The nation’s doctor and the COVID-19 pandemic

The coronavirus pandemic of 2019/2020 has put the spotlight on the role and personality of the Chief Medical Officer for England to an extent that has rarely been the case since Sir John Simon (pronounced Simone), first held the equivalent position in 1855. This prominence in the public eye of the latest incumbent, Professor Chris Whitty, has led to his being described by the Sunday Times as Britain’s most powerful unelected official and ‘Captain Sensible’. ¹ The increase of over 20% in the number of applications to medical school in 2021 is being attributed to his contribution during the greatest public health emergency for 100 years. So how does that contribution compare with that of his predecessors and what does it tell us about the characteristics most needed to fulfil the roles and responsibilities of The Nation’s Doctor?

The origins of the post of Chief Medical Officer date back to the early work of local public health pioneers who cut their teeth on the cholera epidemics in the slums of Victorian England. Best known among these are Liverpool’s William Henry Duncan, who became the world’s first full-time city Medical Officer of Health and the widely celebrated John Snow. Born in York, Snow completed a medical apprenticeship in Newcastle upon Tyne before making his way to the Hunterian school of medicine in London to complete his formal medical education, going on to achieve notoriety and fame for pioneering the use of anaesthesia in Queen Victoria’s last two confinements and taking the handle off the pump in Broad Street, Soho to intervene in the local cholera outbreak there in 1854.^2,3

These local figures had their national equivalents in the London utilitarian philosopher, Jeremy Bentham, for whom what mattered in public policy was ‘the greatest good of the greatest number’, and his disciple, Manchester-born lawyer and social reformer, Sir Edwin Chadwick. Chadwick’s ‘Report on The Sanitary Condition of the Labouring Population of Great Britain’ was the first example of a national analysis of inequalities in health and paved the way for local public health action at the local level, shepherding through the first Public Health Act of 1848 as Commissioner of the Central Board of Health together with its medical adviser, Southwood Smith. Chadwick was a force of nature who did not suffer opponents to his ambitions for sanitary reform lightly, alienating many, including The Times newspaper that published a letter declaring that ‘we would prefer to take our chance with cholera than be bullied into health’.

The General Board of Health was abolished in 1854 to be replaced by a new Board of Health in which medical advice was given a much more prominent place than that sought by Chadwick, who had been much more enamoured by the contribution of engineers. It was into this space that stepped John Simon making his claim to the provenance of Chief Medical Officer that we understand today, although it was to be a further 70 years before the various iterations of the Board of Health with its relationships to the Poor Law and local government administration would lead to the formal position within the new Department of Health in 1919.

When Simon was appointed in 1855, he brought with him seven years’ experience as Medical Officer of Health for the City of London, the first such position to be created under the 1848 Act, which had drawn on the Liverpool experience in creating a general enabling power for local authorities to create such positions. Simon was to prove a formidable operator during his 21-year tenure providing a blueprint for the role for many of successors who were drawn from a background as local Medical Officers of Health, were imbued with a commitment to evidence-based practice, drawing down timely statistics to inform policy and practice, supplemented by investigations, inspections and surveys.

Simon pioneered and initially secured the professional independence of his advisory role with both right of access to ministers and right of report to the public. In managing the tension between serving the public, the government or his professional colleagues in the medical hierarchies and institutions, he steered a path which was to become familiar to each of his successors. ⁴ In laying down the foundations of what came to be known as ‘State Medicine’, both personality and personal ability were crucial, not least when it came to dealing with vested interests whether they be professional or commercial. A man of principle as well as immense energy and ability, Simon resigned from his position when over-centralisation threatened his vision of a strong central public health function in lock-step with a strong locally based system grounded in professional freedom of action.

Such integrity was not to be found among all those who followed him. Notable among those not living up to the standard laid down by Simon was John Charles (CMO 1950–1960), whose tenure was extended by two years from the normal retirement age of 65; in their book, ‘The Nation’s Doctor’, Sheard and Donaldson imply that this may have been on account of his compliance with the tobacco industry in the face of the emerging evidence on the link between tobacco smoking and lung cancer and the opposition to taking action among significant parliamentary forces.

While some of the 14 Chief Medical Officers covered in Sheard and Donaldson’s book may not have lived up to the high standard presented by Simon, others have been recognised as having provided outstanding leadership and done credit to their public health predecessors. While the onerous nature of the job is clear, this has particularly been the case during national or public health emergencies and times of significant social upheaval and change. One of Simon’s remarkable achievements was in establishing a career path into which no fewer than four of his contemporary colleagues would step: Edward Cator Seaton (1876–1879); George Buchanan (1880–1892); Richard Thorne Thorne (1892–1899); and William Henry Power (1900–1908). The downside to this dynastic progression, and that has continued since, has been the domination of the position by men from London and Edinburgh elite backgrounds who have been well connected to the medical royal colleges and in government and higher civil service circles.

Only one woman, Dame Sally Davies, has to date breached the male bastion, and it is only in recent times that ‘outsiders’ from the civil service club have held the post. Although once proper training in the form of the Diploma in Public Health was established in 1889, it became the norm for Chief Medical Officers to hold the qualification. Henry Yellowlees (1973–1983) broke the mould as the first Chief Medical Officer in the Department of Health not to hold the qualification, a reflection of the increased dominance of clinical, National Health Service issues over the broader public health after the establishment of the NHS. When Donald Acheson succeeded him in 1984, Yellowlees told Acheson to expect public health to make up only 5% of his time. ⁴ Despite this, Donald Acheson will go down in public health history as somebody who rose to the challenge of the new HIV virus, causing AIDS, in the 1980s, and is best remembered for this proactive and highly professional stance, simultaneously rescuing public health from the backwater into which it had been becalmed following the demise of the position of Medical Officer of Health in the 1974 Local Government reforms. ²

Also stepping up to the mark and worthy of special recognition as following in Simon’s footsteps are Arthur Newsholme (1908–1919), the first Chief Medical Officer to be ‘headhunted’ for the job and the first ‘outsider’, who oversaw the transition from environmental to preventive medical approach in public health ideology and was in post during the influenza pandemic of 1918–1919 but was undermined by his successor, George Newman (1919–1935) who flashed across the public health sky but faded; and William Jameson (1940–1950) and Sir George Godber (1960–1970) who can be seen as the Chief Medical Officer midwives of the NHS in the teeth of professional opposition. Jameson, having been Medical Officer of Health for Hornsey, and also studied for the Bar, became the first professor of public health in London University, later becoming Dean of the London School of Hygiene and Tropical Medicine before becoming Chief Medical Officer; an outstanding example of the integration of academia with practical service. Godber, in particular, was a rare example of somebody who had senior experience from outside London, having been seconded to Birmingham during World War II, where he administered the Emergency Medical Services, liaising with the local Medical Officers of Health and the Ministry in London.

In recent times, the core skills and aptitudes and experience necessary for the formidable task of Chief Medical Officer have become blurred. For while Sir Liam Donaldson (1998–2010) was the first Chief Medical Officer to have undertaken a comprehensive five-year postgraduate public health training following the Acheson initiative of the 1980s, Dame Sally Davies (2010–2019) was a clinical academic and Department of Health Director of Health and Development, a position she continued to hold while being Chief Medical Officer. In his term as Chief Medical Officer, Liam Donaldson managed to straddle the agendas from population healthcare to health policy belatedly rectifying the legacy of John Charles by ensuring the passage of the Health Act of 2006, which included tobacco control in public places. Professor Chris Whitty (2019–) brings to the position a clinical and epidemiological academic background, and while having had research experience in infectious diseases, has not completed a formal public health training; in fact, when the COVID-19 pandemic struck, only one of the four UK Chief Medical Officers (Frank Atherton in Wales) could claim such a grounding.

It is too early to measure the performance of the current Chief Medical Officer in relation to the current public health crisis. Certainly, there has been much criticism as to how the UK government responded especially in the early days and to date in excess of 150,000 lives have been lost to the virus, many of them needlessly. ⁵ The skill set necessary to make an optimal contribution to protecting the public at a time of public health emergency has been rehearsed many times since 1855: Simon’s ‘broad and far reaching science’, leadership and communication skills, ethical and moral values and an ability to speak truth to power, a solid grounding in the biological and social sciences and practical interventions going well beyond the bio-medical, (while keeping the clinicians on board), political and administrative ability of the highest order and an abundance of stamina. To which I would add ‘a clean mind and dirty hands’. From the earliest days, Simon was concerned about the necessary qualifications for sanitary engineers and Medical Officers of Health; I wonder what he would have to say in 2021?

For Sheard and Donaldson, the job of Chief Medical Officer is what you make of it. ⁴ Faced with COVID-19, would any of Chris Whitty’s 16 predecessors have been able to make a bigger fist of it? When Donald Acheson was confronted with the HIV virus and the challenge of persuading a prudish administration to embrace policies that ran against its grain, Sheard and Donaldson were to conclude that ‘He proved to be the right man in the right place at the right time’. Only history can be the judge of whether the current Chief Medical Officer deserves the same epithet.