Florence Nightingale and Public Health Policy: Theory, Activism and Public Administration

Paper for Origins of Public Health Policy
CSAA Meetings, York University 2006
by Lynn McDonald, PhD
University professor emerita, Dept. of Sociology, University of Guelph

Florence Nightingale (1820-1910) is still typically thought of as the heroine of the Crimean War, the major founder of the modern profession of nursing and a hospital expert. Here I propose to present her rather differently, as a major formulator of public health policy, in this the 150th anniversary of the launching of her social reform career (on return from the Crimean War in August 1856). There are implications for Canadian policy as well, for our comprehensive public health care system was significantly influenced by Britain, and Nightingale is the source of the earliest vision of a comprehensive public health care system, itself framed within the context of a welfare state or “social safety net” as it is often now called in Canada.

As well as proposing a model for reform Nightingale contributed much practical work to the early stages of implementation. In this paper I will relate the theoretical framework that shaped her goals, the activism directed to their realization (particularly the recruitment of collaborators and use of the media) and her understanding of public administration (especially the role of social statistics in monitoring results), for Nightingale was a social scientist who saw social science research as a tool for achieving important social reforms.

The material for this paper has been taken from original sources gathered for the Collected Works of Florence Nightingale, of which the first 8 volumes have now been published. Volume 5, Society and Politics, and volume 6, Public Health Care, are the main sources for the points made here.

Nightingale’s goals were big, no less than a comprehensive approach to public health care in a broader social welfare mode. She well understood that health status is related to living conditions, especially housing. Hence measures to promote income security, home ownership and pensions were public health concerns. Public works to provide jobs in times of economic downturn (pre-Keynes, let us note) and education for all (an early understanding of human capital theory) needed to be part of social policy, for public health.

Her ambitious goals were grounded first on a religious faith: God made the world and runs it by laws; we can learn these laws by conducting thorough, preferably quantitative, research, and then intervene for good. This is classical theory à la Montesquieu. She was a liberal politically, a supporter of the Liberal Party and various independence movements. Moreover she had seen great reforms actually come into being. Her maternal grandfather, a long-time MP, had worked for the abolition of the slave trade, political rights for Catholics, Jews and dissenters—all of which were achieved. She had met early members of the Italian independence movement, and saw it make headway in throwing out the Austrian occupiers of their country.

Nightingale’s approach to health care was systemic and holistic. She consistently stressed health promotion and disease prevention. The foundations for good health were:

decent housing (a rarity in her day, even for the wealthy);
clean water and air (large numbers died from water and air-borne diseases);
good nutrition (especially a problem for the poor, but lack of standards in the food industry harmed everyone);
safe childbirth (mortality rates were much higher then, both for childbirth and post childbirth from puerperal fever);
good child care (a major subject in her Notes on Nursing) and no child should ever be in a workhouse (when many were).

Yet, even with the best of conditions—a long time yet in realization—some people would become ill. Her strategy for dealing with illness was again holistic and comprehensive, but note its conservative strain, for intervention can be dangerous:

home visiting by nurse and doctor;
minimal use of hospitals—concern over mortality rates in general (acute-care) hospitals;
linking of general (acute care) hospitals in city centres with convalescent hospitals in the country or seaside.

Means of Social Change

Because the best-intended social actions may have harmful consequences all new programs had to be monitored for their effectiveness. Nightingale had learned from Belgian statistician L.A.J. Quetelet that different medical treatments had negligible effects on outcomes. Also that institutions, like foundling hospitals, with the most benevolent of intentions—saving infant lives—nonetheless had high mortality rates. Her own experience in the Crimean War, carefully written up afterwards in Notes on Matters Affecting the Health, Efficiency and Hospital Administration of the British Army, 1858, showed appalling mortality rates from disease, despite the provision of a system of hospitals. She attributed these terrible death rates to underlying sanitary conditions—soldiers weakened by months of poor food and cold, and then subjected to badly overcrowded conditions when in hospital. The mortality rates did not go down until a visiting team of sanitary experts had the sewer system cleaned out and other engineering work undertaken.

Caution about unintended results led to Nightingale’s insistence that new social programs start small. Get some experience first, she advised: see how the institution (hospital, program, ward, training school, prison, whatever) works before you are committed to large buildings, fixed programs, etc. Nightingale became a pioneer advocate of what would later be called “evidence-based health care,” and did some of the pioneering work in data collection with “uniform classification of disease” so that comparisons in outcomes could be made.

Prevailing Social Theory

The scope of Nightingale’s goals for reform must be seen in the light of the prevailing political and economic orthodoxy of her day: laissez-faire liberalism. This was nineteenth-century Britain with the “iron law of wages” à la Ricardo, and the dismal predictions of overpopulation leading to starvation by Malthus. Herbert Spencer is an excellent sociological example of this mind set, which held not merely that the private sector did things better than government, but that political interference in the economy would be at best futile, at worst cause more problems. The poor had best not reproduce and otherwise accept their unhappy lot. Trade unions and collective bargaining, legislation for minimum wage and minimum standards, measures for welfare assistance, etc., would only result in increasing their numbers—hence more mouths to feed—and greater numbers starving in the future.

Spencer in a paper, “The Coming Slavery,” disagreed with the “vociferously” expressed notion that “all social suffering is removable, and that it is the duty of somebody or other to remove it. Both these beliefs are false. To separate pain from ill-doing is to fight against the constitution of things” (23). His paper was first published in a periodical, later with others in a collection appropriately entitled The Man versus the State. Other titles of papers serve to make the point: “From Freedom to Bondage,” “The Sins of Legislators” and “The Great Political Superstition.” Beatrice Webb, in her development as a social investigator and later a socialist, had to come to terms with this ideology, nicely demolishing it in My Apprenticeship.

Karl Marx and fellow Marxists of course were staunch opponents of laissez-faire liberalism. So also were a great range of social reformers: democratic socialists, Christian socialists, trade unionists and advocates of producers co-operatives, factory legislation and other minimum standards legislation, educational reformers and promoters of savings banks, credit unions and friendly societies, Chartists and suffragists (for the working class and for women). The great difference between these two broad groups of reformers versus revolutionaries is that Marx and company, with the political economists, believed that capitalism could not be reformed. But the Marxists believed it could be overthrown, and would be when the contradictions between the forces and means of production were sufficiently strong. Nightingale and a great range of reformers, some as strong in their condemnation of capitalism as the Marxists, yet believed that reform within the system was possible.

Classical social theorists who omit Nightingale from their teaching and their textbooks miss a great opportunity for analysis. There were (and are) three great approaches to capitalism: acceptance as inevitable (the political economy approach), overthrow à la Marxism, and reform (of which Nightingale’s vision is one of the boldest and most comprehensive). Social theorists and authors who omit Nightingale lose this fine and clear set of alternative treatments of capitalism.

Political Activism towards Public Health Reform

Nightingale was an astute political actor. Although as a woman she did not have the vote she knew the political process well and was on friendly terms with many of the leading, especially Liberal, leaders. Her status as heroine gave her a hearing also with Conservative politicians and senior bureaucrats. She used her connections to the hilt for her causes.

A “Nightingale method” can be discerned in her approach, although she never set it out as such. Nowadays it appears as simple, common sense; it will be quite recognizable to anyone who has taught basic methods of social research:

Get the best information available in print, especially government reports and statistics;
Read and interview experts;
If the available information is inadequate, send out your own questionnaire; test it first at one institution and consult practitioners who use the material;
In report writing send out a draft to experts for vetting before publication.

Because she was so careful in the material she produced she had great credibility. She provoked controversy, too, for she was often dealing with difficult issues and often her recommendations were far reaching. But by and large politicians and opinion leaders open to a reformist approach knew they could rely on the papers and reports she produced.

Nightingale had a large number of people she could call on for expertise. She of course was not a doctor, indeed had never even gone to school, let alone university. Leading public health experts like John Sutherland, Edwin Chadwick and William Farr worked with her behind the scenes to prepare material and later to defend it when it was attacked.

Implementation was the point, so there had to be a strategy for moving from a set of recommendations to their legislation or realization otherwise in programs.

Reports are not self-executive; implementation must be worked out while the report is being written
specific actions by specific agents, institutions, government departments, etc., must be identified and assigned;
the report must circulate through opinion leaders to the public; hence reviews in academic journals, the leading “progressive” periodicals and such high-status newspapers as the Times must be sought;
the political system has to be worked: Cabinet ministers, senior public servants, back-bench MPs, committees; briefings have to be arranged for and questions drafted; these actors themselves have to be motivated, one of the purposes of the reviews, etc., immediately above.

A fine example of Nightingale’s activism, tempered with social science research, can be seen in the introduction of trained nursing into the dreaded workhouse infirmaries of Britain. These institutions, run by the local Poor Law board, were the “real hospitals of the sick poor,” housing five patients for every one in a regular civil, i.e., fee-paying, hospital. This, in my view, is one of the most important achievements of Nightingale’s career, and the British National Health Service is scarcely imaginable without some such reform as hers being first instituted.

In Canada the major formulator of our public health care system of course was T.C. Douglas, premier of Saskatchewan in the 1940s when the major components of Canada’s system were first legislated, and from which the national system was developed in the 1960s. While Douglas’s work took place nearly a century after Nightingale’s, a comparison of the two might be of some interest to sociologists. Both were visionaries with a strong religious faith grounding their work (Tommy Douglas was a Baptist minister, much influenced by the social gospel tradition in the Christian church). What may not be realized is that Douglas had a considerable amount of social science training, as well as theological; he notably studied “Christian sociology” at the University of Chicago, effectively applied sociology. For both persons religious faith was accompanied by political beliefs nourished by the Enlightenment, Douglas’s more left wing than Nightingale’s, but he early on gave up on the public sector running the economy, so that their differences in social policy would have been a matter of degree, not kind. Both were hugely ambitious in the scope they saw for planned change, the possibility of applying social knowledge to make society better.

Douglas also shared Nightingale’s insistence on not doing too much too soon: “piecemeal socialism” it was jokingly called. Saskatchewan pioneered many social reforms, including the first bill of rights in Canada, but the great reforms in public health care were brought in gradually, when they could be afforded (he even paid down the debt his government inherited in the course).

The establishment of an efficient public service, with appointments based on merit, not political connections, the awarding of contracts through competitive bidding, not patronage and kickbacks, were related reforms. Not only were such reforms morally an advance over existing practice, they were necessary for the effective administration of the greater number and range of programs the government wanted. Both Nightingale and Douglas saw a highly-trained, properly-appointed civil service as key elements in the development of public health care. Nightingale tried to get applied statistics, Quetelet’s “social physics,” introduced into Oxford University, the institution that trained the most senior civil servants and politicians.

The major source at the national level for Canada’s welfare policy was the Marsh Report, 1943, Report on Social Security for Canada, presented to the Special Committee on Social Security. It makes for an interesting comparison with Nightingale’s model of nearly a century earlier; it is far more detailed and comprehensive (although housing is not a topic). It offers a concerted plan for how to get there from here. The case for “adequate medical care” is made as “a basic need in itself, required by all members of the population” (55). “Physical fitness” in turn is justified as a matter of public interest, like education and examples of other countries that had already provided for it are given. Even so, Canada’s national medicare dates only from 1965 with the Canada Health Act, a Liberal government under Lester Pearson finally acting, now a full century from Nightingale’s early vision.

Statistical Monitoring in Public Administration

Nightingale’s best biographer, E.T. Cook, called her a “passionate statistician” with reason. Statistics were a crucial element for ascertaining if the intended results were actually being achieved. Good intentions, as noted earlier, were no guarantee of benevolent results.

The importance of accurate and relevant data to guide actual work became clear through the disasters of the Crimean War. After the war (1854-56) in which seven soldiers died of (preventible) disease for every one who died of the wounds of war, Nightingale got a royal commission established to investigate precisely what went wrong and how to prevent such tragedy in the future. In the course she soon learned that the reports sent back from her hospital to the commander in chief of the army, and to the minister for war in London, were grossly misleading. The principal medical officer cited statistics of death and sickness as percentages, e.g. 0.5 percent deaths, without noting that these were the deaths per week. The normal practice was to cite rates per annum, so that the number would be 52 times greater; if 0.5 percent of an army continued to die per week, it would soon be wiped out. The establishment of a statistical department was one of the most important recommendations of the report, which was in fact done. Nightingale herself helped to design the forms to be used for data collection.

The 1861 International Statistical Congress was held in London, not long after the royal commission reported. Nightingale’s contribution was two papers, each only a page long, on uniform hospital statistics. It was crucial that outcomes be comparable from institution to institution, country to country. She continued throughout her life to make similar recommendations, and assist with questionnaire design to the end of collecting useful comparable data.

The lack of comparable data we know remains a problem, now roughly a century and a half later, even in countries, like Canada, with sophisticated data collection agencies like Statistics Canada. Recently data were reported which show that hospital errors (accidents and incorrect medication) are a major cause of death. Yet along with these reports came the information that precise comparisons among hospitals on this point cannot be made because there is no common way of collecting and reporting such data.

Conclusions

How useful is Nightingale’s work for solving the public health problems of today? Obviously medical science has changed so much in intervening years, making expectations of cure so much higher than in her time. Other technological changes have changed the functioning of hospitals (she assumed large wards, for a nurse had to be able to see each patient, whereas now there is electronic monitoring, call bells, etc.). Yet her goal of quality care for all is still worth remembering, especially in Canada where we risk a return to the “two-tier” system we thought our public medicare system got rid off.

Nightingale’s urging of rigorous quantitative research on results is still to be acted on (her start got little follow-up). It is risky for institutions, for they can look bad, but essential for the system as a whole, for us as patients and taxpayers. As costs skyrocket and competing claims become harder to prioritize we see a renewed turning to statistics to help make those decisions. The reduction of wait times certainly needs careful statistical monitoring, but there is enormous opportunity for unintended consequences: reducing wait times for certain procedures by sidelining other patients with perhaps more pressing needs. Hospitals with too high mortality rates for certain operations brought them down, by increasing the numbers of lower-risk patients given the same operation (possibly a good thing, but possibly not).

Nightingale chose her fields of endeavour for their potential to save the most lives, for reformers fundamentally are utilitarians. That’s why she worked on the great administrative reforms to achieve public health. It’s why fighting the cigarette companies today is a good thing; others with similar motivation might choose the fight against HIV/AIDS. Poverty, lack of clean water, and now increasingly polluted air were Nightingale’s targets and should be ours, too, certainly internationally, and still often enough for Canada. Saving the environment, in the face of global warming, resource depletion, increasing pollution and declining biodiversity, are the subjects for today’s ambitious activists.

References

Cook, E.T. The Life of Florence Nightingale. 2 vols. London: Macmillan 1913.

Marsh, Leonard C. Report on Social Security for Canada. for the Advisory Committee on Reconstruction. Ottawa: Cloutier 1943. presented to the Special Committee on Social Security on March 16, 1943, by Hon Mr Mackenzie, Minister of Pensions and National Health.

McDonald, Lynn, ed. Florence Nightingale on Society and Politics. volume 5 of the Collected Works of Florence Nightingale. Waterloo: Wilfrid Laurier University Press
— Florence Nightingale on Public Health Care. volume 6.
— The Party That Changed Canada: The New Democratic Party Then and Now. Toronto: Macmillan 1987.

Nightingale, Florence. Notes on Matters Affecting the Health, Efficiency and Hospital Administration of the British Army founded chiefly on the Experience of the late War. London: Harrison 1858.

Spencer, Herbert. The Man versus the State. Caldwell, Idaho: Caxfor 1960 [1884].

Webb, Beatrice. My Apprenticeship. 2 vols. Harmondsworth: Penguin 1938 [1926].

Abstract

“Florence Nightingale and Public Health Policy: Theory, Activism and Public Administration”
Paper for Origins of Public Health Policy
CSAA Meetings, York University 2006
by Lynn McDonald, PhD
University professor emerita, Dept. of Sociology
University of Guelph

This paper presents Nightingale’s proposals for public health care within the context of a broad social welfare system. Her goals, practical methods towards their achievement and the role of public administration and statistics are set out. Comparison is made between her conceptualization and that of T.C. Douglas, “father of medicare” in Canada.

Nightingale’s theoretical work is seen as a major contribution to nineteenth-century classical social theory. Her position is contrasted with that of the political economy school (to her right) and Marxism (the revolutionary left). The omission of Nightingale as a major classical theorist, it is argued, means the omission of a major exponent of the mainstream reformist middle of social theory.