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18 June 2008

The Nation's Health: Delivering healthcare in the twenty-first century, Jonathan Miller, BBC Radio Series, 2002

Public health was, probably is, and very well may be far more important for health than "medicine," meaning, individual-based therapies. Click the bolded links below to launch RealPlayer.

In a six part series, Jonathan Miller offers his unique perspective on the development of the nation's health since the end of the Second World War. You can listen again to each of the programmes (see below), visit the Picture Gallery and hear extended interviews with Jonathan's guests.

Jonathan Miller is well placed to diagnose the nation's health. A medical student in the 1950s at University College Hospital, he qualified as a doctor in 1959 and had first-hand experience of the early years of the National Health Service. Although his subsequent career has taken him into opera and the theatre, Jonathan has maintained his interest in medicine. During his lifetime, the nation's health has improved dramatically. But Jonathan stresses that the maintenance of a healthy society requires the full co-operation of all its members; the health of each individual is dependent on the health of the wider community.

During the making of this series, Jonathan has interviewed eminent historians and medical ethicists; he's spoken to pioneering doctors, surgeons and epidemiologists. But the programmes are also about Jonathan Miller and his unique perspective on the nation's health. Delivered in his own inimitable style, Jonathan hopes that these thought-provoking programmes will contribute to the continuing debate about the best means of delivering healthcare in the twenty-first century.

1. Getting Started

In the first programme, Jonathan talks to medical historians Chris Lawrence and Charles Webster about the origins of the 'nation's health'. Health is something we now regard as a social right - but it has not always been that way. Victorian military planners were alarmed by the poor health of recruits for the armed forces, and well into the twentieth century, poverty coupled with inadequate diet blighted the lives of millions of Britons. It wasn't until the creation of a National Health Service in 1948 that political steps were taken to improve the lives of ordinary citizens, in terms of better housing as well as improved medical care.

One of the groups active in the 1930s that provided much of the impetus for the creation of a National Health Service was the Socialist Medical Association. Jonathan talks to three of its surviving members, John Pemberton, Richard Doll and Jerry Morris, all of whom saw at first hand the impact of poverty and malnutrition on the nation's health. Jonathan also talks to Anne Oakley about the innovative statistical work carried out by her father Richard Titmuss - work which, for the first time, established clear links between poor social conditions and ill health. One of the most dramatic pieces of post-war research analysed the experience of childbirth among women of different social classes. The research showed beyond doubt that malnourished women were likely to have longer and more dangerous labours. Jonathan speaks to Barbara Thompson, who was one of the researchers on the original Aberdeen project.

2. Public Health

In the second programme, Jonathan talks to some of the pioneering epidemiologists whose statistical work underpins our ability to track illness and disease across society at large. As well as establishing beyond doubt that poor social conditions, particularly malnutrition, have a profound impact on public health, epidemiologists also began to investigate links between illness and social behaviour. Richard Doll showed that smoking caused lung cancer; Jerry Morris demonstrated the importance of exercise to combat coronary heart disease; Alice Stewart proved that exposure to TNT could lead to the development of leukaemia.

As the links between ill health and social conditions became an accepted part of medicine, it became even more important that the public should have access to good healthcare as and when they needed it. With the help of Tony Ryle, Sheila Silcox and Howard Baderman, Jonathan discusses the post-war development of General Practice and Casualty. But the more we learn about the impact of social behaviour on our health, the greater the amount of information we have to absorb. The challenge facing present-day public health epidemiologists like Klim MacPherson is to find ways of delivering a health message that sounds neither patronising nor irrelevant.

3. The Risks of Safety

In the third programme, Jonathan investigates some of the issues surrounding immunisation. While vaccines against infectious diseases like polio, tuberculosis, diphtheria and measles have undoubtedly played a part in reducing mortality, we shouldn't forget that improvements in hygiene, nutrition and living conditions have also had a major impact on life expectancy. Nor can we shirk the fact that vaccines carry risks of their own.

As parents agonise over the rights and wrongs of allowing their children to have the MMR vaccine, health professionals are agreed that the public needs reliable information upon which to base their decisions. But statistical analyses are never the easiest things to make sense of, and even if the man or woman in the street knew enough maths to make a fair judgement of the figures, it doesn't necessarily mean they would act accordingly. As Jonathan argues, 'People don't think of risk or reward in rationally quantitative terms. And when it's a question of acting on behalf of someone else, especially a loved one, the perception of probability is skewed even further'.

With the help of health professionals Elizabeth Miller from the Public Health Laboratory Service and Ian Chalmers from the UK Cochrane Centre for evidence-based medicine, and medical ethicist Jonathan Glover, Jonathan explores the complexities of how we assess information about immunisation - and how, in the final analysis, subjective impressions tend to carry more weight than any amount of objective, statistical data.

4. The Amiable Juice

In the fourth programme, Jonathan traces the development of what used to be called the National Blood Transfusion Service. With the help of haematologists Jean Harrison and Helen Dodsworth and blood donor Charles King, he discusses how on-the-spot transfusions for blitz victims led to the development of blood banks - and how the introduction of plastic bags in the mid-seventies revolutionised our ability to fractionate whole blood into its respective components.

But blood donation is much more than a physical transaction. Jonathan argues that giving blood is a symbolic act which 'dramatises our social solidarity'. He describes blood as a 'rich liquid asset, a priceless deposit which can neither be spent nor accumulated'. With sociologist Ann Oakley, he explores the concept of blood donation as a 'gift relationship', an idea first put forward by Richard Titmuss who had himself been inspired by the French anthropologist Marcel Mauss.

Some, like Peter Howell, archivist for the British Blood Transfusion Society, argue that as society becomes more individualised, it becomes harder to persuade people to act altruistically and donate blood regularly. Could our growing reluctance to give blood be a reflection of our loss of a sense of community?

5. Doing What Comes Naturally

In the fifth programme, Jonathan discusses organ transplants, and the developments in our understanding of the body's immune system which makes transplants possible. Jonathan talks to Leslie Brent, one of the pioneering immunologists who, together with Nobel prize-winner Peter Medawar, made the theoretical breakthroughs that opened the way for surgeons like Sir Roy Calne to begin a programme of organ transplants. Jonathan is particularly interested in the kidney - it is, he says, 'one of most important mechanisms for maintaining our physiological stability, without which the cells we are composed of would be unable to survive or thrive'. Kidney specialists Hugh de Wardener and David Kerr describe the development of an Artificial Kidney - and how, despite early setbacks, Artificial Kidneys now support more than 15,000 dialysis patients in the UK. But while increased organ transplantation demonstrates how dependent we've become on our fellow citizens for a regular supply of organs, John Harris, a bioethicist at Manchester University, believes we have to find ways of increasing the availability of organs for transplantation. He argues that we have to overcome our scruples about removing organs from cadavers - in his view, people are not entitled to an intact body after death.

6. Who Cares?

In the final programme in the series, Jonathan Miller discusses the beginnings and endings of life, and how the development of Intensive Care has made it possible for machines to take over when the body's regulatory systems fail. Technological advances have prolonged our expectation of life, and there's now a pressing need for long-term social care to support the very old. Can we provide our old people with a quality of life they deserve?

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