 |
The Case for State Medical Services for the Poor The Highlands & Islands 1850by Dr Morrice McCraeIn 1845 the potato blight, Phytophthora Infestans, descended on Ireland destroying the essential source of nourishment of a whole population. The famine that followed profoundly changed the demography and even the history of that country. In the late summer of 1846 the same fungus spread to Scotland. The potato crop in many parts of the country was 'all but a complete failure.'1 The calamity was felt most severely in the Western Highlands and Islands where the mass of the people, dependent on the potato and living constantly at subsistence level, were never more than one harvest away from scarcity and hunger. For almost ten years the suffering of the people was made worse by the lack of medical aid. A medical service only recently put in place proved to be entirely inadequate. In August 1845 an Act for the Amendment and better Administration of the law relating to the Relief of the Poor in Scotlandbecame law. For some three centuries responsibility for the administration of the Poor Law in Scotland had been devolved to the Kirk and almost nothing had been spent on medical aid even for those registered as paupers on the parish rolls.2 Under the new Act the state set up Parochial Boards in every parish to 'have and exercise all the Powers and Authority hitherto exercised by the Heritors [landlords] and the Kirk Sessions.' In the nineteenth century, the need for some new provision for the poor had become compelling. The remorseless industrialisation of Britain had destined to poverty an ever-growing proportion of the population - the new overworked, poorly paid and badly housed urban industrial workforce. In the years of economic depression that had followed the Napoleonic Wars the poverty of the working poor deepened further and become even more widespread. There was a growing fear in the country that 'the condition and disposition of Working Classes is a rather ominous matter at present; that something ought to be said, something ought to be done, regarding it.' 3 In the 1834, Parliament responded to this increasing public anxiety. A Poor Law (Amendment) Act was passed for England and Wales, based on the Utilitarian ideas that had become influential in England. The greatest good of the greatest number was to be achieved by reducing the threat that pauperism and its attendant evils presented to the general public and by containing the financial burden that increasing pauperism forced on the productive and self-supporting majority. Since Elizabethan times, the Poor Laws in England had determined that a small number of the poor - those whose poverty was so absolute that they had been obliged to surrender the normal privileges of citizenship in order to become officially designated as paupers - were entitled to support from the community in which they lived. In 1834 Edwin Chadwick, the Benthamite architect of the new Act, aimed to contain the rising cost of the every increasing numbers maintained under the old laws. Relief was to be administered with greater economic efficiency but even more important, the year on year increase in the number entitled to relief was to be halted. Chadwick identified the diseases and disabilities of the working poor as the chief cause of the decline of so many of their number into destitution and pauperism. He was persuaded by the belief, then common in England, that the chief cause of the pauperising diseases of the poor was miasma, the noxious effluvium from urban filth. He was confident that by eliminating miasma from the country's towns and cities by a program of sewerage and drainage, the chief cause of urban pauperism would be removed. Not only would the numbers, and therefore the cost, of the paupers be contained but the slums which harboured the urban poor would no longer be the breeding grounds of disease and the source of a constant threat to the health of the community at large. The English Act of 1834 made no provision for the personal medical care of paupers, even where their pauperism was due to sickness.4 Chadwick, the chief architect of the Act, looked only to prevention; doctors were 'necessary evils not likely to last,' destined to become redundant as his sanitary measures to remove miasma took effect.5 For over a decade there was well argued objection to the government's intention that the provisions of the English Act should also be made to apply in Scotland. Opinion in Scotland was unconvinced by Utilitarian ideology and the medical profession discounted miasma as a significant cause of pauperism. The accepted model of the relationship between disease and poverty was an inversion of that held in England. From Cullen and Buchan in the eighteenth century,6 physicians in Scotland had held that poverty - through poor diet, inadequate clothing and shelter, overwork and overcrowding - led to 'debility.' In the nineteenth century medical students at Glasgow and Edinburgh were taught that it was the 'debility' of poverty that was at the root of the health problems of the urban working class.7 Led by W. P. Alison, then the Professor of Medicine at Edinburgh University, social reformers in Scotland argued that any new Poor Law must include support for the able-bodied poor so that, when deprived of employment for whatever reason, the worker and his family would not necessarily be reduced to destitution, debility, depression and disease.8 Equally, the sick poor must have access to the medical treatment that might make it possible for them to return to work and to provide for their families. Alison, and his follow reformers were only partially successful. Since the sixteenth the century, the Poor Law in Scotland had not required parish authorities to provide for the able-bodied and that ancient principle was continued in the Poor Law (Amendment) Act in 1845. The Act did not extend the reponsibities the new Poor Law to include the able bodied; 'poor,' in this context, continued to mean only 'pauper'. Although the new legislation did nothing to prevent the able bodied from falling into pauperism, it did offer those pauperised by ill health some assistance to recover their ability to work. In the Bill presented to Parliament Parish Boards were to be obliged to raise 'Funds for the Relief of the Poor' from within the parish either by voluntarily offerings or by assessment and were required, out of these funds 'to provide for Medicines, Medical Attendance, nutritious diet, Cordials and Clothing for such poor and in such a manner and to such an extent as seem equitable and expedient.' In the House of Commons, Scottish members continued to object that this proposed enabling legislation did not go far enough. They demanded that the Poor Law must ensure that every parish had the services of a resident medical officer and that, to provide the necessary funds, assessment should be made compulsory. The Home Secretary, Sir James Graham, agreed that 'general assessment must be desirable but considering the difference of opinion he thought it infinitely more wise to leave the public of Scotland, by a voluntary act, to adopt assessment themselves rather than by an enactment to make it compulsory.'9 The Prime Minister, Sir Robert Peel considered that the provision of a paid medical officer in every parish was impractical and that Scottish members were being over ambitious. 'He entertained a strong objection to giving the people of Scotland a positive assurance that the poor should at all times be supplied with medical relief. He thought there should be caution in how they excited expectation which could not be realised. Everything that was possible ought to be done but fallacious hopes should not be raised.'10 Nevertheless, after the Act was passed, Scottish pressure continued11 and in 1848 the government offered a compromise. An annual grant of £10,000 was made to the Board of Supervision of the Poor Law to finance a subsidy for any parish that agreed to finance the formal appointment of a medical officer. Sir John McNeil, the Chairman of the Board, was confident that, with this inducement, a full complement of medical officers would be recruited throughout Scotland.12 On first introducing his the Poor Law (Amendment) Bill in 1845, the Lord Advocate had referred to the problem of increasing poverty in the towns and cities to which there had previously been 'perhaps some indifference - or rather a want of attentive observation.'13 He also drew attention to the very different, but equally pressing, problems of poverty in the Highlands and Islands. In many districts a great change of circumstances has been occasioned by the alteration in the system of management of land. Small farms have been thrown together into large farms and the consequence is that there are fewer people able to contribute to the relief of the poor now than formerly. Then again in some extensive locations along the coast the entire annihilation of kelp manufacture has thrown many persons out of employment and while the means of the contributors has decreased and the fund for reliving the poor has become lessened. The poverty and misery of the labouring classes has naturally increased. It was appropriate that although the people of the Highlands and Islands made up little over 10% of the population of Scotland their poverty should have special attention. Although communications by sea had recently improved with the introduction of steamboat services from the Clyde, the Western Highlands and Islands were still remote from the main body of Scotland. In 1845, the way of life and the usual language of the people, as much as geography, set the community apart and its social problems were it own. Since the seventeenth century the old military Gaelic society and its clan structure had been disintegrating. In theory the lands occupied by the clan had been communal but in practice the clan was ruled by a hereditary aristocracy in what was in effect a ruler-owns-all society. Traditionally the economy had depended on the rearing and exporting of cattle and by the communal farming of scattered and intermingled holdings and open fields. The destruction of this ancient Gaelic society was purposefully accelerated by government fiat in the aftermath of the Jacobite rising of 1745.14 It was now legally recognised that the tradition of common ownership of the clan lands had long been a myth. Clan chiefs were now to be regarded as no more than landed gentlemen, legal owners of vast estates that were grossly overpopulated and burdened by an obsolete agricultural economy. Many estates were soon bankrupt and almost all urgently required new investment to make them commercially viable. Some of the old aristocratic families raised the necessary funds by selling part of their estates; others sold out completely, usually to men who had made fortunes overseas or in the new industries of the south. This new generation of owners introduced modern agricultural practices to the best of their arable ground and gave over other vast acres to profitable sheep runs. In this restructured agricultural system there was a place only for landowners, their large tenants and a limited agricultural workforce. Employment could only be found for the few; the great majority of the population of Highlands and Islands was now redundant. A few of the minor gentry became large tenant farmers but most found that they could only maintain their life style by moving away. Numbers of the ordinary people - those who could find the means - also moved away, emigrating in the hope of a new and better life in the south or in North America. Those who remained were displaced from the inland glens to peripheral coastal land and settled on crofts too small to provide a livelihood for a family. In the early years of the nineteenth century almost every crofter had to rely on additional income from employment in the local kelp industry or from the earnings of those of the family who could find seasonal work in the fishing fleets operating from the east coast or temporary employment in the industrial south.15 The Highlands and Islands made an essential contribution to nineteenth century Britain by supplying wool for the expanding industry in the south, labour for the expanding economy and, as ever, manpower for the country's armed forces. But the society that had emerged in the Highlands and Islands was not one in which a professional middle class could flourish. There were few people of substance; the overwhelming majority of the people now belonged to a crofting community that was poor almost by definition and, as its numbers continue to increase during the first half of the century, so also did its poverty. In giving particular attention to the Highlands and Islands when introducing the new Poor Law Bill to the House of Commons in 1845, the Lord Advocate was recognising the poverty and misery of the crofting community had increased even further since the end of the Napoleonic Wars. A sharp fall in cattle prices had made the crofters' few beasts almost worthless, the collapse of the kelp industry had had closed their chief opportunity for local employment, and a failure in herring fishing and the general recession in Scotland had made it more difficult to find work elsewhere. Few crofters could see any prospect of prosperity in Scotland and many, perhaps a majority, were 'inspired with the spirit of emigration. Nothing but the reluctance to part with their scanty stock of cattle, at present at very low prices, seems to retard the emigration of a great many people.'16 The crofters could contribute almost nothing to the economy of the estates and most were allowed to remain on the land ' by humanity alone.'17 But they remained in dire poverty, badly housed and poorly clad. 'Their domestic economy is frugal . beyond conception. The produce of foreign soil, as tea, coffee and sugar, and the common conveniences of art, as knives and forks &c. are to them altogether alien. Their ordinary food consists of oat and barley meal, potatoes and milk, variously prepared.'18 Then, a year after the introduction of the new Poor Law, the people of the Highlands and Islands were further 'blasted by providence.' The potato blight that had been devastating Ireland since 1845 had spread to Scotland and for a decade the people of the Highlands and Islands were unable to grow the crop on which they chiefly depended for sustenance. Meal had to be brought in by relief organisations and paid for by the people in whatever cash they still possessed or, when that was exhausted, by their labour. Whereas in Ireland during these years the structure and functioning of society was undermined, 20,000 died of starvation and a further 193,000 died from typhus ('famine fever').19 In the Highlands and Islands social order was maintained and enough meal was shipped in to prevent deaths from starvation. Typhus, which had been a continuing scourge in Ireland since the great epidemic there in 1816-19, never reached epidemic proportions in the Highlands and Islands.20 The Great Highland Famine was not a cause of death but a cause of great poverty and destitution. After four years of distress caused by the Highland Famine, Dr John Coldstream drew attention to the great deficiency of medical aid. Coldstream, a friend and former colleague of Charles Darwin, had abandoned a career in natural history to return to Edinburgh to practice medicine and to take part in the missionary work of the new Free Church of Scotland.21 The Free Church had been one of the principal agencies delivering relief to the Highlands and Islands during the Highland Famine and, in July 1850, Coldstream gave an account of conditions there in a paper to the Royal College of Physicians of Edinburgh. He attributed the difficulty in finding assistance for the sick poor to the very small number of medical men practising in the region.22 Since he could give no exact figures, the College applied to the Board of Supervision 'for such information as it happened to be possessed of, regarding the supply of medical aid in the northern districts of Scotland.'23 On being informed by the Chairman of the Board that the relevant information 'was not to be found,' The College appointed a committee to assist Coldstream in conducting an inquiry 'to determine the proportion which the Practitioners bear to the whole population and to ascertain whether there be much complaint on the part of the people of the difficulty in getting medical aid.' 24 A questionnaire was sent to 'the Ministers of Parishes and some others resident in the counties of Argyll, Bute, Inverness, Ross, Sutherland, Caithness, Orkney and Shetland to the number of 320, in 170 parishes'. The Ministers were asked to give the names and addresses of all doctors in each parish, to state whether the number of doctors was increasing or decreasing, to assess the extent the inadequacy of medical aid in their districts and for suggestions for improvement. A questionnaire was also sent to all 71 doctors known by the College to be practising in the region at that time.25 Almost all the questionnaires were returned and many of the ministers and medical practitioners took the opportunity to set out their assessments of the situation and their proposed solutions at much greater length. There were then 370,000 people living in the 14,000 square miles of the Highlands and Islands during the Famine and in the winter of 1850 there was little to distinguish paupers from the general population. The small numbers of paupers (2-4% of the population)26 - those entitled to free medical care under the Poor Law - had hardly changed since the Famine began. Yet one typical parish 'contains upward of 2000 of a very scattered population who, except for six families are in a pauperised condition.'27 From another parish, Dr MacLean reported that although he was 'paid by the Boards only to attend the paupers of two parishes, I have out of my own pocket to physic and attend a population of 3000 who are unable to pay a medical man.'28 In all, the parish ministers of the Highlands and Islands were able to identify only 133 medical men in the whole region and not all were regarded as reliable. In many cases it was suspected that the practitioner had no proper training or qualification. In 1852 later it would have been discovered from the first Scottish Medical Directory that 36 had no registered qualification, 53 had qualified as surgeons as licentiates of the Royal College of Physicians of Edinburgh, the Royal Faculty of Physicians and Surgeons of Glasgow or the Royal College of Surgeons of England and 44 had university degrees (MD or CM). Although all 133 made themselves available to treat anyone in urgent need of attention, not all were in full time practice as doctors. Four parish ministers and seven large farmers had medical degrees and gave assistance when required but took no income from medical practice. Ten practitioners were in semi-retirement from service in the Royal Navy, the Hon East India Company, the Hudson's Bay Company or from the army. The distribution of the 133 medical practitioners bore little relation to the parish structure of the region. No fewer than 92 parishes had no resident doctor although several reported that, if absolutely necessary, they could call on the services of a doctor from a neighbouring parish. As many as 41 parishes, mostly in Ross, Sutherland and the Islands, were 'never visited by any regular practitioner and may therefore be regarded as destitute of medical aid'.29 Although, in 1850, many were receiving a 'salary' under the new Poor Law, medical practitioners did not necessarily base themselves on parishes which employed them. The practice of medicine was an entrepreneurial business and those medical men who were dependent for their livelihood on the practice of their profession based themselves in the market towns or in those villages which had a few shops, a post office and some promise of commercial activity. For the majority of the people of the more landward areas these commercial doctors were remote and their services were neither immediately available nor affordable.30 Medical men could not make a living from private practice among the people in the more remote districts. In Skye, the population being 'so much scattered' and, in normal times 'the health generally so good,' Dr. Ferguson found that in his district even a single practitioner could not find reasonable living; there were few prosperous tenant farmers, no middle class and the 'people, being so poor, are unable to pay either for attendance or medicine.'31 In the Highlands and Islands, earnings from fees were seldom more than a few pound a years and income had to be supplemented from some other source. Most combined medical practice with 'small' farming and for some farming was their chief employment. In a very few parishes, the medical practitioners could depend on an annual salary, varying from £6 to £20, from a scheme of 'Mutual Insurance'32 organised by the local tenants.33 On some great estates the proprietor lent financial support. On his vast estates in the north the Duke of Sutherland employed district surgeons on an annual salary of £40, which, with their other earnings made them among the most financially secure medical practitioners in the Highlands. However, few proprietors were so wealthy or so careful of the welfare of their people. Many estates were 'in the hands of a Trustee - a poor proprietor with a poorer tenantry.'34 After 26 years in practice, one dispirited medical man wrote It has been a life of labour but not an age of ease. Owing to the miserably inadequate remuneration I could not afford, after supporting my wife and family, even to insure myself or make any provision for myself or for them. As my family increased, I was obliged to give up a medical periodical and I could scarce afford to give my family the common rudiments of an education.35 Over the years many well-qualified medical men had attempted to establish themselves in the Highland and Islands but, finding too few patients able to pay for their services and unable to find other financial support, were forced to leave. Now, as poverty increased in the years after the Wars, even some of those who had seemed well established began to drift away When, in 1846, the arrival of the potato blight in the Highland and Islands turned poverty into destitution, that drift increased. Almost every practitioner now complained that 'the poverty is so great that few can afford to pay a medical man for his services although on all occasions they insist on prompt attention for which, generally speaking, they are quite unable to pay.'36 'All the tenants, crofter and cottars, except those farmers who hold sheep alone, are in a state of, or bordering on, bankruptcy and not able to pay their rents since the failure of the potatoes and the depression of the price of black cattle.'37 When tenants could no longer find the means to meet their rents, some previously benevolent landowners withdrew their support for the local medical practitioner. In South Uist, Col. Gordon generously guaranteed my salary on behalf of his tenants for which I attended their wants. The condition of the people having come to such indigence of late the proprietor could not find it possible to extract rents far less his other land taxes including the doctors salary so that last term day he withdrew this and now I cannot count on anything.38 While a few practitioners discriminated in their attendance on patients - 'now resolved not to attend to their wants except in cases where a remuneration may be accepted'39 - the great majority continued to be 'the humble servant of everyone night and day'40 attending those unable to pay and bearing the cost of medicines and travel from their own resources. For almost all, medical practice became both commercially impossible and personally oppressive. I cannot see how efficient medical practices can be supported in this place. Some of us expend a large .sum on medicine for the people in indigent circumstances who, though not in receipt of parochial relief, cannot afford to pay for medical attention. And further the discomfort a medical man endures by being obliged to ride or drive eight or ten miles in severe weather and then forced to remain for many hour in a miserable hovel without warmth and almost invariably without food, is unknown to those who have not experienced it.41 The demands were particularly severe on practitioners on the remote coastal districts. There the daily round could be dangerous as well as financially unrewarding. Take for instance a bad case of midwifery and a coarse night journey of 20 to 30 miles crossing arms of the sea. It may be very inaccessible to get to and to hire any conveyance or means of shifting that is safe and dry is out of the question. And after all that fatigue and expense I am sorry to say that not more than three out of ten can pay anything. So in a pecuniary point of view, I would be much better stopping at home had it not been for the suffering of humanity.42 Suffering form lack of access to medical help was most severe on the small islands. When the case is critical and the doctor must be sent for they have to cross the distance separating this island from Sanday in a small open boat. At certain time of the year a fortnight, or even longer, may elapse before the attempt can be made with safety. In some islands, death has ensued before his arrival. In many cases his advice has only been sought at the eleventh hour when his services are unrewarding.43 As the repeated failure of the potato crop deepened widespread poverty into destitution, medical practitioners continued to leave the Highlands and Islands. The measures introduced in 1845 by the Poor Law (Amendment) Act, even when strengthened by the subsidy added in 1848, did little towards reversing that trend. In 1851, together the ministers in the Highlands and Islands reported to Dr Coldstream the loss of a further 35 medical practitioners from their parishes. Five had died and had not been replaced. Four had emigrated - two to the Hon. East India Company and two to Canada - and one had joined the army. Five had remained in the Highlands but had moved to practice in more prosperous villages or had abandoned medical practice for full time farming. All the others had left to practice in the Lowlands or in England. While the exodus continued, a total of 15 new doctors had come to the Highland and Islands but of these three, although qualified to practice medicine, had come to the Highlands principally as farmers. Of those who, following the implementation of the new Poor Law, had come expecting to make a living from medical practice, four had become disillusioned by 1851 and were already looking for employment elsewhere. Of the 200 parish ministers who replied to the College's inquiry, the great majority (141) reported that the new Poor Law had brought no improvement in medical services in their parishes and 32 reported that the number of medical practitioners available to their people had continued to decreased. In general the reputation of the medical practitioners who continued to practice was enhanced the during the difficult years of the Highland Famine. There was 'no class of men more extensively and actively charitable than the Medical Practitioners in the Highlands.'44 However, in spite of their individual efforts, the service they were able to deliver was far from satisfactory. The medical men of the Highlands are usually humane and in every instance inadequately remunerated, but at the same time the difficulty of procuring their services and affording any remuneration for them are so great that it is only in very extreme cases that medical aid is usually sought by the poorer classes. In such cases, especially when we consider that his stay is necessarily short that his visits, if repeated at all, are so only at distant intervals and that his prescriptions, if administered in his absence, are given unsatisfactorily and partially under much injudicious treatment calculated to counteract their efficiency, the medical attendant can be of little service and hence, without regard to these circumstances the people have but too generally lost due confidence in medical aid, and thus from day to day we, the Clergymen of the Highlands, who are necessarily conversant with their condition see what appears at the outset but the simple ailment, assuming by neglect, inattention and unskilful treatment the aggravated form of the dangerous and it may be fatal illness. In cases of childbirth the poor females of the Country are usually subjected to the most ignorant treatment, left dependent as they generally are on female attendants of their own class who have rashly assumed a calling in the nature of which they never had one hours instruction. Indeed I am fully persuaded that due inquiry on this point, while it would lead to surprise that so few lives are sacrificed, would at the same time unfold details of the most trying and lamentable nature.45 A number of ministers took the opportunity not only to comment on the general deficiency in medical aid but to express disappointment in the qualities of medical officers recruited since 1845. From Gairloch, the Rev. John Mackay complained that 'Charles Robertson, surgeon and little farmer, was procured for the paupers and crofters on the Gairloch property and for other inferior purposes. It seems to be an increase numerically speaking but we are worse than wanting a medical man for all I know and hear.'46 From the parish of Bressay the Rev. J.M. Hamilton reported that 'it would almost be better to have none at all than an ignorant half educated person.'47 In other cases it was not only professional competence that was found wanting. 'Some of them, I regret to say, have yielded themselves to habits of intemperance.'48 In Westray a resident doctor had been recruited but the minister, the Rev James Brotchie, 'found it necessary to have no intercourse with him.' From Kildalton, the Rev Alexander Mackenzie wrote: 'Let it suffice to say that he is employed by no respectable family in the district nor by any of them that can possibly avoid it.'49 Some new appointments, though eminently successful and greatly valued by the parishioners, seemed unlikely to last. From Helmsdale, Rev. John MacDonald reported that Thomas Rutherford 'was the only Medical Practitioner of standing and respectability who has resided for any length of time in this place.' The parish was .a most important place for a qualified medical practitioner not only on account of the largeness of the population but on account of its being one of the principle herring fishing stations on the coast. Many flock to it from all parts of the country during the fishing season, many of them poor people who are exposed to accidents, on sea and on land, of which there have been many since I became connected with the place. Among such a multitude of people accidents must happen, sometimes severe ones in consequence of mishaps and the upsetting of boats, so much so that, unless medical help were at hand, life would be in the greatest danger.50 However the heritors of the parish were making no effort towards 'keeping a respectable medical practitioner in the place.' In 1850, overworked and under paid, Dr. Rutherford was already planning to leave. Five years after the passing of the Poor Law (Amendment) Act, and in spite of the subsidy offered to the Parish Boards in 1848, the number of medical practitioners was even more inadequate than before. There were fears that even more medical men would be forced to leave. Many could not afford to stay without an income from their small farms and farming was in recession. For the minister on Barra this was a particularly pressing problem. 'Supposing the medical men residing in this parish transferred their agricultural capital elsewhere the deficiencies in supply of medical aid could not be relieved.'51 Deficiencies could only be made up by attracting new medical practitioners 'but there is little likelihood at present of anyone making the experiment.' By 1850 it was clear that the implementation of the medical provisions of the Poor Law (Amendment) Act, and in particular the Treasury grant, had not been well managed. The primary intention had been to provide medical care for the paupers on the Poor Roll in every parish in Scotland. For the Highlands and Islands there was an important second intention; it was hoped to improve the medical care available to the working poor indirectly by encouraging an increase in the total number of medical practitioners in the region. As Sir John McNeil wrote in a letter to the RCPE, it was intended that 'more particularly in the remote parishes' the Treasury grant would 'doubtless exert a direct influence on the actual supply of medical aid to the mass of the people.'52 In the event, the scheme only succeeded in slowing the drift of medical practitioners form the region. Even with the subsidy offered by the Treasury, parochial boards found it difficult to appoint a medical officer since the Treasury grant had to be matched by an equal contribution from parish funds. In an exceptional arrangement, the parochial boards of Creich and Lairg in Sutherland and Kincardine in Ross and Cromarty found it possible to employ Alexander MacEwan as an additional practitioner for their three parishes only by pooling their resources. More typically, the Treasury grant only made it possible for the parish to persuade an existing practitioner to stay. Dr Fenton of Bowmore, for example, reported that 'without the £35 from the Parochial Board I should been compelled to leave.'53 However, in many cases the Treasury grants were neither taken up nor used so effectively. Across the region, parochial boards were often arbitrary and inconsistent in their use of the subsidy and some chose not to apply for it. In Orkney, parochial boards may have been unduly influenced in rejecting the offered grant by one of the long established medical practitioners. Dr Duguid, already grieved that 'druggists interfere very much with the emoluments of the professional man,' resisted the recruitment of even more competition. 'I regard the Orkney Islands as abundantly supplied with medical men.tho' no doubt some of the islands suffer inconvenience at times from stormy weather preventing them from sending boats across the ferry.'54 The grant was refused, leading a less influential surgeon to complain: The islands of Walls, Hoy, Fara, Cava and Flota have no medical aid. I am often called there and detained from bad weather. The boats they send are often very bad and, were funds allowed, a good one could be got. I have to land on the barren shore far from the houses and remain until daylight, not being able to trust the boat. If I could get a good boat I could visit them oftener.55 The Rev. Joseph Caskey, agreed that an opportunity had been lost. There is no one here who pretends to medical skill with the exception of a retired schoolmaster and the sick nurse and it is doubtful how far their pretensions could be trusted. There are no heritors resident in the parish and, in general, the inhabitants are not wealthy but, with a view to obtaining a suitable doctor, I think between the Parochial Board and the inhabitants the sum of thirty pounds might have been depended upon. A doctor is very much required here and, with aid from some other quarter, he could have a comfortable living.56 Paradoxically, it was in the poorest and most badly served parishes that the offered Treasury grant could not be matched from parish funds and had to be rejected. In more prosperous parishes, where the need was less pressing, it was almost invariably accepted. As we have seen, the parishes that made up the Duke of Sutherland's estate were already well served by the practitioners employed on a salary from the Duke. One of them, John McLean, who also had a good income, was able to report that, with the additional sum from the Treasury grants, he was financially secure: My salary from the Duke of Sutherland £40 Surgeon to the Parochial Board of Edderachyllis £15 Surgeon to the Parochial Board of Assynt £20 For attending farmers £20 with a house £100 In many parishes, where the grant was accepted, its distribution became a cause of resentment and even anger. The Parochial Board of Kilcalmonell received a grant of £25 but allocated the greater part to a practitioner who did not live or practice in the parish. The resident surgeon, John MacKeller, complained: 'Only four lousy pounds for advice and medicine to the paupers in a parish 16 miles in length and containing 100 paupers. So much for justice.'57 On Arran, both parishes - Kilmorie and Kilbride - allotted the whole of their grants to Andrew Stoddart, an unqualified practitioner based in Brodick. Charles Cook, the surgeon at Lamlash, complained that Stoddart . is upwards of 18 miles from many of the paupers and he is not able to attend them all. Often I have to give advice and medicine without any remuneration. There are only two medical men on the island. If the salary of two parishes was divided, as he lives in Brodick and I at Lamlash, the north would answer to him and the south to me. I am sure the poor would get better justice.58 Neither Charles Cook nor Andrew Stoddart had any proper registerable qualification. In 1850, few parochial boards distinguished carefully between qualified and unqualified practitioners in appointing medical officers. This added further to the dissatisfaction in many parishes that the Treasury grant had not been distributed rationally or fairly. Even where the grant was used to the best effect, it often proved insufficient to relieve the almost overwhelming financial pressure on the local medical practitioner. Colin MacTavish, a surgeon on Islay complained: Although the medical practitioners of this place are allowed thirty pounds and some odd shillings for attending the paupers on the roll, some of us have to expend a large proportion of that sum on medicine for the people in indigent circumstances who, though not in receipt of parochial relief, cannot pay for medical attention.59 By 1850 it was apparent that the Poor Law (Amendment) Act, even with the addition of the annual Treasury grant, had not succeeded in ensuring the provision of adequate medical care in a poor community. Although the measures allowed by the Act had not been carried out fully in every parish and the best use had not always been made of the funds available by the Treasury, these were not seen as the fundamental causes of the scheme's failure in the Highlands and Islands. The fundamental problem that the overwhelming extent and severity of the poverty. The few paupers whose care was directly financed by the state, made up far too small a proportion of the total number of those who were too poor to pay for medicines and medical attention. In many prosperous regions in Scotland, medical practitioners could earn enough in fees from those who could afford to pay to allow them to provide services gratis to that manageable proportion of their patients who could not. In the Highlands and Islands those who could pay were too few to support the parish medical practitioner; by providing medicines and service gratisto all those who required it, he faced financial ruin. In many cases the practitioner was only saved from being overwhelmed by the restraint of the great majority of poor. 'The people seldom think of calling a medical man until there is manifest danger and often cases are too far gone before advice is had.'60 Fortunately, throughout the Highland Famine the population remained 'generally healthy.'61 Typhus was 'lurking on the islands'62 and caused a number of deaths in 1949. A small number of people from Canna, returning from an unsuccessful attempt to find work in the industrial south, brought smallpox with them causing three deaths.63 Although the medical practitioners were in constant fear that ' were any serious epidemic to visit, the mortality will inevitably be painful in the extreme,'64 the great epidemic that was then causing the deaths so many thousands in Ireland, did not descend on the Highlands and Islands. Nevertheless, during the years of scarcity 'things were sufficiently bad' and in their distress 'the bulk of the people were not able to get proper medical attention.'65 In 1850, the poverty that was at the root of the problem in the Highlands and Islands, was not seen as passing phenomenon and was not related specifically to the years of failure of the potato crops. In the 232 reports received by John Coldstream, the parish ministers and medical practitioners seldom mentioned the potato famine. Without exception they saw the problem of poverty as set to continue indefinitely and many described the situation as hopeless. It was agreed that there could be no improvement in medical services while the endemic poverty of the Highlands and Islands continued. A few believed that the chronic poverty could be relieved by new legislation that would force every tenant in the Highlands to introduce modern agricultural practices. Individual landowners had attempted to rationalise the management of their estates but often in haphazard and crudely conducted 'clearances' that were inevitably resisted by many of the small tenants. Properly conducted modernisation of the agricultural economy was seen as the only answer and if its potential was to be fully exploited it was seen as imperative that access to the region should opened up by extension and development of the new steamboat services. These were long-term and unexceptionable ambitions. However, a number of Coldstream's correspondents made proposals for more radical measures, proposals that were remarkable at a time when Victorian philanthropy was 'widely thought to the most wholesome and reliable remedy for the nation's ills'66 and when government was committed to a policy of laissez faire. Every constructive proposal called for increased state interventionIt was proposed that the new Poor Law scheme should be made more effective by additional legislation to make assessment of parishes obligatory, to increase the Treasury grant and to oblige Parochial Boards to accept it. In addition the Treasury should underwrite the cost of medicines for those who could not afford them, medical practitioners' travel expenses when attending the poor and free vaccination services for the whole population. To ensure continuity of service the Treasury should also fund the employment of locums for medical practitioners whenever necessary. One correspondent, possibly mindful of the Medical Bill then under discussion, suggested that the position of medical practitioners should be protected by legislation to prohibit the activities of those quacks, parish ministers and other unqualified 'persons who injure the profession by visiting and prescribing, not only among the poor but among those who are able to pay.'67Most medical practitioners felt that, without state support in some form, they would remain insecure and undervalued. Owing to the dependent circumstances in which all of us are placed in consequence of our small incomes, we cannot hold the status in society to which out profession entitles us. We are often looked down upon, even treated disrespectfully and contemptibly, by people who are our inferiors in every sense. We are in fact slaves of many masters. In this parish has a population of 3000 and for a trifling contribution to my small income I must be the humble servant of every one of them night and day. Superhuman labour is attendant on our professional avocation yet a mechanic in the south is a much more independent man than a district surgeon can aspire to here. Medical practitioners in these remote quarters ought to be on the same footing as the parish clergymen. Their labour is a thousand times more valuable in the eyes of the community, their education is equal if not superior and their experience greater than that of a clergyman. Most parish ministers and medical practitioners were agreed that improvement in the income and status of medical practitioners could only be achieved as part of a radical reform of medical services. It was clearly anomalous that the state should provided those few parishioners permanently on the paupers rolls with free medical care while the great majority in every parish, the working poor, had no guarantee of medical aid even when, in times of particular hardship, they could not find the funds to buy it for themselves and their families. It was imperative that there should be free medical treatment 'in the case of any family such as a tradesman or workman, previously supporting himself and his family but now laid upon a sickbed' and this could only be achieved by creating some new form of service. It was implicit in every suggestion for the future of medical services in the Highlands and Islands that reliance on philanthropy must be abandoned. Rev. Alexander Shand of Nesting spoke for all: 'I cannot see what philanthropy can do.' Philanthropy must be set aside and so also must the government's policy of laissez faire.It was accepted that nothing worthwhile could be achieved without government intervention. The more cautious proposed that government should introduce new legislation to obliged parishes to combine in small groups [new local authorities] and required, with Treasury support, to employ salaried medical officers to provide free services for all those in need. More innovative schemes called for new services to be provided directly by central government: The simplest and cheapest plan to give medicines and medical aid to tens of thousands living in the Hebrides would be to employ a few sober men of good character and energy, provided with medicines and instruments and a small steamboat (as the Marquis of Salisbury has done for Rum) to move constantly about among the people when they could conveniently assemble to be cured of their diseases. By this plan [salaried medical practitioners] would more economically and efficiently be brought into contact with the sick and the maimed than by the establishment of stationary practitioners.68 From the mainland parishes it was suggested that an 'association' should be organised to appoint an adequate number of salaried medical officers in service for every district. This new service, financed by the Treasury, could be staffed by the 'many of our own Army and Navy surgeons, unemployed and inadequately provided for.'69 It was further suggested that, because of 'the filth and wretchedness of the hovels' in which the people lived, local hospitals should be established 'containing 10 to 20 beds.' This, in itself 'the best, and at all events the most practicable, scheme for the improvement of the chief evils to which the poor are exposed in cases of sickness,'70 would also provide local centres for the proposed domicilliary medical services. In 1850 these were radical proposals. They proceeded from the experience and pragmatic judgements of those with immediate professional responsibility for the welfare of the people among whom they lived. However they ran counter to the prevailing ideologies of the metropolitan intelligentsia who directed the governance of the nation. At the Reformation, Scotland had adopted a religious ideology. The Kirk had become 'the real State in Scotland'71 taking on important areas of collective responsibility, including the welfare of the education and welfare of the people. At the Union, the Kirk lost some of its authority but had come under little pressure to relinquish these responsibilities. After the split caused by the Disruption of 1843, the diminished established Kirk had to accept that its parishes could no longer command the financial resources to provide for their poor. However, its Moderate leadership remained tied to the Union and inhibited in promoting radical independent initiatives for Scotland. The new Free Church was more vigorous and, led by its evangelical first Moderator, Thomas Chalmers, insisted that in Scotland the church, not the state, must retain responsibility for the welfare of its people. The Royal Commission that had prepared the ground for the new Poor Law was much influenced by Chalmer's philosophical outlook72 but its members had also recognised that, most clearly in the growing urban centres created by industrialisation, there was a 'new order of things.' The parish structure and organisation that had served mixed rural communities for centuries could not be successfully replicated in the new urban communities, especially in those parishes populated almost entirely by the new industrial poor. But the industries which had created these new communities owed their success to free trade and a government policy of laissez-faire. Political economists had provided the intellectual arguments for a minimal role for government and, whenever possible, the avoidance of state intervention. Scotland's Samuel Smiles, in his phenomenally successful book, Self Help,would soon to be at the forefront of the promotion of moral improvement, personal initiative and personal responsibility as the only way to success. The Royal Commission had laid down that 'if a man will not work, neither should he eat.' Any calls for state aid for the poor and economically redundant could expect little sympathy and in the 1850s calls from the Highlands and Islands could expect no sympathy at all. Majority opinion in England and in Lowland Scotland had turned against the people of the Highlands and Islands. The arrival of the potato blight in the Highland and Islands in 1846, and the hunger and destitution visited on the people had initially provoked widespread and generous concern but it had also attracted critical attention. The Times expected a 'substantial calamity'73 in Scotland comparable with that in Ireland. Aid must be provided but, at the same time, the Glasgow Heraldthought it must .press upon the public attention .that no time may be lost in inquiring into the condition and prospects of the population who are thus deprived of their chief, and in the majority of cases, the sole means of subsistence.74 That inquiry brought down the judgement of both press and public. For five years observers commissioned by the nation's leading journals examined the causes of the endemic poverty in this distant part of Britain. They concluded that the explanation for their poverty lay in the people themselves. 'They preferred their habitual mode of life, their few days of desultory labour intermingled with weeks of lounging gossip, their half clad condition, to regular well paid toil.'75 Even the Scottish press decided that 'the great cause of the destitution is not the failure of the potato crop but the intense and abominable idleness of the inhabitants.'76 Due to a 'lack of energy, persevering vigour, enterprise and commercial spirit,'77 no middle class had emerged to challenge an outdated patriarchal society made up of a few landlords and an ever-increasing number of poor. When it had first become obvious that the potato crop had failed, schemes of relief had been quickly organised, principally by the Relief Committee of the Free Church of Scotland and by the Relief Committees set up in Edinburgh and Glasgow and a Central Board London. The system of relief was conducted according to the principles of the time. To give assistance to the able-bodied without demanding work in return was to encourage idleness and moral degradation. Meal must be paid for 'in the shape of labour.'78 Over the next four years the relief schemes were successful in that there were no deaths from starvation and no deaths from famine fever (typhus). But the Highlanders' reluctant and dilatory response to the demand for labour in exchange for meal brought disappointment and anger. The potato blight had attacked crops in almost every part of the British Isles but it had only caused destitution among the Gaels of Ireland and the Western Highlands and Islands of Scotland. These Celtic people, it was said, had 'submitted year after year to the visitation of famine have folded their arms and prayed for better times, but to put their shoulder to the wheel, to know that Providence helps those who help themselves, is a lesson which they have yet to be taught.' It could be said of the Highlanders, as of the Irish, that 'morally and intellectually they are an inferior race.' 'The whole wealth of the Lowlands, if it were now poured into the Highlands, would wither away, as if under the judgement of Heaven, among the idle hands of this people.'79 In advancing schemes for the improvement of medical services for their people, the parish ministers and medical practitioners of the Highlands and Islands were as voices crying from the wilderness. They were appealing on behalf of a distant and alien race whose predicament was the 'fruit of their vices.'80 Help was being demanded from the industrious people of Britain, and to give such aid would be against, not only the popular principle of self-help, but the successful government doctrine of laissez faire. The RCPE was well aware of the views of the public. But it was sympathetic, in principle at least, to the reforms proposed by the ministers and medical practitioners. In his book Observations of the Famine of 1946-47,81 W. P. Alison, a prominent Fellow and former President, insisted that in spite of the many prejudices that had been expressed, the plight of the working poor in the Highlands was essentially no different from that of the working the poor elsewhere in Scotland. In 1852, the Council of the College was of a mind to promote the idea that there should be state intervention to correct 'the evils of deficiency of medical aid' and particularly the 'anomaly of the very poor, who are recipients of parish aid, receiving more attention than those who are in comparatively independent circumstances, although unable to pay for medical aid.'82 However, after some weeks of consideration, the strength of both public and government opinion was admitted and 'keeping in mind that the College should never aim at any object which they are unlikely to obtain'83 it was decided to let the matter drop for the moment. The College was already deeply engaged in a campaign that seemed more urgent and more promising of success. Its President, Sir James Y. Simpson, along when many others in the profession in Scotland, was concerned that doctors were being 'admitted to the honour of that name without learning.'84 Along with other medical bodies the College was pressing for the reforms soon the be embodied in the Medical Act of 1858. The College gave first priority to ensuring that the public in Scotland would be able to rely on the competence of their medical practitioners but did not lose sight of the need to make competent medical services available to those who urgently required them. In August 1852 the College published a Statement Regarding the Existing Deficiency of Medical Practitioners in the Highlands and Islands setting out only the statistics gathered in the inquiry inquiry. The radical proposals for some from of state medical service for the working poor, the great majority of the people of Britain, were not included and John Coldstream's correspondence was consigned to the College Archive. In 1852, proposals for state intervention, to provide essential medical care for those for whom it would otherwise be unaffordable, were out of their time. But in 1913, the same ideas reappeared in the creation of the Highlands and Islands Medical Service, the first comprehensive and free state health service in Britain, and the forerunner of the National Health Service thirty five years later. Unlike the Poor Law (Amendment) Act introduced for England in 1834, the Scottish Act required that the provisions for the welfare of paupers must include personal medical care. It was assumed that this innovation would benefit, not only the paupers in every parish, but the population in general since it would ensure the presence of a resident doctor in parishes 'where otherwise there would have been none.'85 From the beginning social reformers in Scotland forecast that the provisions of the new Act would prove to be inadequate. For over a decade they had argued that state support should be given, not only to those who had been forced by circumstances into pauperism, but also to those able-bodied poor who found themselves, for whatever reason, unable to provide for their families. The new Poor Law might establish a doctor in every parish but only the paupers were entitled to his services without charge. In little over a year the inadequacy of the new medical provisions became all too clear. In 1845 the potato blight, Phytophthora Infestans, descended on Ireland destroying the essential source of nourishment of the population. By the late summer of 1846 the same fungus had spread to Scotland and the potato crop in many parts of the country was 'all but a complete failure.' The calamity was felt most severely in the Western Highlands and Islands where the mass of the people were more dependent on the potato than those elsewhere in Scotland and, living constantly at subsistence level, never more than one harvest away from scarcity and hunger. In the ten years of this 'Great Highland Famine'86 suffering was made worse by the lack of medical services for the sick. In the winter of 1850-51, those with the immediate professional responsibility for the welfare of the people of the Highlands and Islands, the parish ministers and the local general practitioners, described 'the lamentable condition' of their people and reported that the great majority of the sick in their parishes 'certainly cannot procure the services of a medical man.'87 In correspondence with the Royal College of Physicians of Edinburgh, ministers and medical practitioners alike, urged that medical aid must be provided for the able-bodied poor, the overwhelming majority of their people. Already in 1851 they had come to understand that the great deficiencies in medical services in their parishes could only be made good by further intervention by the state. They put forward a number of proposals that anticipated the creation and expansion of state medical services that was to take place in the next century. However, in the 1850s their proposals were in conflict with the ideologies of the time and were received in dismissive silence.
|
 |
|