention to its cross-national variation. The hygienic revolution drew its impetus from America and continental Europe in the late nineteenth century, and Britain was slow to adopt some of its principles (Hardy, forthcoming).

For health services, the relationship between public and private in terms of provision and funding has been a strong theme in recent work. In the British context in particular, historians have thrown light on the relationships which prevailed in pre-NHS health services as part of the ongoing revision of the ‘moving frontier’ of public private relationships in health, with private here also including the role of charitable endeavour.

In some senses, National Health Insurance (NHI) in Britain after 1913 provided the model of an interaction between public health and private provision, but in the form of social insurance it offered something outside both. As Steve Sturdy has recently pointed out, central to the moral justification of NHI, was the fact that the scheme was to be administered through the provident friendly societies and so would bring with it many of the same moral benefits associated with voluntary forms of organized self-help. It was both public and private and something different. The German health insurance scheme which combined state benefits and voluntary organization was seen as a model (Sturdy, 2002).

Here again cross national variation was important in the ways in which these systems operated. Noel Whiteside’s comparison of British and French health insurance has compared the pre-war British National Health Insurance system with the post-war French caisses. She has shown how in the UK NHI was subject to central control, while, in post-war France, accountability was devolved downwards rather than upwards. Relationships between public and private financing and services were differently organised both nationally and locally (Whiteside, 2002 unpublished).

The relationships between public and private in health service provision did not die out after 1945. Recent work by John Mohan, Martin Gorsky and others, which is being presented at this conference, draws attention to the continuance of mutual health insurance even after the establishment of the NHS. They have drawn attention to the changing nature of the hospital and the public who supported it.

Post-1945 and the health of the public

I will change from survey to special pleading at this point. My focus is the years after 1945, a period, where, as yet, there is less historical work even though its starting point is more than fifty years distant. Most work here has concentrated on the development of health services, but I will concentrate on public health and health policy rather than health services because here there are some interesting interrelationships between concepts of public and private.

The dominant initial theme is the shift from infectious to chronic disease, from potentially public infection to private behaviour as the focus of public health post-1945.The emergence of the chronic diseases – cancer, diabetes, heart disease – as matters of main concern for health was consolidated post-World War Two, and these became seen as matters of private, of individual responsibility. The public became private.

The case of air pollution and/or smoking

Let me focus down on a period in Britain in the late 1950s and early 1960s, where we can see this change being negotiated. The discussions around the relative responsibility of smoking or of air pollution for lung cancer in the British context give us a sense of the rationales behind these developments. Whether air pollution or smoking was the prime cause of lung cancer in a sense epitomised the public/private tension within public health at this stage. Here I mean public in the sense of environmental and private in the sense of behavioural and individual. We can see a change of emphasis – away from air pollution – very clearly in the discussions which took place in the committee appointed by the Royal College of Physicians in 1959 to consider the smoking and air pollution issue.

The committee was set up as one on smoking and air pollution. It was to consider both, the connection between them, and to produce a report. But the committee decided not to do this, and its reasons were interesting. At its meeting on 17 March 1960, it decided that it would publish a separate report. Smoking had to be given priority.

There were also political reasons for this focus. The British government was alarmed, not at the smoking issue so much as at the political implications of too much stress on air pollution. In the late 1950s when the MRC proposed to include in a statement that up to 30 per cent of lung cancer might be caused by air pollution, there was political alarm. This would give air pollution, the minutes of the Cabinet committee record, ‘unwarranted prominence’. The committee thought that Professor Bradford Hill and Dr. Doll had failed to show any substantial difference in risk among non-smokers in greater London and in rural areas. So the politicians asked the MRC to re-examine their statement. Both statements, so it was commented, had obvious political implications. The statement was subsequently modified. The MRC had re-examined their draft and proposed to modify the references to atmospheric pollution which implied that it might be responsible for up to 30 per cent of such deaths. The section would read instead,

A further section was modified to read: ‘A proportion of cases, the exact content of which cannot yet be defined, may be due to atmospheric pollution.’

The pollution issue was effectively headed off. Cigarette smoking was preferable as a public health issue. Financial responsibility could be, at this stage, contained at the local government level; the scientific evidence pointed in that direction; and the action to be taken was really up to the individual. Air pollution was the issue with wider public implications which had to be damped down politically (Cabinet Office 1957).

What we are seeing here at the end of the 1950s and the early years of the 1960s is the rise to significance of a new style of issue which emphasised individual responsibility rather than environment, occupation, class or work. One can see that as ‘science driven’. The epidemiological research on smoking and lung cancer was ultimately decisive, and that certainly played its part in this transition. Also in play, as I have indicated here, were direct political factors, which caused the modification of the MRC’s statement, but also wider issues of changes in the whole outlook and location of public health?

Here was a new public health struggling to be borne, no longer an environmental issue rather a question of remedying the defects in individual lifestyle. The rise of this style of thinking can be traced both nationally and internationally through, for example, the 1974 Lalonde Report and through documents like Britain’s Prevention and health: Everybody’s business. A reassessment of public and personal health (1976).

Private is also public

But the emphasis on private behaviour was always located paradoxically within frameworks which can be termed public, and it is these interactions and their change over time which I want to spend some time exploring. There is a paradox here that private and public were reconfigured and interrelated in the new public health, but in ways in which we can also tease out different definitions of public and private.

Take, for instance, the notion of public in public health science. The scientific discipline at the heart of the transition in the public health focus, risk factor epidemiology, stressed individual behaviour modification and individual responsibility for health. Yet the concepts of epidemiology married concern for a population base – for overall public change – with whatever benefits accrued to the individual. The individual was only important, as the British epidemiologist Geoffrey Rose wrote, as part of the population as a whole. This was the prevention paradox. Population change was necessary, although the benefits to the individual might be more intangible (Rose, 1992). Risk was a concept which was both private and individual and public at the same time.

Individual behavioural concerns concentrated on smoking, on diet and on the role of heart disease. But it was perhaps AIDS in the 1980s which highlighted this tension between private behaviour and its impact on the population. AIDS was an epidemiological syndrome par excellence; and it also exemplified key tenets of the new public health, stressing individual behaviour modification, individual responsibility, but also the rights of the individual, all within a context which had the interests of the population, the public at large, as a primary political and health concern (Berridge, 1996).

Publicity and private behaviour

Mention of AIDS – and of the other public health topics – brings us to another dimension of the continuing public/private interface in post-war public health. This is the key role of publicity and the media in the post-war concern for the modification and regulation of private behaviour. Drinking, smoking, eating, drug taking, sexual activity – private behaviour – became public property through what David Miller and Jenny Kitzinger in their study of AIDS and the media, have called a ‘circuit of mass communication’, a network of interests ranging through politics, health, media production and dissemination processes (Miller and Kitzinger, 1998). This was a process which also has a history and one which is beginning to be traced. In the post war period media matters took on a wholly new dimension. As Kelly Loughlin has shown in a forthcoming paper, notions of privacy and confidentiality, of the private nature of the doctor/patient relationship were affected by the coming of the NHS. She uses the media furore in the 1950s surrounding the birth of conjoined twins to demonstrate how the dual influences of the growing media interest in health and the establishment of a state funded health system brought in their train an extended and altered notion of confidentiality (Loughlin, forthcoming). This was the media interest in health which was also symbolized by Charles Fletcher’s path-breaking programme about surgery, Your Life in Their Hands, in 1958.

These developments were accompanied by the establishment of a sophisticated press and public relations machinery within medicine’s professional base. For example, the British Medical Association’s (BMA) policy towards the media began to shift in the late 1950s. Active and targeted engagement with the media by BMA spokespeople was seen as a way in which to reinforce its public perception, pressing the associations’ contribution to medical science rather than the self-interested issues of pay and conditions. In doing this, the representatives of medicine were interacting with a new type of specialist in the media – the health services correspondent. Medico-politics and the NHS was an area pioneered by John Prince, a former lobby correspondent at the Times who moved to take up the position of health services correspondent at the Daily Telegraph in 1957.

Medicine in general was becoming more public. But these developments were particularly noticeable in the area of public health, where the emphasis overall was on the modification of private behaviour. Public education, of course, had long been part of the public health and hygiene remit. But this transmuted into a new mass remit from the 1960s. Let us look at a committee which epitomized the change, the Cohen committee of 1964. Here we can see a style of health education and public health in development which was very different both from pre-war health education with its group discussions, ‘filmlet shows’ or home visits. The committee itself was permeated by a strong media focus. Its deputy chair came from the Consumers Association (and previously the BBC), while, along with the traditional medical contingent, were an advertising agency representative and the health editor of Woman magazine. The traditional health education focus had been on individual advice to mothers and advice on specific action like vaccination and immunization. But the committee considered that more education was needed on human relationships – sex education, mental health, the risks of smoking and being overweight, and the need for physical exercise. These were difficult areas, the report commented, where self-discipline was required.

There was a strong emphasis on the role of individual risk avoidance, mingling moral and medical imperatives. The report placed emphasis on a greater degree of central publicity, using habit changing campaigns and social surveys, as well as strengthening the new profession of health educators. This new breed was to be trained, on the American model, in journalism, publicity, the behavioural sciences and teaching methods. Training people would involve both imparting knowledge and inculcating self-discipline – a telling phrase. The brief of health education was changed from the earlier information dissemination model just a few years earlier. Telling people and giving information about health also involved, it stated, persuading people to take appropriate action. Knowing about the risks of cigarette smoking was no good unless accompanied by an appeal for appropriate and urgent action.

The report emphasised the role of the mass media in health education. One TV programme, it commented, could reach 5 million people, whereas it would take 250,000 group discussions of20 each to target the same audience. There should be a central body to take forward these changes and to evaluate them. It would be staffed by new health educators, trained in psychological skills, decision-making by group skills. The Report ultimately led to the setting up of the Health Education Council (HEC) in 1968, reconstituted in the early 1970s (Cohen Report, 1964).

The committee’s report was the portent of a new style for public health. Post war public health and health education took the central role of the media in society as its animating idea in modifying private behaviour. The campaign mounted by the advertising agency Saatchi and Saatchi for the newly established HEC in the early 1970s demonstrated the new ethos, derived from changes which had their origin in the US advertising scene. Advertisements in 1971 showed smokers crossing Waterloo Bridge intercut with film of lemmings throwing themselves off a cliff. A voice over said:

Women re-emerged in the 1970s as a major focus of new style health education for smoking. The most striking image from a campaign run in 1973/4 was a naked mother smoking. ‘Is it fair to force your baby to smoke cigarettes?’ it asked. There was a clothed version of the pregnant smoking woman, but evaluation concluded that it was less effective as a campaign tool. The commercialization of the private was seen as necessary for the modification of public behaviour (Berridge, forthcoming a).

Health activism and science: public and private

Use of the media in this way – through behaviour altering campaigns – has remained central to public health, as much with AIDS in the 1980s and 1990s, as smoking or diet in the 1970s. A distinctive style of health activism emerged which used the media rather than mass membership as its negotiating tool. ASH (Action on Smoking and Health), founded in 1971, was a prime example. Media ‘stunts’ and ‘spin’ were pioneered in the 1970s for health. The basis of such groups epitomized the public/private interface; ostensibly private associations of concerned citizens, they were in fact almost entirely state funded (Berridge, forthcoming b).

The centrality of the role of the media for public health was underlined by the way in which restriction of opposing media became the central policy strategy. Public health activists saw mass media as the central terrain to be used and to be fought over. Restriction and ultimately prohibition of tobacco advertising became central to the public health case from the 1970s.

Increasingly, the scientific advice on which behaviour change was to be based came to be a media event. Stephen Hilgartner’s recent Science on Stage sees the emergence of three reports on nutrition and health in the US in the 1980s as an example of the stage management of expert authority. He draws out the contrast between a ‘backstage’ of production (negotiation and dispute among committee members) and a deliberately staged ‘front stage’ of unequivocal consensus (Hilgartner, 2000). The role of journalists and public relations specialists in this process should also be acknowledged and the changing nature of the interactions. When the Royal College of Physicians (RCP) launched its first report on Smoking and Health in 1962, it deliberately aimed the report at public and policy makers. A public relations specialist was hired, and the College held a press conference for its launch – then an unheard of event. (Berridge, 1998). Increasingly the public health fact is a media event.

Private industry and public health

One issue which this media focus underlined was the role of another sort of private – the role of private industry and public health. Here the media publicity agenda has been one determinant of a strongly anti-industry line. As Mike Daubed, an early Director of ASH, told me in an interview, he used the US activist text, Rules for Radicals where it said ‘personalise the problem’ – ‘the people running the major companies are responsible for those deaths’. Increasingly, hostility to private industry became the public face of public health activism – notably for smoking, but also in relation to diet and the role of food interests and for alcohol as well. This became allied to an absolutist agenda from the 1970s which aimed at the elimination of harmful individual behaviours rather than their modification.

Yet there is another side to the relationship between public health and private industry which has been less explored. In the British context, there was the continuing cooperation ‘behind the scenes’ between industry and some public health interests during the 1970s and 1980s. Although this cooperation was centred around the issue of ‘safer smoking’ and the development of tobacco substitutes, later through work on the role of nicotine and what role nicotine could play in the reduction of smoking related harm. It is not helpful historically to see such interactions only through the US inspired ‘heroes and villains’ framework inspired by the revelations of industry documents.

There are also other ways in which the role of private industry in public health is beginning to be explored. Vivienne Quirke, for example, in a forthcoming paper, has looked at the role of pharmaceutical industry interests in the development of drugs for chronic disease. She has shown how developments in private industry – pharmaceutical innovation – also underpinned the rise of lifestyle public health (Quirke, forthcoming). The industrial dimension to public health change needs further exploration; the ‘invisible industrialist’, recently much discussed in science and technology studies, should make an appearance here too.

1980s and 1990s: public health draws on private and public

I drew attention at the beginning of this paper to the focus on individual and private behaviour implicit in the new post-war public health. In the 1980s and 1990s that has begun to change. The environment and the role of the public have made reappearances, although in ways which stress the interaction of public and private which has been a theme of this paper.

For smoking the concept of passive smoking essentially combined the individualism of 1970s public health with the environmentalism of the new public health. No longer was this simply a matter of private risk; now it was a matter of risk to the community as a whole, an argument similar to those advanced at about the same time in relation to HIV/AIDS. The ‘innocent victim’ was a powerful component of the new relationships between private and public.

This was the private individual in public or workplace space. Environmentalism at the level of the city or locality can mean control of the individual, for example, through the concept of ‘community safety’ and its recent elaboration in drug and alcohol-free spaces.

Research agendas and methods

Mention of drugs and alcohol brings me near a concluding section which will focus more on what needs to be done with some comments on research methods. I started this paper with an outline of the differing meanings of public and private which could be drawn on. Some of these I have touched on in the paper, but there is obviously room for much more. Let me just outline a few ideas.

• 1. Specific diseases or policy areas is one way into this arena – and many of the papers in the conference take this approach. Drugs and alcohol provide some good example of interrelationships. Sarah Mars will be talking about public and private in relation to addiction treatment later on. Alcohol policy also provides a good example of how different national cultures and regulatory regimes can combine public and private in different ways.

• 2. Cross national comparisons are an important part of examining the interaction between public and private. The state alcohol control regimes in some Scandinavian countries have distinctive histories and are being or have been dismantled under the impact of EU requirements.

• 3. Global and European dimensions. For a post-1945 historian, the European Union (EU) and its role in health is an important part of the public/ private interface. So, too, are the global health agencies which so far have been little mentioned. The recent enthusiasm in WHO for global public/private partnerships is a historically contingent phenomenon which should be studied. There is now a whole host of international agencies which have been promoting the role of the private sector in public health for some while. The World Bank and the World Trade Organisation have been major players in globalisation of health regimes – for example, the requirement for policies of structural adjustment in developing countries. The health economists at LSHTM who specialise in developing countries have long had public/private as an arena of research.

So there is plenty to be done and much material available. Among that material is, of course, the testimony/evidence of those who are ‘living actors’ in events. I am still surprised how little such material is used. Working in an environment such as the London School, I am surrounded by historical actors, although ethical restrictions may make such interviews and access more difficult in years to come. The public testimony, individual ‘witnesses’ may perforce become private.

There is no lack, too, of archival material. Our Centre at LSHTM has been well served recently by the UK health department which has given several of us access to very recent material – a development which other historians, who assume they have to stop archival work in the 1970s, seem not yet to have noticed. Such material is complemented by the internet offerings which are becoming ever more frequent. The recent Hutton inquiry documentation into the death of the Iraq scientist David Kelly placed on the internet is part of a trend which has seen the British government’s BSE papers and other enquiries also made available. Like the industry archives also revealed in recent years, these sources need to be treated with caution. More than most archival material we know little about what has been produced and what has not and the contextual background. Nevertheless, this is part of a trend by which the historian’s ‘private’ material is potentially available to a wider public, an as yet undeveloped part of the enthusiasm for ‘public history’.

So there is plenty more which could be said about post-1945 public health and about the interactions between public and private which have characterised it. Historical work in this area is vital, for it can uncover the changing meanings of these terms and the close interactions between private and public which have characterized the changing nature of public health and health policy.