|AIDS:The Burdens of History|
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Not least among the issues raised by the AIDS epidemic is the problem of how to square individual freedom with the public good. Under what circumstances, if any, would a state be justified in taking compulsory powers (screening, hospitalization, isolation, enforced treatment, etc.) to prevent the spread of a lethal disease, a disease that constitutes a threat to other people's right to health and to liberty in general? Present discussions of this dilemma in Great Britain have all too often been emotional, even hysterical, and have lacked philosophical rigor, a sense of historical context, and social realism. On the one side, certain well-meaning members of the medical profession have too readily presumed that any action is better than none, that necessity knows no law, and that medico-scientific knowledge confers a right to power. On this model, "doctor's orders" should be applied on a national scale and the medical imperative should be sovereign. On the other side, radical libertarians of all political hues have equally fiercely contended that the state's assumption of any compulsory powers believed to counter AIDS would form part of a conspiratorial agenda for the creation of a police state, leading to the criminalization of illness together with all other forms of deviance, as in Samuel Butler's teasing dystopia Erewhon .
In the heat of debate, it is easy to treat these dilemmas raised by AIDS as if they were something new, as if governments had never before been faced with agonizing problems of having to regulate lethal diseases, or (looking at it from another angle, from "below") as if individuals had never before proffered rational arguments against the unwise enforce-
ment of health regulations. Nothing could be further from the truth. Throughout the nineteenth century the spread of what was variously called sanitary science, public hygiene, preventive medicine, and state medicine necessarily tilted the balance between public power and private liberty.
But the crises of health in that newly industrialized and urbanized society, and the availability of new medical and sanitary practices by no means led straightforwardly and inevitably toward the medicalization of life and the therapeutic (welfare) state. Dissent, pressure groups, controversy, policy reversals, and compromise formed the order of the day in Victorian England. Medical, metaphysical, legal, moral, and religious arguments all fought for mastery, and the outcomeâone that endowed the administrative state with considerable powers while falling well short of the general policing, let alone the criminalization, of diseaseâsmacked more of pragmatism than of philosophy. Amid all the noise of competing ideologies, the subtle art of the administratively possible was central to the politics of health.
This chapter will survey a number of major initiatives chiefly in the fields of socially and sexually transmitted diseases in England over the last century and a half. Its aim is to focus attention on what has been a long-running debate on the relations between state powers and individual liberties, the public health and individual medical care (as classically inscribed in the one-to-one confidential contract between patient and doctor). These legal, philosophical, and ethical issues have been largely neglected by historians surveying the rise of the welfare state from Edwin Chadwick to William Beveridge and Aneurin Bevan. That history has traditionally been written either as a celebration of the march of the public health movement as progress, leading up to the National Health Service, or (in more recent, "alternative" accounts) as the marginalization and expropriation of medical sects (e.g., homeopaths) by the juggernaut of state-medical imperialism.
Contemporaries, however, were not deaf to such concerns, debating the connections between physic, philosophy, and politics with a clarity and a passion uncommon today. Our approach here is first to survey the Victorian ideological battleground, and then to explore the complicated relationship between what battling ideologues proclaimed, what found its way onto the statute book, and (not least) what was finally put into practice by medical officers of health, magistrates, and police. This background should afford a better understanding of what is truly at stake today in the contending ideas and policies over AIDS.
One of the earliest comprehensive and systematic philosophical vindications of the fundamental rights of the individual against the state is set out in William Godwin's extremely influential Political Justice , published in 1793. Godwin believed that existing governments improperly invaded the rightful liberty of the individual in many departments of life; the fundamental freedoms of speech, of publication, of assembly, of conscience, of moral belief and action were all unjustly impeded. Yet there is one conspicuous absence in Godwin's indictment of the state. He makes no complaint about the state's interference with the health or the medical choices of the individual. The silence is not an omission, but merely reflects the realities of England at the close of the eighteenth century. Though there was a state religion, there was no state medicine, unlike in many parts of the Continent. Indeed, the very phrase "medical police"âso common in the parlance of enlightened absolutism on the Continent as a part of Kameralwissenschaft (the science of bureaucracy), and known even in Scotlandâwas hardly even an Anglicized expression.
Some two-thirds of a century later, in 1859, John Stuart Mill published On Liberty , the classic mid-Victorian philosophical defense of the freedom of the individual. Fighting what he saw as the tyranny of mass opinion, which he believed was fast being consolidated into a new legislative tyranny, Mill argued for the priority of the individual over the claims of state and society. The fundamental purpose of the state was to protect natural personal liberties, rather than (as in Edmund Burke's political philosophy) to enforce political, religious, and moral allegiance and orthodoxy within a superorganic whole. Mill brought to bear arguments partly metaphysical (individuals had the fundamental right to dispose of their lives as they pleased), and partly utilitarian (self-reliance built character, intellectual dissent stimulated the march of mind, and in the long run these benefited both individual and society). The only ground for curbing one person's liberty, he argued, was when its exercise materially interfered with the free exercise of another's.
Mill clinched his case for liberty through pious appeals to the martyrs of historyâSocrates, Galileo, and so forthâand presented telling illustrations from everyday life. Suicide should be decriminalized, because in the last resort it was for the individual, not for society, to decide what to do with his or her life. Similarly, poisons should be sold freely, as should narcotics and alcohol. Society had the right to educate
and caution against, but not to prohibit indulgence in, such vices. The danger of their abuse was less than the stifling evils of what then was called paternalism.
Mill is strangely and revealingly silent, however, on matters of public health. He believed that bad morals and bad practices should be permitted, because they would be destroyed by free and fair competition, and that truth would prevail. But did the same apply to bad air, bad drinking water, and contagious diseases? To what extent and under what circumstances was the enforcement of public health proper? Mill does not say.
It is hardly anachronistic of us to put this question to him, especially given that the powers of the state to enforce the public health were controversially transformed beyond recognition during his own lifetime. The General Board of Health, set up by the Public Health Act of 1848, had been granted unprecedented powers to regulate such matters as dangerous sewers and contaminated water suppliesâpowers that Edwin Chadwick, its only paid and chief commissioner, exploited to the hilt. This board proved unpopular and short-lived, but it was succeeded by a new medical department established at the Privy Council, with additional powers of inspection and supervision of public health services, under the expert judgment of Sir John Simon. The Medical Act of 1848 also empowered local authorities to establish medical officers of health, who were mandated to monitor morbidity and coordinate the provision of statutory services in local sanitary districts, and granted a broad range of legal powers under a series of Nuisance Removal acts passed in the 1850s. Most radically of all, legislation of 1853 made universal childhood smallpox vaccination compulsory, carrying fines and even imprisonment for defaulters.
Faced with this tide of administrative centralization, the Tory press expressed its horror at the rising tide of Whig paternalism and its interference into private property and local government. The Herald claimed that "a little dirt and freedom, may after all be more desirable than no dirt at all and slavery." But this Canute-like gesture proved in vain. The current of compulsory public health, backed with state sanctions, was flowing powerfully. In the 1860s the Contagious Diseases acts (1864, 1866, 1869) empowered the medical inspection (under specific circumstances) of women believed to be common prostitutes. If found diseased, they could be compulsorily detained and treated. Somewhat later, the whole domain of infectious diseases came under surveillance and administrative regulation. Notification of Diseases acts in 1889 and
1899 required any incidence of a listed infectious disease (smallpox, diphtheria, scarlet fever, croup, typhus, etc.) to be compulsorily reported to the medical officer of health, who then had it in his powers to remove and isolate sufferers and their families and to compel medical treatment.
Looking back as early as 1868, less than a decade after Mill's On Liberty , Sir John Simon was loquacious about the dramatic benefits of this enlargement of the domain of public health regulation:
It has interfered between parent and child, not only in imposing limitation on industrial uses of children, but also to the extent of requiring that children should not be left unvaccinated. It has interfered between employer and employed, to the extent of insisting, in the interests of the latter, that certain sanitary claims shall be fulfilled in all places of industrial occupation. It has interfered between vendor and purchaser, has put restrictions on the sale and purchase of poisons, has prohibited in certain cases certain commercial supplies of water, and has made it a public offence to sell adulterated food or drink of medicine, or to offer for sale any meat unfit for human food. Its care for the treatment of disease has not been unconditionally limited to treating at the public expense such sickness as may accompany destitution: it has provided that in any sort of epidemic emergency organized medical assistance, not peculiarly for paupers, may be required of local authorities; and in the same spirit it requires that vaccination at the public cost shall be given gratuitously to every claimant.
Thus the high noon of free trade and individualism in the manner of Samuel Smiles's Self Help (1859), was also, paradoxically, a time when the state made staggering inroads on the freedom of the individual in the name of the national health. A battery of different ideologies contributed to breach the citadel of laissez-faire. Through trusty disciples such as Edwin Chadwick, Jeremy Bentham's doctrineâthat it was the duty of the legislator to secure the greatest happiness of the greatest number through the deployment of science, expertise, and legal sanctionsâhad its impact, especially in the public health domain. In other fields of abuses, particularly those concerning children and lunatics, Evangelicalism's moral paternalism overcame the dogmatic defense of hallowed individual rights. And, as recent historians have been concerned to stress, pragmatic pleas of necessity in the teeth of "intolerable" evils such as cholera disarmed opposition.
Regarding particular abuses, it is important to stress the presence of a variety of distinct ideologiesâin some ways complementary and in others competingâthat could be used to argue for limited state action to safeguard the public health. The debates over legislation for sanitation, smallpox, or venereal disease never resulted in simple gross polar-
izations of opinionâWhigs versus Conservatives, religious versus secular enthusiasts, the medical establishment versus the people at large. Rather, we see internal fractionalization within each of the powerful parties, professions, and estates of the realm. Each instanceâwater supply, burial grounds, vaccinationâbrought about new alliances and allegiances, leading to a jerky, uneven development of powers that often reflected the preoccupations of a particular influential reformer (such as Lord Shaftesbury with lunacy law reform) or a pressure group of zealots.
It is in this context that we should interpret Mill's peculiar silence. Issues such as religious bigotry and humbug over private morality concentrated and united all his principles and prejudices. By contrast, the questions raised by the possibility of enforcing public health cut confusingly clean across his beliefs, as they did for many other Victorian intellectuals, physician and civil servant alike. Mill was deeply wedded both to utilitarianism and to libertarianism, and he believed that in the long run they were totally compatible. In the medium term the causes of happiness, progress, and utility, Mill contended, would best be served by maximizing liberty. Yet (in a way that might seem casuistic) he was also willing to countenance state intervention, or the infraction of liberties, in certain cases to ensure the effective operation of freedom, as he saw it. Thus, no man should be allowed to exercise the "freedom" of selling himself into slavery, because servitude itself denied human liberty. Similarly, Mill believed, the state was duty bound to compel parents to educate their children (despite the interference with the normally sovereign rights of parents), because without education no young person would be in a position to exercise freedom properly. This approach, which T. H. Green was soon to call "hindering hindrances," incorporated a certain paternalism within the philosophy of liberalism. The state could act to protect the liberty of those who could not protect themselves, or it could interfere in the lives of those who had abused their liberty. In its various ideological garbs, such a doctrine provided a key legitimation of selective state action (in allegedly exceptional or anomalous cases) for those eminent Victorians who deplored Prussian or French bureaucracy and primarily saw themselves as crusaders for liberal freedom.
Given the strength of this prevailing liberalism, it should not be surprising that the most dramatic initial inroads on the individual right and duty to monitor one's own health came with a group particularly unable to protect themselvesâthe insane. The prereform-era English state had permitted the unchecked growth of a uniquely laissez-faire method of managing madness. In most of continental Europe from the seventeenth century onward, some form of state authorization was required for the legal confinement of a mad person by his or her relatives or friends (in France, for example, it was by royal lettre de cachet , in the United Provinces, by order of town councils).
In England, by contrast, the state had kept completely clear of the trade in lunacy. Through most of the eighteenth century anyone could be indefinitely confined in a privately owned madhouse by the agency of friends or family willing to pay the fee; the transaction was purely private. In 1774 medical certification of the insane and licensing of private madhouses were introduced for the first time. Inspection, however, remained rudimentary until the establishment of the Lunacy Commission, set up for the metropolitan area in 1828 and extended to the whole country in 1845. Thereafter, a state-appointed board, chaired for fifty-three years by the indefatigable Evangelical, Lord Shaftesbury, vigorously overruled what would otherwise have been the free contractual relationships of the market, acting on behalf of the putative interests of the insane.
In the case of lunatics, the ground for intervention was simple: By reason of unreason, the insane were legally non compos mentis , incapable of minding their own affairs. Legally irresponsible like minors, they needed a competent body to act on their behalf. Laws licensing and regulating madhouses and preventing improper confinement would protect lunatics; in return for that protection, they were to suffer the suspension of their freedom, their civil rights. In time, the range and number of people undergoing certification increased, as the rationales for confinement were enlarged from the initial restrictive one (preventing harm being done by the lunatic to self and others), to the more expansive ideal of therapeutic cure. In other words, the state became more interventionist by moving from a negative notion of freedom (preventing harm) to a positive one (doing good). At the same time, the scope of
the activities of the Lunacy Commission expanded, regulating asylum management in greater detail. The case of lunacy exemplifies the emergence of the state regulation of health at its most pure, complete, and unchallenged.
The tacit ideology in the development of compulsory legislation to prevent infectious disease took a slightly different tack. Here advocates of state medicine, such as Sir John Simon and Henry Rumsey, claimed that what we might call the sovereign right of the individual to contract, die of, and spread infectious disease should be suspended for the benefit of the health of the community as a whole. In this context two sets of legislation were passed during the 1850s and 1860s that made great inroads on the civil liberty of individuals to have autonomy over their health and sickness. The Compulsory Vaccination acts of 1853 and 1867 placed a legal obligation on parents to have their children vaccinated within the first year of life; fines or imprisonment were the penalties for default. Compulsory smallpox vaccination constituted a remarkable infringement of the normal rights of parents over their children, especially in view of the fact that few legal restrictions on child labor existed at this time, and there was no statutory obligation on parents to educate their children; parents also still possessed an almost unlimited right to neglect or punish their offspring.
The lunacy laws had met little resistance from normally vociferous libertarians, but compulsory smallpox vaccination proved a very different kettle of fish. A powerful opposition lobby was formed, spearheaded by the Anti-Vaccination League (founded in 1867), pressing for repeal. It had numerous strings to its bow, advancing statistical, technical, and medico-scientific arguments for the inefficacyâindeed, the gross dangerâof vaccination itself. But it also campaigned on the platform of freedom from medical tyrannyâsome of its members seeing compulsory vaccination as a manifestation of the menace of medical imperialism comparable to the growing practice of vivisection. At the heart of the league's campaign lay the philosophy of Mill, summarized in an epigraph at the head of each issue of its journal, the Vaccination Inquirer : "He who knows only his own side of the case, knows little of that."
Appealing to that cluster of populist and radical interests that paraded themselves as Davids ranged against the Goliath of the Victorian establishment, the Anti-Vaccination League was able to flex sufficient muscle to secure a substantial attenuation of the acts: The act of 1898 allowed parents to forgo vaccination if they could prove to a magistrate
that they had genuine conscientious objections to the practice of injecting contaminated material into the bodies of their infants. Later, in 1907, a further amendment made exemption much easier through formal applications to a justice of the peace. The new legislation merely ratified the status quo in existing antivaccinationist strongholds, such as Leicester, where the original act had proved impossible to implement against the wishes of large numbers of refractory parents, not least because the union authorities had themselves been divided on the issue.
It would be inaccurate to characterize the struggle over smallpox vaccination as a simplistic division of authoritarian versus libertarian ideologies. Simon, the main architect of the 1867 act, was concerned to improve the quality of the system, making it as comprehensive as possible and ensuring the standard of lymph supply necessary for vaccination. He was less concerned about the stringency of compulsion. For its part, the antivaccination lobby was not consistent in its arguments against compulsion. Although it characterized vaccination as medical despotism, it was prepared to support compulsory notification and isolation of smallpox victims in Leicester. The antivaccinationists called this the sanitarian's method, but medical officers of health, who operated notification, hailed it as the triumph of a scientific, medical approach to infectious disease and advocated its use in conjunction with vaccination, as in the 1896 Gloucester epidemic.
Compulsory vaccination was one of two pieces of legislation created during the mid-Victorian period aimed at the prevention of infectious diseases. The second was the Contagious Diseases acts (1864, 1866, 1869). English legislatorsâall men, of courseâhad long since essentially accepted that prostitution was a commodity in the market economy, relating to elemental desire. So long as there were men, there would be a demand; so long as there was a market, there would be a supply. Prostitution, therefore, should essentially remain an unregulated free-market activity, subject to sporadic criminal prosecution. This "solution" (which had the additional benefit that the state was not "tainted" by giving sexual vice official recognition) was quite contrary to the system of policing employed for centuries in so many continental nations, in which prostitution came under the aegis of administrative jurisdiction through the close licensing of brothels.
The consequence in England was that the chief legislation regarding prostitution was enacted ostensibly because of its threat to health. During the Crimean War it was discovered that the British army and navy were riddled with venereal disease. The euphemistically named Con-
tagious Diseases acts (1864, 1866, 1869) attempted to counter venereal disease by enforcing the compulsory medical inspection of streetwalkers in specified garrison towns and ports. Women suspected of common prostitution could be taken into police custody, subjected to medical examination, and if found venereally infected, detained during the course of treatment.
What is significant, however, is the collapse of the acts in the teeth of widespread and varied criticism (the acts were repealed in 1886). As with the antivaccination lobby, opposition to the Contagious Diseases acts formed into societies, such as the National Anti-Contagious Diseases Association (formed in 1869 and led by Josephine Butler), which won the support of a range of radical elements battling against what they saw as the improper encroachments on civil liberties. Libertarian arguments against the acts were advanced: Even the British Medical Journal initially denounced the acts on the grounds that they infringed the "civil liberties" of prostitutes. Medico-scientific arguments were added: The acts (it was alleged) were bound to prove ineffective in reducing venereal diseases. And most powerfully of all, perhaps, a moral groundswell stigmatized the actsâwith their explicit avowal of the sexual double standardâas deeply offensive to women and as condoning vice by rendering such sex safe for men.
There is no denying that a vocal section of the medical professionâarmy and navy doctors in particularâsupported the acts, backing their case with an ingrained professional misogyny. Others, including no less an eminence than Sir John Simon, expressed considerable reservations, being unwilling to embroil the profession in the disreputable business of acting as moral jailers. Neither can one find a simple libertarian/ authoritarian polarization in the minds of the repealers. For many members of the Ladies National Association, the "liberal" campaign to spare prostitutes from the police and the "instrumental rape" of the surgeon often accompanied a revivalist "social purity" campaign (eventually organized in the National Vigilance Movement) to "protect" women by introducing legal restrictions aimed at outlawing prostitution. "Votes for women, chastity for men" soon became Christabel Pankhurst's suffragist rallying call.
The argument legitimating compulsory legislation to prevent infectious disease championed the health of the community over the individual's autonomy in matters of health and sickness. The common argument of the repealing organizations objected to the gross invasion of the bodies of its subjects by an authoritarian state: "Against the body of a
healthy man Parliament has no right of assault whatever under pretence of the Public Health; nor any the more against the body of a healthy infant. . . . The law is an unendurable usurpation, and creates the right of resistance." The development of compulsory intervention in public health began with the bodies of those who were least able to protest. The interventionist state was then able to achieve its aim under the guise of paternalism, protecting those unable to protect themselvesâlunatics and children (in the case of vaccination)âand later moved to protecting society against a section of its supposedly least responsible elements, such as prostitutes.
It is often alleged nowadaysâindeed, in the case of AIDS itselfâthat governments, particularly those of the right, irresponsibly whip up scaremongering "moral panics," which they then exploit to introduce repressive legislation dressed up in the benign language of public health. The compulsory smallpox vaccination legislation and the Contagious Diseases acts indicate a rather different scenario. For in both these cases, the legislation itself was passed sub rosa, without a noisy, public panic, because a small band of committed advocates, politicians, and civil servants diplomatically pushed a bill (in the case of the 1853 vaccination act, a private member's bill) through the House with minimal discussion. The grande peur was then created by repealers , who, in the case of smallpox, argued that vaccination was more liable to create epidemics, not prevent them, and in the case of prostitution, claimed that no woman was now safe from suspicion.
The successes of the repeal cause in both cases is a sign of the relative weakness of the alliance between government and the organized medical profession, and of deep internal divisions within both as to the propriety and prudence of health enforcement. No Victorian government was prepared to take its commitment to preventive medicine to the point of great unpopularity. Equally, the scions of the medical professionâabove all the Royal Colleges of Physicians and Surgeonsâwere keen to preserve their independence and to keep government at arm's length.
It is significant, then, that the major instance of the successful introduction of compulsory powers over adults in the sphere of public hygiene and preventive medicine should have been on a local and case-by-case basis. This lay in the development of the idea of notifiable diseases; i.e., those socially contagious infections that had proved such a hazard in the Victorian urban environment. Under the Local Government Act of 1875, medical officers of health were granted powers to remove sufferers from such diseases out of the community and place them
in isolation or fever hospitals on the ground that they were "nuisances." This procedure was taken one stage further by an adoptive Notification of Diseases Act of 1889, made compulsory under a new act in 1899. This rendered obligatory the notification to the medical officer of health (MOH) of any incidence of a listed infectious disease (including typhus, typhoid, smallpox, erysipelas, scarlet fever, diphtheria, measles, etc.) by the attending physician or head of household. The MOH was subsequently empowered to remove the patient to an isolation hospital until rendered noninfectious and to disinfect the site of infection.
In some ways this legislation represents a striking infringement of the traditional freedom to be sick, and to spread one's sickness, with impunity. There was no organized public opposition to this measure. But some friction was created between the different branches of the medical profession itself. Thomas Crawford, chairman of the Sanitary Institute, pointed out in 1895 that the behavior of medical officers of health regarding the operation of notification and isolation had alienated general practitioners in their districts. The procedure of secondary (bacteriological) diagnosis often undermined the general practitioner's authority, and the detection and threat of prosecution of default infuriated the MOH's clinical colleagues. Crawford claimed that this hostility from general practitioners was matched by that of families who objected to the law: "The English people are not afraid of risking either their lives or their health in the interests of those whom they love and they are consequently not easily persuaded to part with any member of their family simply because he or she happens to be suffering from an infectious disease." The response of medical officers of health, by contrast, was to deny the existence of hostility from family members completely, claiming that the majority was pleased to attend hospital during their sickness, and that in London, at least, the Metropolitan Asylum Board was overburdened by the demand for isolation and its costs. But they were forced to admit the open hostility of the general practitioners, and acknowledged that the success of the notification system depended on the tact and diplomacy of individual officers.
It is noteworthy that Infectious Diseases acts met with so little public opposition. When comparable powers of removal had first been introduced during the 1832 cholera epidemic, the public reacted with extensive rioting (partly on the ground that cholera was what the radical journalist William Cobbett called a "humbug" promulgated to distract attention from the new Poor Law). This new tractability of the British
public suggests that by the last quarter of the nineteenth century the public was becoming acclimated to a new medical rationality that might involve the trimming of its liberties.
For reasons initially more connected with improved nutrition and a healthier environment than with innovations in curative medicine, infectious diseases that had constituted lethal, epidemic health hazards in earlier centuries gradually ceased to pose such a threat. The Notification of Diseases Acts still remain on the statute books but, mercifully, rarely have to be invoked. It is perhaps, then, not surprising that the key debates this century upon the propriety and necessity of compulsory powers for the treatment of disease and the prevention of epidemics have centered on venereal disease (V.D.). New methods of detecting and curing syphilis, with the development of the Wasserman test in 1906 and Paul Ehrlich's development of salvarsan in 1910, revived a preoccupation with reducing the prevalence of the disease (one estimate claimed that in 1913 there were half a million sufferers in London alone). The advent of World War I also fueled fears that wartime morality and concentrations of soldiers would swell the disease to epidemic proportions, threatening the armed forces' fighting ability.
The Royal Commission on Venereal Diseases was therefore established in 1913 and reported to Parliament in 1916. A notable shift in medical and official opinion emerged from the debate. The failures of the Contagious Diseases Acts were accepted from the outset, and the terms of the inquiry were to regard a return to these measures as a nonoptionânot least because the prostitute was no longer seen as the most dangerous source of infection. Increasing social emancipation for womenâespecially as the result of high levels of female employment during the warâled to increased sexual freedom for "ordinary" as well as "professional" women. These so-called amateurs were held responsible for spreading venereal disease at a far greater rate than prostitutes.
The commission made an important discrimination between the prevention of socially transmitted diseases and those that are transmitted sexuallyâthe former being visible and necessitating treatment in their earliest stages, the latter lying dormant and being difficult to detect; sexually transmitted diseases remained contagious without presenting life-threatening symptoms to the carrier. The commission's report acknowledged that early detection was essential to prevent spread, and required the voluntary, active cooperation of infected persons presenting themselves for treatment. It consequently concluded that the stigma
of official notification would hinder rather than help effective control, driving venereal disease underground to quack physicians and their remedies.
Instead, a system of V.D. clinics, for men and for women, was to be established. Attendance would be voluntary. Anonymity and confidentiality would be preserved, and for that reason, the clinics were to have no formal connections with general practitioners and hospitals. Attenders would be encouraged, but not compelled, to inform their sexual contacts. Treatment would be free. It was a system that would "condone vice" no less than the Contagious Diseases Acts. Butâa sign of the timesâit condoned male and female vice equally, and involved no stigmatization of prostitutes. The underlying philosophy was to create conditions that encouraged maximum cooperation and attendance among patients. These recommendations were issued as new regulations by the Local Government Board in July 1916 and became law under a 1917 act. The commission had also recommended that the task of mass education be given to a voluntary organization, the National Council for Combating Venereal Disease (NCCVD), formed in 1914. The NCCVD (later to become the British Social Hygiene Council) subsequently undertook a propaganda lecture program among the troops and the civilian population, together with poster campaigns and documentary films.
The medical profession's response to the commission's report was generally favorable; the doctors welcomed the free treatment centers and laboratory services provided by the state. A section of the profession (mostly those who had served in the army and navy medical corps during the war) formed themselves, however, into the Society for the Prevention of Venereal Disease, which promoted the adoption of compulsory notification and the free dispensing of prophylactics, which had been so successful in reducing levels of infection among the troops. They pressed also for penalties to be imposed on defaulting patients who failed to complete, or deliberately refused, treatment.
In 1923 the Trevethin Committee examined the workings of the clinics and argued that their success made notification unnecessary. Those who continued to support notification, however, cited the successes of Sweden and Western Australia, which had adopted compulsory systems in 1915 and 1911. Sweden had attacked vice and venereal disease at their heart, it was claimed, by making detention compulsory, introducing prosecution for knowingly spreading infection, and making marriage illegal for a patient until he or she was cured. The medical
profession largely rejected these examples. The Lancet in 1916 suggested that the Swedish approach could be successful only for a small population, and emphasized that because it "bristles with penalties," it ran the risk that patients "may so dread this compulsory pilgrimage to health that they will refuse to seek medical help, . . . a risk which must be avoided in the working of the new legislation in this country." In 1937 a delegation from the Ministry of Health was sent to Scandinavia and Holland to report on the system but concluded that "the degree of success in reducing the incidence of syphilis in the countries employing compulsory treatment and in those which rely on a voluntary system is broadly similar."
As the result of a sharp rise in the incidence of venereal disease from 1939 to 1941, and a slower but steady increase in 1942, the government added Regulation 33B to the Defence (General) Regulations. This regulation made compulsory the medical treatment of a person identified as a contact by two or more people. The relative merits of a voluntary system and a compulsory one were once more evaluated. Advocates of compulsion, including prominent members of the Medical Society for the Study of Venereal Diseases (MSSVD) claimed that the rates of people defaulting on treatment in some parts of the country had reached 82 percent compared with only 2.5 percent in Sweden. The operation of Regulation 33B was questioned by promoters of general notification, such as Dr. Edith Summerskill. She claimed it operated unfavorably against women, who were more reluctant to identify contacts and were, moreover, liable to imprisonment for failing to comply with treatment, while her male contacts were not: "Can the minister justify the position in which an individual informed against under Regulation 33B can be sent to prison, but the two informers, people suffering from the disease and liable to transmit it . . . are not penalised in any way?" The Health Ministry dodged Dr. Summerskill's questions and her demands for a comprehensive system of compulsory notification for all patients, which she believed would restore the balance.
The British Medical Journal lent its support to the arguments of M. J. Laird who, at a widely reported meeting of the MSSVD in April 1942, suggested that to assert that compulsion was not consonant with the "British idea of the liberty of the subject" was outdated by the facts of rising incidence and default from treatment. The journal suggested that it was "late in the day to talk about the liberty of the subject" when the medical profession and the British public
raise no objection to a law which may inflict a penalty upon any person who, "(a) knowing he is suffering from a notifiable disease, exposes other persons to the risk of infection". . . . Nor is any voice raised against the regulations which make it possible to "remove to hospital any person suffering from a notifiable disease if . . . [there is] a serious risk of infection being caused to other persons."
The editorial believed that notification of venereal disease would operate efficiently and equitably, provided that confidentiality were maintained. By the end of the war it was clear that this line of argument was supported, as The Lancet pointed out, by a majority of medical officers of health but was opposed by "those in closest touch with the patient."
Critics of compulsion, such as Dorothy Manchee from the British Hygiene Council, deplored the fact that notification "struck at the root of the relationship of trust and confidence between doctor and patient"; it would, moreover, open the door to blackmail. Colonel L. W. Harrison, who was the inspector at the Ministry of Health responsible for the V.D. service, believed that "private practitioners would not notify their cases." Manchee also agreed that doctors would "not comply" with such a system, which "smacked of Hitlerite Germany." Physic and police should not be unwisely mingled.
The medical profession generally came out strongly in favor of the existing system of voluntary clinics, whose efficacy could best be improved by free and frank educational campaigns, removing shame and the conspiracy of silence, and putting V.D. on an equivalent footing with every other disease. The wartime Ministry for Information, the Central Council for Health Education, and the Ministry of Health combined forces to launch a new propaganda campaign through the newspapers and via the radio, giving out "Ten Plain Facts about V.D." The publicity was more explicit than ever before, so much so that it only just managed to carry the support of the church (the archbishop of Canterbury demanded that the government should insist on denouncing the moral evils of promiscuity). The propaganda stressed that family life was the safe, if not the sole, sexual course. For some, the campaign still fell short of what was needed. The Lancet suggested that "unfortunately, as the Daily Mirror has pointed out, the original wording of the advertisement has been watered down to meet the mistaken sense of delicacy of the proprietors of the daily press."
Correspondents to The Lancet agreed that "prudery, hypocrisy and cant" continued to dog efforts to educate the public about the plain fact that V.D. was preventable. This body of opinion held that the pub-
lic should be told that "if abstinence is not possible, a condom intelligently used will give a high degree of protection." John Ryle, the first professor of social medicine, was criticized, for example, for taking only a long-term view of the need for social and economic change, and not acknowledging the immediate need to inform the public that "if during the next six months every man in the British Isles wore a condom for extramarital intercourse, syphilis . . . would disappear entirely." The campaign continued throughout the war, and the demobilized population was targeted by new propaganda in 1945 and 1946.
The analysis offered in this chapter has charted how connections between medical practice and state power in Britain have increased. The state has made greatest inroads on the freedom of individuals in the causes of giving asylum to the mentally ill and preventing infectious disease.
The legal basis for the operation of the notification laws and the incarceration of the mentally disturbed has been a form of internment without trial. To reduce levels of infectious diseases, the state has suspended the right of habeas corpus in order to prevent an individual from infecting his or her fellow citizens. This suspension of liberty has been justified by the advocates of state medicine on the grounds that the period of "unfreedom" is limited and that hospitalization would give the best chances of cure; but, most important, it has argued the benefit to the community at large gained from the reduction of risks of epidemics.
In the case of diseases that are transmitted through ordinary social contact, the aim of "internment" was to prevent dissemination, because the very presence of the patient among the healthy spread infection to them. In the case of sexually transmitted diseases, the patient, once informed of his or her condition, could not spread infection unless he or she deliberately chose to do so. After 1916 those who supported compulsory detention of V.D. sufferers offered statistics to suggest that the high levels of default demonstrated that the efficiency of the system could not be entrusted to the voluntary cooperation of patients. Those who argued against compulsion claimed that default was no greater in voluntary than in compulsory systemsâindeed default would certainly increase once confidentiality were breached. Thus, in the twentieth century the focus of the controversy surrounding prevention of venereal disease moved from disease to default.
The Victorians recognized that the balance between individual liberty and the higher public good of preventing infectious disease was a delicate one. Securing the health of the community frequently depended not so much on philosophical discourse but on the balance, and imbalance, of power between preventive and curative medicine. The argument that eventually won the day in the British context for the forces of nonnotification had less to do with the importance of personal liberty than with the power of the clinical profession to maintain the private, contractual relationship with the individual patient as the jewel in the crown of medical practice. Medical officers of health and practitioners of community medicine have consistently remained the Cinderellas of the profession, in contrast to the consultants and the clinicians. These legacies of a bygone age help to explain why health enforcement has always been, and remains, a low priority for the medical profession.
The AIDS policies being pursued in Britain by the Department of Health at the time of this writing reflect this legacy. No move has been made, either by government ministers or by the department itself, to make AIDS a notifiable disease. Compulsory screening has also been rejected both by the government and by the medical profession. Instead, a forceful educational program, stepped up in December 1986, has sent information leaflets to every household in the kingdom, informing the public of the existence of AIDS and its modes of transmission, warning of the possible growth of the epidemic, making it clear that it is not a "gay" disease but presents an equal threat to the heterosexual community, and advocating safe sex: "Keep to one partner. If you can't, use a condom." Advertisements, information programs, and "light entertainment" features on the national television and radio networks have been used to publicize the Health Department's messages. There have been explicit statements from health ministers condemning social prejudices against AIDS victims and stressing that the AIDS virus cannot be transmitted through normal social contact. The Department of Employment has announced plans for distributing information leaflets to employers, emphasizing the need not to discriminate against virus carriers or sufferers.
There has been a certain response to the epidemic from pockets of far right and religious fundamentalist opinion, among whom should be included the chief constable for the Greater Manchester area, James Anderton, who has claimed that AIDS demonstrates that homosexuality is unnatural and against the will of God. There have been mutterings in the popular right-wing press to the effect that AIDS demonstrates that the legalization of homosexuality over the last generation was impru-
dent. The government's health campaign has also itself met with some hostility on the ground that its vernacular message is needlessly offensive to delicate minds. And a few voices from within the medical profession have called for further government powers, including the power to make screening compulsory. Until now, however, government policy has been to resist all such demands.
The Department of Health and its ministers have, in fact, achieved a considerable degree of support from responsible lay and medical opinion for its current policies. The major objections from the Opposition parties (Labour, Social Democratic, Liberal) in Parliament and from its critics in the medical profession have been over the inadequate level of funding. Michael Meacher, the Labour party spokesman for Health, in particular argued that insufficient funds have been earmarked both for research and for treatment. Money is still lacking to provide additional staff and resources for the urogenital clinics, where consultations take place. Major inadequacies are predicted to arise among hospital provision for sufferers. The Department of Health, however, has claimed the need for financial caution in view of the obscure future epidemiology of the disease. Critics, however, have been suggesting that the care and support system is already breaking down from insufficient funding and that current, not merely future, needs already outstrip the means made available to the health services for coping with the epidemic.
In July 1987 a special debate on the AIDS crisis was held at the annual meeting of the British Medical Association (BMA). A motion was proposed that it was perfectly within the bounds of ethical conduct for doctors to perform tests for AIDS without the knowledge or consent of their patients, and allowing physicians discretion to do so. Those favoring this proposal suggested, inter alia, that the fear of infection among hospital staffs, medical and lay, was now so great that such procedures would be necessary to preempt industrial action. A fierce debate among doctors resulted in the resolution being passed contrary to the advice of the association's leadership. The first British professor of venereology, Michael Adler, of Middlesex Hospital, announced to the national media networks his abhorrence of the BMA's decision. His horror was echoed by the chief medical officer to the Department of Health and numerous other leading members of the medical profession. BMA members retreated from this position at the annual meeting in 1988.
Divisions within the medical profession are thus beginning to appear. In the BMA debate, a speaker who opposed the screening of hospital patients was filmed by the news network as he was announcing a list of
the reasons why it would be a serious error for the profession to begin to tread the path of compulsory health policies. He concluded his speech with an emotional appeal to his colleagues to consider the "heart of this issue," the destruction of what the profession held more sacred than anything else, "the confidence, and confidentiality, between patient and practitioners." Here we have a strong echo of the attitudes of earlier generations of physicians. He and many of his profession deplored the fact that this voluntarist ideology, which has dominated British health policy on venereal disease, was, for the first time, being undermined from within the medical profession itself.
1. See Roy Porter, "History Says No to the Policeman's Response to AIDS," British Medical Journal 2 (1986): 1589-1590.
2. See the discussion of Professor Julian Peto's proposals in R. Mckie, Panic : The Story of AIDS (New York: Thorson's, 1986), 102-107, and of Professor Richard Doll in J. Laurance, "The Ethics of Testing for AIDS," New Society , 13 February 1987, 20. For other medical views see E. D. Acheson (chief medical officer to the Department of Health and Social Security), "AIDS: A Challenge to the Public Health," The Lancet 1 (22 March 1986): 662-666, and "British Medical Association's Evidence on AIDS to Parliament," British Medical Journal 1 (1987): 61. For further general histories and medical background, see Graham Hancock and Enver Carim, AIDS : The Deadly Epidemic (London: Victor Gollancz, 1986); Nicholas Wells, The AIDS Virus : Forecasting Its Impact (London: Office of Health Economics, 1986).
3. M. Fitzpatrick and D. Milligan, The Truth about the AIDS Panic (London: Junius, 1987); M. D. Kirby, "AIDS LegislationâTurning Up the Heat?" Journal of Medical Ethics 12 (1986): 187-194; Raanan Gillon (editor of the Journal of Medical Ethics ), quoted in Laurance, "The Ethics of Testing for AIDS," 20; Nigel Pugh, "Civil Rights under Threat," Community Care : The Independent Voice of Social Work , 22 January 1987, 13-15.
4. See R. Lambert, Sir John Simon , 1816-1904 , and English Social Administration (London: Macgibbon and Kee, 1963); and A. Wohl, Endangered Lives : Public Health in Victorian Britain (London: Methuen, 1984).
5. See W. M. Frazer, History of English Public Health , 1834-1939 (London: BalliÃ¨re, Tindall & Cox, 1950); George Rosen, A History of Public Health (New-York: M. D. Publications, 1958); C. F. Brockington, The History of Public Health in the Nineteenth Century (Edinburgh: Livingstone, 1965); R. H. Shryock, The Development of Modern Medicine (1937; Madison: University of Wisconsin Press, 1979).
6. For discussion see Medical Fringe and Medical Orthodoxy , ed. W. F. Bynum and Roy Porter (London: Croom Helm, 1986).
7. Don Locke, William Godwin : A Fantasy of Reason (London: Routledge & Kegan Paul, 1983).
8. George Rosen, From Medical Police to Social Medicine (New York: Sci-
ence History Publications, 1974), 120-157, and for a much earlier instance, R. Palmer, "The Control of Plague in Venice and Northern Italy, 1348-1600" (Ph.D. diss., University of Kent, 1978). The concept of medical police had been more readily taken up in Scotland by Andrew Duncan and his successors; see B. White, "Training Medical Policemen," paper presented at the conference on the History of Legal Medicine, University of Lancaster, 1987. In England the most aggressive policing had been used during the seventeenth-century plague years. See P. Slack, The Impact of Plague in Tudor and Stuart England (London: Routledge & Kegan Paul, 1985).
9. John Stuart Mill, On Liberty (1859; Harmmondsworth: Penguin Classics, 1986).
10. R. P. Anschutz, The Philosophy of J . S . Mill (Oxford: Oxford University Press, 1969); Isaiah Berlin, Four Essays on Liberty (Oxford: Oxford University Press, 1969); Gertrude Himmelfarb, On Liberty and Liberalism : The Case of John Stuart Mill (New York: Knopf, 1974).
11. S. E. Finer, The Life and Times of Edwin Chadwick (London: Methuen, 1952), 319-474.
12. Lambert, Sir John Simon , 261-560; R. M. Macleod, "The Anatomy of State Medicine," in Medicine and Science in the 1860s , ed. F. N. L. Poynter (London: Wellcome Institute, 1968), 201-227.
13. Wohl, Endangered Lives , 199, 308-319.
14. Lambert, Sir John Simon , 250-258.
15. Quoted by David Roberts, Paternalism in Early Victorian England (London: Croom Helm, 1979), 200.
16. Paul McHugh, Prostitution and Victorian Social Reform (London: Croom Helm, 1982), 35-43; Judith Walkowitz, Prostitution and Victorian Society : Women , Class and the State (Cambridge: Cambridge University Press, 1980), 69-89.
17. Sir Arthur Whitlegge and Sir George Newman, Hygiene and Public Health (London: Cassell, 1917), 526-543; D. E. Watkins, "The English Revolution in Social Medicine" (Ph.D. diss., University of London, 1984), 214-239.
18. Sir John Simon, Report of the Medical Officer to the Local Government Board , vol. 9 (London: His Majesty's Stationery Office, 1869), 11.
19. Finer, Edwin Chadwick , 12-37; see also R. A. Lewis, Edwin Chadwick and the Public Health Movement (London: Longmans, Green, 1952).
20. For a review of the debate see R. M. Macleod, "Statesmen Undisguised," American Historical Review 78 (1973): 1386-1405.
21. Michel Foucault, Madness and Civilization : A History of Insanity in the Age of Reason , trans. Richard Howard (New York: Random House, 1985).
22. W. L. Parry-Jones, The Trade in Lunacy (London: Routledge & Kegan Paul, 1971), 14.
23. N. Hervey, "The Lunacy Commission, 1845-60, with Special Reference to the Implementation of Policy in Kent and Surrey" (Ph.D. diss., University of Bristol, 1987).
24. D. J. Mellett, The Prerogative of Asylumdom (New York: Garland, 1982).
25. See Henry Rumsey, Essay on State Medicine (London: Churchill, 1856),
and Essays and Papers on Some Fallacies of Statistics (London: Smith, Elder & Co., 1875), 30-36; John Simon, English Sanitary Institutions (London: Cassell, 1890), 433-487.
26. B. J. Stern, Should We Be Vaccinated? A Survey of the Controversy in Its Historical and Scientific Aspects (London: Harper, 1927), 58-61.
27. William White, The Story of a Great Delusion (London: Allen, 1885), is the best account of the history of the antivaccination movement told by a historian from within the movement's own ranks. In this vein, see also William Scott Tebb, A Century of Vaccination and What It Teaches Us (London: Swan Sonnenschein, 1899).
28. Dorothy Porter and Roy Porter, "The Politics of Compulsory Smallpox Vaccination and the Gloucester Epidemic 1895-96," Medical History , forthcoming.
29. Porter and Porter, ibid.; R. M. Macleod, "Law, Medicine and Public Opinion: The Resistance to Compulsory Health Legislation, 1870-1907," Public Law 107 (1967): 189-211.
30. Stuart M. F. Fraser, "Leicester and Smallpox: The Leicester Method," Medical History 24 (1980): 315-332.
31. Lambert, Sir John Simon , 391-394, 437-447.
32. Porter and Porter, "The Politics of Smallpox Vaccination."
33. Alain Corbin, Les Filles de Noce (Paris, 1978), and "Commercial Sexuality in Nineteenth-Century France: A System of Images and Regulations," in The Making of the Modern Body : Sexuality and Society in the Nineteenth Century , ed. C. Gallagher and T. Laqueur (Berkeley and Los Angeles: University of California Press, 1987), 209-219.
34. McHugh, Prostitution , 35-53; Walkowitz, Prostitution and Victorian Society , 69-89.
35. McHugh, Prostitution , 55-70.
36. Walkowitz, Prostitution , 77.
37. Keith Thomas, "The Double Standard," Journal of the History of Ideas 20 (1959): 195-210.
38. McHugh, Prostitution , 48; Lambert, Simon , 405-406.
39. Walkowitz, Prostitution , 108-136.
40. This was a quotation from Francis W. Newman, professor at University College London, which the Vaccination Inquirer frequently used, together with the quotation from Mill, as an epigraph to each issue. See, for example, April-July 1894.
41. Fitzpatrick and Milligan, AIDS Panic , 1-4. There are historical parallels of scaremongering during the cholera epidemics of the nineteenth century leading to a variety of social responses, from "choleraphobia" to riot. See Michael Durey, The Return of the Plague : British Society and Cholera 1831-32 (London: Gill and Macmillan Humanities Press, 1979), 131-140, and R. J. Morris, Cholera 1832 : The Social Response to an Epidemic (London: Croom Helm, 1976), 95-127; Roy Porter, "Plague and Panic," New Society (12 December 1986): 11-13.
42. Watkins, "English Revolution in Social Medicine"; Whitlegge and Newman, Hygiene , 526-543; A. Newsholme, Hygiene and Public Health (London:
Gill, 1902), 317-334; B. Burnett Ham, Handbook of Sanitary Law (1899; London: Lewis, 1938), 69-94.
43. This is true with the exception of emergency powers for medical policing introduced during periods of widespread epidemics such as cholera in 1832-1833. See Durey, Return of the Plague , and Morris, Cholera 1832 .
44. Watkins, "English Revolution," 299-302.
45. Thomas Crawford, "The Position of Medical Officers of Health in Regard to the Administration and Working of the Infectious Diseases and Notification Act," Journal of the Sanitary Institute 16 (1895-96): 353-361.
46. Watkins, "English Revolution," 215-216, 301-302.
47. Morris, Cholera 1832 , 109-114.
48. Ibid., 97.
47. Morris, Cholera 1832 , 109-114.
48. Ibid., 97.
49. "The Control of Venereal Diseases," Public Health 26 (1913): 51-52; "The History of the Fight against Venereal Disease," British Medical Journal 2 (1916): 230-231.
50. Public Health 26, ibid., 51. The editorial in Public Health is quoting from an official inquiry into venereal disease, undertaken for the Local Government Board by Dr. R. W. Johnstone in 1912 and published as part of the Annual Report of the Medical Officer of the Local Government Board , 1913-14 .
51. "Final Report of the Royal Commission on Venereal Diseases," The Lancet 1 (1916): 575-576; "The Treatment of Venereal Diseases by the State," The Lancet 2 (1916): 869-870.
52. See quotations from Johnstone's report and Arthur Newsholme's introduction in the Annual Report of the Medical Officer to the Local Government Board , 1913-14 in Frazer, History of English Public Health , 338. See also Arthur Newsholme, Medicine and the State (London: Allen and Unwin, 1932), 212.
53. Final Report of the Royal Commission on Venereal Diseases [cd.8189] (London: His Majesty's Stationery Office, 1916).
54. Ibid., 60-62; The Lancet 1 (1916): 575-576.
53. Final Report of the Royal Commission on Venereal Diseases [cd.8189] (London: His Majesty's Stationery Office, 1916).
54. Ibid., 60-62; The Lancet 1 (1916): 575-576.
55. The Venereal Diseases Act, 1917.
56. Final Report . . . on Venereal Diseases , 64. For a history of some of the controversies that surrounded the education policy, see Bridget A. Towers, "Health Education Policy 1916-1926: Venereal Disease and the Prophylaxis Dilemma," Medical History 24 (1980): 70-87.
57. "The Prevention and Treatment of Venereal Diseases: The Intervention of the State," The Lancet 1 (1916): 153-154; "The Fight against Venereal Disease," The Lancet 1 (1916): 682; "The State Treatment of Venereal Diseases," The Lancet 2 (1916): 283-284.
58. Towers, "Health Education," 75-77, 80-83.
59. "Control of Venereal Disease," British Medical Journal 2 (1942): 611-612.
60. "Medical Society for the Study of Venereal Diseases," The Lancet 1 (1942): 561-562.
61. The Lancet 2 (1916): 284.
62. British Medical Journal 2 (1942): 611.
63. "Venereal Disease in War-Time," The Lancet 2 (1942): 21.
64. "New Compulsory Powers in Control of Venereal Disease," The Lancet 2 (1942): 589; N. P. Shannon, "The Compulsory Treatment of Venereal Diseases under Regulation 33B," British Journal of Venereal Diseases 19 (1943): 22-25.
65. British Medical Journal 2 (1942): 611.
66. The Lancet 1 (1943): 691-692.
67. The Lancet 1 (1944): 167.
68. The Lancet 1 (1943): 723.
69. British Medical Journal 2 (1942): 612.
70. The Lancet 1 (1946): 615-616.
71. Ibid., 615.
70. The Lancet 1 (1946): 615-616.
71. Ibid., 615.
72. "Control of Venereal Disease," The Lancet 2 (1942): 577-578; the Ministry of Health and The Central Council for Health Education, "Ten Plain Facts About V.D.," newspaper advertisement issued in 1942.
73. The Lancet 2 (1942): 738.
74. The Lancet 1 (1943): 317 (27 February).
75. R. A. Lyster, "Prevention of Venereal Disease," The Lancet 1 (1943): 476. Lyster was then president of the National Society for the Prevention of Venereal Disease.
76. Shakespeare Cooke, "Prevention of Venereal Disease," The Lancet 1 (1943): 350-351. See also correspondence of James Sequeira in The Lancet throughout 1943.
77. Ibid., 511.
76. Shakespeare Cooke, "Prevention of Venereal Disease," The Lancet 1 (1943): 350-351. See also correspondence of James Sequeira in The Lancet throughout 1943.
77. Ibid., 511.
78. The Lancet 1 (1945): 324; "Venereal Diseases: Educational Campaign," Ministry of Health Circulars 42/45 and 92/45, 1945.
79. Frank Mort has suggested that the British state opted for a basically noninterventionist policy with regard to STDs largely because the "personal life of mass society" remained outside the traditional boundaries of its broader political culture. See Frank Mort, Dangerous Sexualities : Medico-Moral Politics in England since 1830 (London: Routledge & Kegan Paul, 1987). For a history of American policy, including the current issues surrounding the AIDS epidemic, see Allan M. Brandt, No Magic Bullet : A Social History of Venereal Disease in the United States since 1880âWith a New Chapter on AIDS (Oxford: Oxford University Press, 1987).