Jerry Morris

Virginia Berridge

Health Promotion Research Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.

I well remember my first meeting with Jerry Morris. It was in the autumn of 1985 during a Society for the Social History of Medicine conference at the Institute of Historical Research in the University of London. The subject was ‘From Public Health to Community Medicine'. I then knew little of this topic, but, as Chair of the Society, I introduced our President, Professor Margot Jefferys, a well-known medical sociologist, speaking on ‘The Transition from Public Health to Community Medicine: The Evolution and Execution of a Policy for Occupational Transformation'. I noticed that, as Margot began to speak, a man came into the room and stood at the back. When Margot finished speaking, he indicated his wish to comment. After some minutes, I began to think that the chair's intervention might be needed. Who was this commentator and should he be tactfully encouraged to let others take the floor? But Margot stopped me. ‘Let him go on speaking; this is important'.

It was indeed. The man was Jerry Morris, and he was giving his perspective on the events of the 1950s and 60s which were the subject of the presidential address. His comments were a defence of the structural changes of that period which had seen the demise of the Medical Officer of Health (MoH), located within local government, and the establishment of a new clinical speciality of community medicine located within health service rather than local government structures. Margot's address had been critical of these and related changes. No-one was recording his comments that day, but doubtless notes were taken and the comments informed the discussion of those events in subsequent publications.1–4 The study of the post-World War II transformation of public health both as a medical occupation and as an ideology of health practice has been of increasing interest to historians and to those aiming to redefine the earlier focus of social medicine.5–9 Jerry Morris's influence in those areas has been profound; numerous scholars and other investigators have beaten a path to his door and requests for interviews have proliferated. Jerry also gave his own Presidential address to the Society for the Social History of Medicine recently, surveying aspects of his career. An earlier video interview is deposited in the video archive of the Royal College of Physicians in London and Oxford Brookes University.10 The purpose of this brief introductory paper is not to attempt any full-scale assessment. Its aims are to set out a future research agenda by indicating some key themes and where some largely unexploited research materials are to be found. It touches on some of the issues in his career which have emerged already through published historical research and analysis, of which public health researchers may be unaware. My aim, as an historian, is to bring some of that historical discussion of Jerry's career and its context to the attention of those currently working and researching in epidemiology and public health.

I little thought, 15 years ago, that I would be leading a group of historians working in the same Unit as Jerry at the London School of Hygiene and Tropical Medicine, or that, with colleagues, I would be organizing a conference to mark his 90th birthday. Yet historical research in our group on post-World War II health policy and the papers and recollections from colleagues and former students published in this special issue, indicate how Jerry's career symbolizes the post-war redefinition of public health as a medical occupation and as an ideology of what is meant by the health of the public and how to improve it. This brief introduction will touch on some of those issues.

Social medicine

Jerry Morris was born in Liverpool in 1910 and educated in Glasgow and London, qualifying in 1934, then gaining wide clinical experience.

After an early stint in Nottingham Public Health department and as Assistant Medical Officer of Health (MoH) in Middlesex, 1939–1941, he spent most of the war as a clinical specialist in the Royal Army Medical Corps (RAMC) in India and Burma.

During his army service in India, he participated in an early informal demonstration of the efficacy of penicillin, in this case for cavernous sinus thrombosis, which is referred to in the witness seminar transcript. Other evidence shows penicillin was being used elsewhere in the Far East in the latter part of the war.11,12 But his early career was notable for other reasons as well. His association with the social statistician and pioneer of the post-war welfare state, Richard Titmuss began when he made contact with Titmuss, after reading the latter's Poverty and Population, published the year before the war broke out. Thus began what Titmuss' daughter, Ann Oakley, calls ‘an unusually vital working partnership' which lasted until Titmuss' death in the early 1970s and which fuelled research and policy activity. During the war, despite Morris's absence in India, the two produced three papers hailed by the social medicine pioneer John Ryle as the ‘first example of a practical social medicine'.13 These papers were concerned with the epidemiology of juvenile rheumatism; the social history of rheumatic heart disease; and the epidemiology of peptic ulcer.14–16 These conditions were chosen because they could demonstrate the influence of social factors. Oakley has commented that the association between Morris and Titmuss extended Titmuss' own initial careful statistical work into a much broader plan to map how different indices of social and material conditions were related to different health outcomes (Oakley, p.90).13 The voluminous correspondence between Morris and Titmuss in India, most of it on army aerograph forms which have to be read with a magnifying glass, has recently been used by Ann Oakley in her study of her parents' relationship and the context of male/female relationships in the post-war period.17 These are clearly an important source for the history of social medicine and are in Ann Oakley's possession at the Institute of Education in the University of London.

In 1948, this joint interest led to the foundation of the Medical Research Council's (MRC) Social Medicine Unit, initially at the Central Middlesex Hospital in Willesden a suburb in North West London, then the London Hospital in the East End of London and finally, from 1967–1975 at the London School of Hygiene and Tropical Medicine in the University of London. Shaun Murphy has recently produced a valuable study, using MRC archives, of the genesis and early history of the Unit.18 He concludes that support for social medicine was fuelled by the general increase of interest in social issues as well as by a more specific desire to promote occupational health research. This research programme, although not clearly specified, was seen as part of the potential creation of a new type of doctor with wide interests including prevention and the social and class origins of ill health. This had been the vision, ultimately unsuccessful, of the Goodenough Committee on Medical Education of 1944.19 The Unit worked in its early days on projects designed to investigate the influence of social factors on stillbirths and infant mortality, coronary disease and duodenal ulcer. A study of population needs and medical activity within general practice was one of the earliest examples of health services research, which Jerry insisted from the onset, counter to the views of the MRC, was an essential ingredient of ‘social medicine'. Dr Keith Ball, who worked with Jerry Morris in the early days at the Central Middlesex, remembered in the witness seminar at the conference the tremendous buzz of activity in the early days at Willesden, with people like Horace Joules who was among the first to advocate action on smoking and the connection between diet and heart disease, Avery Jones a gastro-enterologist who pressed smoking as an issue for action on the Royal College of Physicians, and Jonathan Miller there later on as a registrar.

Redefining social medicine and public health

This is the institutional history of Jerry's career in the late 1940s and 1950s. But he and his colleagues were also beginning to establish new ways of conceptualizing social medicine and public health. Out of war time social medicine was beginning to emerge a different entity, a new form of public health focused on lifestyle and the modification of individual behaviour as well as on the larger social factors. The prevention documents of the 1970s, both nationally and internationally, signified the arrival of this view in formal policy terms and these will be discussed below. But the roots were laid long before. Jerry's work at the Central Middlesex involved new areas of concern—like coronary heart disease and the connection with physical activity,—on which seminal papers were published in the 1950s.20 A key defining event in this period for the emergent behavioural emphasis and the role of epidemiology was the association of smoking with lung cancer through Doll and Hill's research. Together with Jerry's work, this was beginning the change to a new public health interested in chronic disease and the modification of behaviour as well as on social structure. For smoking, the 1962 Royal College of Physicians report Smoking and Health was of crucial importance in bringing the science into the public and policy arenas. My research on its papers shows that Jerry, a member of that committee, produced for it a document on the relationship between smoking and coronary heart disease. It was he, too, who pressed the committee to consider the role of advertising, at a time when it was almost impossible to find data in that subject. The economic dimension of the tobacco question was his interest—before it became part of the brief of the expanding group of health economists.21,22 His interest in the media and in the public presentation of science and policy had been demonstrated even in the 1940s when he wrote a pamphlet on health to be used through the Association for Education in Citizenship by wartime discussion groups (Murphy, p.391).18 This desire to speak to the public, shared also with Charles Fletcher, showed itself in a 1950s radio broadcast which Kelly Loughlin's researches have uncovered in the BBC radio archives. In 1955, as this extract shows, Jerry was already clearly stating the rationale for the ‘new public health' case.

‘... we are dealing with a different social situation. The nineteenth century epidemics, bred in poverty and malnutrition, arose from failures of the social system. The wave of tuberculosis that followed the industrial revolution and the ubiquitous rickets of the Victorian slums could be regarded as passing faults of society; there was hope and confidence that further social progress would mitigate and in time abolish such evils. But coronary thrombosis ... with its origins apparently in high living standards ... seems to be arising from what we regard as successes of the social system, and from the essential processes of our new industrial society. ... It is becoming clear that in the modification of personal behaviour, of diet, smoking, physical exercise and the rest, which look like providing at any rate part of the answer, the responsibility of the individual for his own health will be far greater than formerly. It will not be possible to impose from without (as drains were built) the new norms of behaviour better serving the needs of middle and old age. They will only come about in a new kind of partnership between community and individual.'23

Jerry recognized the importance of the media presentation of the public health case. As Michael Marmot remarked during the conference, ‘Jerry is the only person who tells me that I ought to watch more television, not less'. This media consciousness was a crucial component of the emergent post-war public health. So, too was chronic disease epidemiology, the quantitative methodology which became the bedrock of the redefined discipline. Here Jerry's Uses of Epidemiology, based on a paper first published in the British Medical Journal in 1955 and with its first edition in 1957, provided a textbook, which, as George Davey Smith's paper in this issue indicates,24 was the cornerstone of further developments and provided the technical blueprint for public health activities.25

Redefining the public health occupation

Historians have been interested in the other dimension of Jerry's career—his policy significance, as demonstrated by the moves to make this ideological and conceptual redefinition of public health a matter of practical occupational policy. As Jane Lewis has shown, academics in departments of social medicine and public health began in the 1950s to urge substantial reform in the training of public health recruits and in public health practice in order to reinvigorate the speciality.26 The hope was that Medical Officers of Health (MoHs) would become broader health strategists. For many practising MoHs, however, administration meant rather the day-to-day organization of services. Their vision of their role was more limited. These new ideas were widely discussed and efforts to reform the public health curriculum in the late 1960s emphasized the role of epidemiology as the core. The role of the MoH as adviser to the health service was central. These discussions became bound up in broader policy concerns, notably the Labour government's emergent plans for the future shape of the health service. Jerry Morris was closely involved in these moves. Kenneth Robinson, Minister of Health in the 1960s, had a small informal group to advise him on the issue, of which Jerry Morris was a member.1 The later Secretary of State, Richard Crossman, also records Jerry's involvement. ‘This evening Brian Abel-Smith gave a little dinner at his house in Elizabeth Street for me, Bea Serota and Professor Jimmy (sic) Morris, who was one of Bea's colleagues on the Seebohm Committee. We had all got together to talk about the reorganisation of the Health Service and they calmed and soothed me a bit. ...'27

It was Jerry's involvement in the Seebohm Committee on the future of the personal social services, together with Titmuss' parallel involvement in the Todd Commission on Medical Education, with as usual much private exchange between them, which pushed these matters forward. The Seebohm report's recommendation for the establishment of local authority social services departments, finally settled the fate of remnant public health departments. It was accompanied in 1968 by reassurance from the NHS Green Paper that public health doctors would find a new and expanded role as community physicians in the reorganized health service.5,26 It is Jerry's vision of this role which the current Chief Medical Officer, Liam Donaldson, discusses in a paper in this issue.28 The community physician became the ostensible lynchpin of the reorganized NHS in the 1970s, although the reality did not correspond to the high hopes at its origin. This changeover has remained controversial in particular because of the loss of public health's roots in local communities.

Accompanying these wider changes was also an occupational transformation of public health into community medicine and debates about the relationship between medicine and the social sciences. This short paragraph does not give detail about these crowded events, but just indicates where historical analysis, and potential new data are to be found. The institutional history has three strands—the establishment of the Society for Social Medicine in the 1950s; of the Faculty of Community Medicine in the 1970s; and the changes which took place in teaching and in training, epitomized by the Social, later Community, Medicine MSc at the London School of Hygiene and Tropical Medicine. The establishment of the Society, encompassing medical and non-medical academic members; its submission of evidence to the Royal Commission on Medical Education; and its involvement in the establishment of the new Faculty, have been discussed by participants and by historians.14,29,30 Jefferys has described in some detail the alliances made within the Society and also with the practitioners of public health outside. Active support for this alliance was provided by Dr Wilfrid Harding, then MoH for Camden, and a participant in the seminar during the recent conference. Dr Harding's comments, and those by Professor Bob Logan at the conference, underlined the importance of Jerry Morris's role in these events, though on the case for an independent entity for the Faculty he was defeated. The difficulties encountered in the process of ‘medical professionalization' embodied in the move to Faculty status were apparent nearly 30 years later. Some of the comments recorded on the day of our conference bore witness to continuing hostilities and a feeling that Jerry Morris should have been the first President of the Faculty. (See p.1212 for Witness Seminar Summary.)

Public health's move from local government into a clinical setting, referred to above, had another dimension. This was the change in teaching and training in public health in the 1960s and 1970s. The old DPH (Diploma in Public Health) gave place to the new membership of the Faculty and MSc courses were established to provide academic credentials in addition to the professional qualification. Those who spoke at Jerry's 90th birthday conference, giving formal papers, like Ian Chalmers,31 or in the ‘witness seminar'—Dame Beulah Bewley, Dr June Crown, Dr Zavina Kurtz, all of whom went on to prominent careers in community medicine—bore witness to the importance of this new style of training in bringing a different generation and gender into public health. These changes in the curriculum and their impact within public health have been studied for the earlier period and for the United States, less so for the United Kingdom.30 Curriculum change is currently an issue on the public health policy agenda. The forthcoming history of the London School shows how Jerry's arrival at the School and pressure also from the Department of Health, led to the demise of the old Diploma in Public Health and the change to a 2-year MSc in social medicine funded by the government and encompassing theory and practical research. This was intended to produce the new breed of community physician which was Morris and Titmuss' vision. In a lecture at Johns Hopkins he delivered to an American audience his vision of the ‘community physician' as the ‘administrator of local services, epidemiologist, and community counsellor', pointing to the need for an ‘effective intelligence service' to underpin local medical services. In the early 1970s, the addition to the department of a Centre for Extension Training in Community Medicine initially under Roy Acheson and then RJ Donaldson, disseminated this vision more widely in the training of public health doctors. Jenny Roberts reminscences of that training formed part of the witness seminar.9,11

‘New public health'

The fascination of the organizational history has meant that other less tangible developments within public health in those years have been less studied, both by historians, and by those who were active participants at the time. Changes in the prevention agenda at the end of the 1970s were in some senses the outgrowth of the earlier moves within social medicine in the 1950s and 60s, as the extract from Jerry's 1955 BBC talk makes clear. Documents such as Prevention and Health; Everybody's Business, published for consultation in 1976, followed by the Commons Expenditure committee's report on Prevention in 1977 and the White Paper, Prevention and Health in the same year, identified targets such as smoking, alcohol, diet, epitomizing the ‘new public health' which was an outgrowth of earlier social medicine. Jerry Morris's role in these developments remains to be studied. But his evidence to the Commons Expenditure committee was clearly important. Cigarettes, inadequate exercise and obesity were major causes of ill health, and the public, he argued, had to be educated into probabilities and understanding risk. Here was the long-standing focus both on epidemiology and on public understanding. What of the social class gradient? How to avoid it was one of the questions he was asked. Here he saw, ‘... the perpetuation of diseases of poverty, because of differences in personal behaviour in relation to the same social class factors as we saw were important in tuberculosis, bronchitis, and rickets and so forth. This is a real mass educational thing ...'33 There is here a change in emphasis since the writings in the 1940s to encompass personal behaviour as well as social class and a new role for mass media interventions. This was a harbinger of more general ideological change in what was seen as the essential task of public health.

Black and inequalities

Jerry Morris's research career was distinguished by its association with research into cardiovascular disease, exercise and fitness. At the centennial Olympic Games in 1996 he was honoured, together with Ralph Paffenbarger, with an Olympic Gold medal in recognition of excellence in the science of sport and exercise and the pioneering studies demonstrating how exercise reduces the rate of heart disease. This strong strand of interest is represented in the papers by Meade,34 Paffenbarger and Blair,35 and by Hardman 36 in this issue. It became obvious in the course of organizing the 90th birthday conference that, for many of our non-historian colleagues at the School, this was what Jerry was known for, for the research and because of his campaigning for the Sports Council and HEA and leadership of the National Fitness Survey. Historians would argue that these activities and developments are symptomatic of the wider ideological changes to which I have drawn attention above. There is therefore a disparity between Jerry's reputation ‘in the field' and that among historians of post-war health who take a broader policy view. The historians' interest in Jerry's advocacy of social medicine; of changes in public health and health service policy; and in occupational organization and training are less known in the field, with the exception of those in academic public health who take a continuing interest in these matters. The research history was known in the public health and epidemiological community—the policy and conceptual history less so. Yet one aspect of the recent policy history was well known. This was Jerry's involvement in that key document, the Black Report on inequalities in health, which continued some of the earlier concerns. A conference at LSHTM in 1999 on history and inequalities enabled us to run a ‘witness seminar' on the Black Report which gathered together almost all the original participants, together with those involved in the follow-up Health Education Council report, The Health Divide. The transcript will be published in a special issue of Contemporary British History together with comments both from Lord Jenkin, who was Secretary of State at the time the report was published, and from Stuart Blume, who was scientific secretary to the committee.37 That transcript reveals interesting new dimensions, among them the desire of some civil servants for a ‘quick and dirty' document which could be implemented before a likely change of government; divisions between members of the committee (Jerry Morris and Peter Townsend) about the nature and form of interventions which should be proposed and discussions between them on the top floor of the London School to iron out a compromise; the way in which the low key launch became of intense media interest. Again, Jerry's role in events was an important one, not least in advancing a more health service/ hospital-based view as well as Townsend's social approach.

As I write, Jerry continues as an active member of the Health Promotion Research Unit, a regular attender at Unit meetings, at staff events, commenting on current trends within public health, urging greater attention be paid to inequalities while maintaining an active personal research programme.38 He looks to the future, while at the same time historians and others recognize his enormous role in the post-war redefinitions and research emphases of public health.

Acknowledgments

I would like to thank the Wellcome Trust, the British Medical Journal and Mars (UK) Ltd for their generous sponsorship of the conference organized at LSHTM to celebrate Jerry's 90th birthday. My thanks are also due to Kelly Loughlin, Melvyn Hillsdon and Ingrid James, who organized the conference with me. George Davey Smith and the IJE editorial office have given valuable support in bringing this special section to fruition. Helpful comments on this introduction were provided by three anonymous referees and also by Jerry Morris.

References

1 Jeffreys M. The transition from public health to community medicine: the evolution and execution of a policy for occupational transformation. Bulletin of the Society for the Social History of Medicine 1986;39: 47–63.

2 From Public Health to Community Medicine. Abstracts of paper by Armstrong D, Watkins (Porter) D, Webster C, Lewis J. Bulletin of the Society for the Social History of Medicine 1986:38:44–59.

3 Jeffreys M, Lashof J. Preparation for public health practice: into the twenty first century. In: Fee E, Acheson R (eds). A History of Education in Public Health. Health that Mocks the Doctors Rules. Oxford: Oxford University Press, 1991, pp.314–35.

4 Porter D (ed.). Social Medicine and Medical Sociology in the Twentieth Century. Amsterdam: Rodopi, 1998.

5 Lewis J. What Price Community Medicine? The Philosophy. Practice and Politics of Public Health Since 1919. Brighton: Harvester/Wheatsheaf, 1986.

6 Webster C. The Health Services Since the War. Volume I. Problems of Health Care. The National Health Service, 1957. London: HMSO, 1988.

7 Webster C. The Health Services Since the War. Volume II. Government and Health Care. The British National Health Service, 1958–1979. London: The Stationery Office, 1996.

8 Murphy S, Davey Smith G. The British Journal of Social Medicine: What was in name? J Epidemiol Community Health 1997;51:2–8.[ISI][Medline]

9 Wilkinson L, Hardy A. Prevention and Cure. From Tropical Medicine to Global Public Health. A History of the London School of Hygiene and Tropical Medicine, 1899–1999. London: Kegan Paul, in Press.

10 Morris JN. Video interview with Dr Max Blythe. RCP and Oxford Brookes video interview archive 9.5.1986. ref 8.

11 Morris JN. Witness seminar transcript, 90th birthday conference, London School of Hygiene and Tropical Medicine, 2000.

12 Private communication, Sir Christopher Booth to Dr Robert Bud, 1996.

13 Oakley A. Making medicine social: the case of the two dogs with bent legs. In: Porter D (ed.). Social Medicine and Medical Sociology in the Twentieth Century. Amsterdam: Rodopi, 1998, pp.81–96.

14 Morris JN, Titmuss RM. Epidemiology of juvenile rheumatism. Lancet 1942,ii:59–63.

15 Morris JN, Titmuss RM. Health and social change: the recent history of rheumatic heart disease. Medical Officer 1944a;LXXII:65–67, 69–71, 77–79.

16 Morris JN, Titmuss RM. Epidemiology of peptic ulcer: vital statistics. Lancet 1944b;ii:841–45.

17 Oakley A. Man and Wife: Richard and Kay Titmuss: My parents' early years. London: Harper Collins, 1996.

18 Murphy S. The early days of the MRC Social Medicine Research Unit. Social History of Medicine 1999;12(3):389–406.[Abstract]

19 Oswald NTA. A social health service without social doctors. Social History of Medicine 1991;2:295–315.

20 Morris JN, Heady JA, Raffle PAB, Roberts CG, Parks JW. Coronary heart disease and physical activity of work. Lancet 1953;ii:1053–57, 1111–20.

21 Royal College of Physicians. Minutes of the committee on smoking and air pollution 1959–63.

22 Berridge V. Science and policy: the case of post war British smoking policy. In: Lock S, Reynolds L, Tansey EM (eds). Ashes to Ashes. The History of Smoking and Health. Amsterdam: Rodopi, 1998, pp.143–71.

23 Morris JN. Twentieth Century Epidemic: Coronary Thrombosis. Transcript of BBC third programme talk 1 December 1955. BBC written archives, Caversham, Reading. Printed version Coronary Thrombosis: a modern epidemic, The Listener, 8 December 1955: 995–96.

24 Davey Smith G. The use of ‘Uses of Epidemiology'. Int J Epidemiol. 2001;30:1160–69.

25 Morris JN. Uses of Epidemiology. Edinburgh: Livingstone, 1957.

26 Lewis J. The public's health: philosophy and practice in Britain in the twentieth century. In: Fee E, Acheson R (eds). A History of Education in Public Health. Health that Mocks the Doctors Rules. 1991, pp.195–229.

27 Crossman R. The Diaries of a Cabinet Minister. Volume 3. Secretary of State for Social Services, 1968–70. London: Hamish Hamilton and Jonathan Cape, 1977.

28 Donaldson LJ. 1969 revisited: reflections on Tomorrow's Community Physician. Int J Epidemiol 2001;30:1186–92.

29 Acheson RM. The British diploma in public health: heyday and decline. In: Fee E, Acheson RM (eds). A History of Education in Public Health. Health that Mocks the Doctors Rules. 1991, pp.272–313.

30 Warren MD. The Origins of the Faculty of Public Health Medicine, formerly the Faculty of Community Medicine. London: Faculty of Public Health Medicine, 2000.

31 Chalmers I. Comparing like with like: some historical milestones in the evolution of methods to create unbiased comparison groups in therapeutic experiments. Int J Epidemiol 2001 30:1170–78.

32 Fee E, Acheson R (eds). A History of Education in Public Health. Health that Mocks the Doctors Rules. Oxford: Oxford University Press, 1991.

33 Preventive Medicine. First Report from the House of Commons Expenditure Committee. Session 1976–77. Preventive Medicine, volume II. Minutes of Evidence. Evidence from Professor JN Morris. London: HMSO, 1977.

34 Meade T. Cardiovascular disease—linking pathology and epidemiology. Int J Epidemiol 2001;30:1193–97.[Free Full Text]

35 Paffenbarger RS, Blair SN, Lee I-M. A history of physical activity, cardiovascular health, and longevity: the scientific contributions of Jeremy N Morris, DSc, DPH, FRCP. Int J Epidemiol. 2001;30:1198–206.[Free Full Text]

36 Hardman AE. Physical activity and health: current issues and research needs. Int J Epidemiol 2001;30:1207–11.

37 Special Issue on Inequalities and Health containing transcript of ‘witness seminar' on the Black Report. Berridge V, Blume S (eds). Contemporary British History 2001, in Press.

38 Morris J, Donkin AJM, Wonderling D, Wilkinson P, Dowler EA. A minimum income for healthy living. J Epidemiol Community Health 2000;54:885–84.[Abstract/Free Full Text]