Thomas McKeown

A reassessment of Florence Nightingale and her achievements requires consideration of her public work, her personal character and the relation between the two, and F.B. Smith has interesting things to say about all of this in his study of the Nightingale Papers and other documents. He recognises her impressive contributions, but not her unique place in the history of ideas related to medicine and public health in the last three centuries. His reading of her character would be more persuasive if she were occasionally given the benefit of a doubt. Was she, for instance, always impelled ‘to fight, to cheat, to bully and to boast’ as well as ‘to save lives’? And is it not the case that without the private character we could not have had the public work?

Although these books have different titles, their subjects are the same: the diseases which have replaced the infections as the predominant causes of sickness and death in technologically advanced societies. The editors of Western Diseases give two reasons for preferring their title to ‘Diseases of Civilisation’: some of the diseases were present, although uncommon, in the ancient civilisations of Egypt, Greece, Rome and China; and the implication that countries where their incidence is low are uncivilised gives offence in the Third World. Neither title is really satisfactory, however. The term ‘Western’ can be used only metaphorically in relation to developed countries such as Australia, New Zealand and South Africa, and in time will need to be applied widely in Asia, Africa and Latin America as the character of health problems changes with economic development. The objection to attributing the diseases to civilisation is that they have become significant only in the last few centuries, in some cases in the last few decades; the infections were still predominant in Renaissance Italy, Elizabethan England and 17th-century France. The common causes of sickness and death in advanced societies are therefore more accurately regarded as diseases associated with industrialisation.

President Reagan’s attention span is known to be brief, and he is said to prefer his memoranda to be limited to a single page. It is therefore unlikely that he will read closely the 640-page report which describes experience of the bombings of Hiroshima and Nagasaki. Nevertheless, it would be useful if he – and Mr Brezhnev – were to look through the photographs, which, for the convenience of those who will get no further, have been wisely placed before the text. They reveal a pivotal fact about the use of nuclear weapons: that the most desirable outcome for those within their reach is not to survive. In these pictures the faces of the living, helpless and hopeless, are more disturbing than the bodies of the dead.

A few years ago an American physician, Leon Kass, drew attention to a remarkable paradox: that at a time when medical knowledge is greater and technology more powerful than ever before, medicine is assailed by doubts about its role and purpose. Some reasons for the doubts are clear enough: uncertainty about the respective responsibilities of public and private agencies for the finance and administration of health services; rapidly rising costs of medical care and the lack of an acceptable basis for limiting them; gross inequalities in health between continents, between countries, and between different sections of the population of the same country; ethical issues which arise particularly from the ability to prolong or terminate life; and formidable problems of litigation attributable to the difficulty of distinguishing clearly between errors of clinical judgment and negligence. But perhaps the most telling source of uncertainty about medical activities is the possibility that we have overestimated what has been achieved, indeed what can be achieved, by treatment of the sick. We begin to suspect that some disease problems may prove to be, as J.B.S. Haldane said of the universe, ‘not only queerer than we suppose but queerer than we can suppose’.

As life must be possible before it can be pleasant, human health and its relation to survival and population growth are among the great themes of history. Why did early man, although apparently well-adapted to his environment, have high mortality rates and a short expectation of life? Why did the change from a nomadic to an agricultural existence ten thousand years ago lead to the predominance of infectious diseases as causes of sickness or death? What was the relation between population growth and agricultural and industrial developments? And where, among the nutritional, environmental, behavioural and medical advances of the past three centuries, are we to find the explanation for the decline of the infections and the modern transformation of health?