Comment for Edinburgh News
by Lynn McDonald, published 31 October 2006.
When Florence Nightingale visited Edinburgh 150 years ago (in September 1856) she had only just returned to Britain as the heroine of the Crimean War. En route to Balmoral Castle, as the guest of Queen Victoria, she stopped in Edinburgh to strategize with a public health expert and ally, Sir John McNeill.
He, the Queen and Prince Albert all helped her to persuade Lord Panmure, the war secretary, to launch a royal commission on the tragic errors of the Crimean War. In that war seven soldiers died of disease for every one who died of wounds and Nightingale resolved that such should not happen again. Her career as a public health and social reformer dates from that royal commission, where she honed her methodology and in the course invented the famous “pie chart,” to show graphically how great preventible mortality was—then to argue how to prevent it.
The methods that Nightingale developed are still useful: good quantitative research, “evidence-based health care” as it is now called. Nightingale believed that God made the world and runs in by laws—she was a woman of faith as well as a social scientist. The best statistics were required to ascertain what needed to be done. Ongoing monitoring was required to ensure that what was done actually had the desired effect—for unintended consequences could be disastrous.
Always start innovations in health care small, and research the results before generalising them. Thus in introducing training for midwifery nurses in London in 1862 Nightingale began with a small number of beds at King’s College Hospital. In proposing the introduction of professional nursing in Indian military hospitals she recommended starting with only a few. Perhaps her greatest reform, bringing nursing into the workhouse infirmaries, began in one, the Liverpool Workhouse Infirmary, funded by a Liverpool philanthropist, William Rathbone. Nightingale’s intentions were for general reform, indeed the virtual abolition on the workhouse system, but the improvements had to be shown to work in one place before the vast workhouses in London and the industrial midlands could be tackled.
In Edinburgh in 1856 Nightingale was taken by the distinguished Dr James Syme to visit that “beastly” and “wretched” place, the Royal Infirmary. She was pleased when the Nightingale Fund was asked to take on the nursing of this “den of thieves” in 1872. Its night nursing was especially notorious. As Nightingale explained to the grand duchess of Baden, it was the duty of the senior house surgeon to see that drunken night nurses were carried into the wards on a stretcher.
The Nightingale School sent a superintendent and head nurses to start up the new system. Getting a tough enough night superintendent was, understandably, a challenge.
Nightingale recalled, when on their third, that the first had “really effected a reform in that lawless place among the drinking, profligate (old) night nurses.” The second proved not to be strong enough “for such a place.” The needed candidate was a “not young, but wiry woman—good on her legs and in her head—absolutely trustworthy and with something of the missionary spirit. For nothing that I had ever known of war hospitals surpassed the wickedness of this Edinburgh Infirmary when we first entered it.”
The Royal Infirmary in Glasgow, alas, was no better, a “detestable place” in 1861 when her advice was sought about materials for a new building: “The best thing that could happen to the Glasgow Infirmary (and what would save much human life) is that it should be burnt down. There will be no other safety for it,” she wrote.
Nightingale’s method and drive are still useful models for today. She took on the greatest challenges of her day—health care for the poorest and even famine in India. Today she would be in the “tobacco wars,” for smoking kills more people than combat. Administrators concerned about the large number of hospital-induced diseases and deaths might usefully reread her 1860 paper on hospital statistics. Comparative statistics, collected on a uniform basis, she insisted, are essential for assessment and improvement.
Nightingale’s ideas on ventilation in hospitals would now seem to be hopelessly out of date: open the windows, cross ventilate, keep the number of people breathing the same (foul) air as small as possible.
Today climate change is our greatest challenge, and the possibility of massive disasters from polar melting and oceans rising go beyond all the normal planning of public health experts. Nightingale’s approach would be to go to the causes, to look at the social and economic links with the biophysical world.
Climate change arguably changes everything. We have to rethink how we live, work, eat and travel. Nightingale’s bold approach to public health and social reform are a useful example of the depth of rethinking needed, and her methodology still works.
Lynn McDonald is university professor emerita at the University of Guelph, Ontario, a former MP, and editor of the Collected Works of Florence Nightingale. She is giving a lecture organised by the Centre for International Public Health Policy on Thursday at Edinburgh University on Teviot Place, entitled Public Health Care: From Florence Nightingale to Climate Change, from 1 p.m. to 2:30 p.m.