Public Health Crises – Exploring Britain’s Medical History

Over the last 600 years, Britain has faced its fair share of public health crises. In this episode, we are investigating four deadly pandemics and epidemics that changed life in the UK: the Black Death, cholera, the 1918 influenza, and the HIV/AIDS epidemic.

Hear unique insights and stories from our records and learn about the long history of public health responses in Britain. How did outbreaks from the past affect real people and how did they change Britain?

Documents from The National Archives used in this episode: C 54/185 m.20d; C 74/1 m.18; CAB 24/71/8; E 163/22/2/60; FO 383/398; HO 44/25; MH 13/47/207; MH 13/53; MUN 4/3702; PC 1/109; PREM 19/1863.

Discover more about cholera as well as Tudor quarantine and social distancing in previous What’s On talks.

Find out more about outbreaks by watching a series of films created as part of the Outbreak to Archive project with a group of young people, and film-maker Nigel Kellaway, in the summer of 2020.

Listeners, we need your help to make this podcast better! We need to know a bit more about you and what themes you’re interested in. You can share this information with us by visiting


[Intro – clips taken from the episode set to music]

Euan Roger: This is On the Record at The National Archives: uncovering the past through stories of everyday people.

I’m Euan Roger.

Sarah Castagnetti: And I’m Sarah Castagnetti.

Euan and I are both historians at The National Archives in Kew, West London, where we research, look after, and help our audiences better understand the Archives’ collections of historical government and public records, records that date back over one thousand years.

Euan: Our job is to help the public understand and use the records in our collection. And during the current pandemic, we’ve seen an increase in interest in our public health records. So, as we near the one year mark since the first UK lockdown, we’re going to spend this episode investigating four stories of epidemics and outbreaks from 600 years of British history: the Black Death, the cholera pandemic, the deadly 1918 influenza, and the HIV/AIDS epidemic.

Sarah: Usually, if we wanted to learn more about the Black Death, Euan and I could have just walked over to chat with our colleague Paul Dryburgh at his desk,

Euan: …and I’d get there first as my workspace is closer than yours…

Sarah: but since we’re all working from home right now, we gave Paul a call to ask him what little-known facts and stories our records can tell us about the much-studied medieval plague.

But before we continue, please note that this episode contains descriptions of disease and mention of sexual acts which may not be appropriate for all listeners.

[outgoing ringing tone]

Paul Dryburgh: Hi everyone, so I’m Paul Dryburgh. I’m one of the medieval records specialists at The National Archives, and effectively that means that I research our old collections, so anything from Domesday Book in the 11th century, all the way through to the Reformation, really, in the 16th century. But I specialise in the 14th century, which is going to be the topic of our conversation today. And I look at things like warfare, government, politics in that century.

Sarah: Paul, I think most people know what the Black Death is, but can you just give like say a 30-second summary of the plague?

Paul: Okay. Well, I can try. The Black Death or the plague isn’t just one event. There are three major episodes. There was something called the Justinian Plague in around 500 to 750 AD. Then there’s the Black Death, the bubonic plague, which lasts from the 13th century all the way through to the 18th century. And then there’s the modern plague, which has kicked off again in the 19th century, and is still hanging on today in places around the world.

The Black Death, in our context, in the British Isles, its main outbreak was in 1348-9, and it affects all of England, Wales, Scotland and Ireland. It develops in waves across the 14th century. So in England, you have the first episode, 1348/9, but you have subsequent waves in 1361-2, 1368-9, 1375, and it seasonally recurs.

So it’s probably the deadliest pandemic in history. And I mean that in terms of both the numbers killed and the percentage of the population who died from it. Estimates of deaths in England are around 40 to 50%. I think there was a study done on London, and that comes out at around 50% of the population dying in that short couple-of-year window in the middle of the 14th century. But obviously, some places were much lower, and others even above 70%. It can be really, really destructive and devastating in certain areas.

Effectively, it’s an incredibly rapidly-spreading epidemic disease. It’s caused by the bacteria called Yersinia pestis. Usually, it comes from being bitten by an infected flea, and so if you were bitten and you were infected, you tended to get symptoms like fever, a headache, you felt really weak, and then you started to develop swellings–tender and painful lymph nodes which are called buboes, which is obviously where the bubonic plague comes from. They would tend to be filled with pus, and it would be really nasty and horrible. Effectively what the bacteria does though, according to the scientists, it cuts off the ability of the body’s cells to communicate with the body’s immune system so it can’t fight the disease, and it rapidly sends you downhill, and it’s a very nasty and painful death.

Sarah: That sounds completely appalling. I’m struggling to comprehend the idea of 40-50% of the whole population not just being infected but actually dying. I can’t begin to imagine what that must have been like for the survivors – watching half your village or community dying within a few years – literally one out of every two people – it’s like a post-apocalyptic film.

Paul, can you tell me more about how we know so much about the Black Death?

Paul: The one thing from a record-keeping perspective, which is why we know so much about it, is it’s the first widely-recorded mass incidence of disease. Record-keeping in England at least kind of starts in the early 13th century. The English royal government starts recording its business; it takes copies of material it sends out, so we can see that as the archive of the royal government develops, you’re going to find out more about what’s going on in the country. And so we hold lots of records, both of the national government and local records that shed light on the Black Death.

Sarah: Most people in the UK probably know about the Black Death and have an idea of what it was, so let’s give them some details they might not have heard before. What do we have in our records that’s particularly interesting?

Paul: One of the key things that we enable researchers to look at is what the government response was. And actually, you can see a lot of what the government does is an early response, kind of a public health-type response. As the pandemic spreads, you can kind of see government shutting itself down. So in January 1349 for example, a couple of months in, they close all the law courts.

We have a really brilliant entry on the close roll, so that’s copies of letters that go out from the Crown.

And basically, Edward III, who’s King at the time, tells the mayor and citizens of London that they have to stop the throwing of human faeces out of domestic dwellings into the tight little streets of London. They have to send the carts in to remove it as far away … because the air is infected and the city’s poisoned. So there was an awareness that the miasma there and the poisonous air could be a real issue, and there is obviously an attempt to clean the streets and try and avoid some of the worst issues.

But it doesn’t really work in the short term. Even people really high up in government, like the Chancellor, dies. This is a disease which kills everybody across society. This isn’t necessarily a disease that is restricted to the poor in society, although disproportionately those that live in unsanitary conditions are going to be worst affected.

The other thing and a public health issue, of course, is as you can imagine, the bodies pile up and churchyards around the country just cannot cope with the amount of dead that are being brought to them. So in London particularly, there’s a new burial ground consecrated near Smithfield, and apparently at its height, over 200 people there are being buried per day, and the Bishop of London and a really prominent knight called Walter Manny, they come together and they work to purchase land near to property owned by St Bartholomew’s Hospital.

And they set up a chapel, where priests can pray for those who’ve had to be buried so quickly, because obviously if you die really quickly, nobody’s there to pray for you. Nobody’s there to speed your soul to Heaven. So by creating this new plague chapel, the Bishop of London is hoping that spiritually, those people who have died are going to find some succour in the afterlife.

Sarah: For medieval Christians, how you died had a big impact on your afterlife. Ideally, you would pass away at home in your bed; friends and family would gather around you, and a priest would take your final confession and administer your last rites. Without these last rites, you faced a longer stay in purgatory or even hell.

So thousands of people dying suddenly without a priest to pray for them was a spiritual crisis on top of a physical one. And in some sense, society had a better infrastructure for addressing the former than it did the latter. And the public health style response of the Church can of course be found…in Church records.

Paul: So in 1362, for example– this is another entry from the York Archbishop’s registers–there’s a village called Stainburn in West Yorkshire, and the parishioners there actually petitioned the Archbishop of York and they ask if they can not bury their dead in their parish church, they say it’s five leagues from their parish church, which means that they’re going to have to cart loads of dead bodies across trackways that are already flooded. They say it’s inundated by the winter, so they’re asking if they can have temporary permission to bury their dead in just this local church, which is just a chapel in this particular parish.

The Archbishop says, “That’s fine,” but as soon as the pestilence has passed, then the bodies again will be buried in the parish church, so the parishioners will then have to travel those five leagues. So you can see even in very rural, very urban settings, some of the issues are pretty similar, and you can’t imagine being one of the survivors or those that live through this having to deal with just being surrounded by the dead, by suffering on a daily basis, and actually having to just come up with practical solutions to crises that you’ve got no medical solution for.

Sarah: Paul came across this request to the Archbishop while working on a special inter-archive project.

Paul: So the Northern Way project is a collaboration between The National Archives, the University of York, the Borthwick Institute at York and York Minster. My role is as co-investigator, and I lead a researcher at The National Archives looking to find records in the government archive that relate to the administration of the Church of York in the 14th century, but also how that Church interacts with government.

And one of the things that jumps out at you really from the pages, is just how high the mortality is; and it will say, “This church is vacant because of the death of the previous incumbent” actually have two or three vicars of that same church within the next 18 months, because just the death rate is so high.

Sarah: So what do we know about how everyday people experienced the plague? What was it like to live through it, and how did people have to respond, or how did they adapt so that they could protect themselves?

Paul: In terms of how people reacted, there’s some spiritual solutions as you’d imagine, and there’s also some practical solutions. In terms of spiritual… there’s a really, really good entry in one of the Archbishop’s registers from February 1357, so it’s eight years after the plague has struck in Yorkshire. And Archbishop Thoresby, the Archbishop of York, he basically tells a guy called Brother Hugh of Collingham, … And he was asked to absolve a lady called Isabella, who was the wife of John Dogmersfield, from a vow that she’d taken during the time of the pestilence. She’d vowed that she was only going to consume bread and water every Saturday for the rest of her life.

Basically the Archbishop says, “Well look, you know, she’s now so suffering from personal bodily infirmity that she just can’t carry on. She’s just going to kill herself.” So he basically says to this guy Brother Hugh, that she is to be absolved from that vow, and that somebody else more convenient is allowed to perform that particular vow for her. She’s obviously so taken aback by the plague. The assumption in lots of people’s minds is that it must be a consequence of sin, that the country is being so badly affected that it must be their sinful lifestyle that’s created this.

Now on a more practical point, we, The National Archives, we’ve got a really fantastic recipe for what is called a cure. Obviously it wasn’t really a cure. The documents say it’s a medicine against the pestilence. And so the document survives, and it lists handfuls of similar herbs and flowers, things like roses, marigolds, sorrel, that are supposed to be steeped together and then drunk in this potion. Now, it’s not going to be effective, but when you think about it, when all you’ve got is home medicine, you’ve got no antibiotics, you’ve got nothing there to help you from a medical point of view, that’s the only realistic thing you can do. You’ve got to access what’s around you to try and come up with something, but again, they just had no idea how the virus was being transmitted, so anything that they’re doing is just not going to work.

Sarah: Wow, ok so how did the plague change society? What were the lasting impacts? I’m sure the answer to this question could fill an entire episode, or more, but what perhaps are some of the most interesting or far-reaching effects of the Black Death?

Paul: Well, I guess the main one is population collapse. Across Europe in the early 14th century, there’d been a really bad famine and episodes of animal disease too, so the plague on top of that caused a massive collapse in the population. In England, we think then around 1300, the population was about six million. By 1450, it’s down to two to three million, basically halved in a century. And those levels from 1300, you only reach them again in the 16th century-ish.

You can imagine just how that depopulation leads to the abandonment of communities across the country. There may be many people listening to this who’ve either heard of or have been to Wharram Percy, the deserted medieval village in Yorkshire, but there were many other deserted medieval villages across the country.

You can’t really imagine just how horrifying it would have been for those where the plague strikes. Death is round every corner, kind of thing. Your whole family or large parts of some communities are going to be wiped out relatively quickly. Obviously I’ve already mentioned the difficulty of coping with vast numbers of dead bodies, but at The National Archives, we have what are called inquisitions post-mortem, so when somebody who holds lands from the Crown dies, there’s normally an inquisition to see who the next heir is and what the value of those lands are. And so in the years between 1348 to 50, for example, we’ve got loads and loads of mentions of where the value of the manors have been diminished because of the deaths from plague of all or many of the tenants.

So it’s got a massive impact on local life. You often see things like telltale phrases in the Latin, something like, “These lands have no value, as they are waste due to the pestilence.”

Obviously, government also has to acknowledge that the burdens that were placed on society often couldn’t be met. During the second half of the 14th century, lots of communities receive rebates from taxation, or they’re pardoned from paying taxation. Newcastle-upon-Tyne, for example, gets a pardon from taxes in 1350 and 1352.

However, on the other hand, depopulation does have advantages for those people that survive, because in terms of work, demand massively outstrips supply. So workers can start to demand higher wages. You won’t be surprised to learn that the government and the aristocracy and the employers don’t like this. There’s a statute that’s brought in. And obviously The National Archives holds statutes, so we have rolls on which statutes are recorded, and we’ve got lots of copies of those. And Edward III basically says, he’s reacting against, and I quote now, “…the malice of servants who are idle and not willing to serve after the pestilence without excessive wages,” and that these kinds of servants, both men and women, should be bound to serve, bound to work, and that those who refuse to serve for those lower wages would be imprisoned. It’s pretty bad. And the Parliament says, that “By the petition of the Commons, “and I quote again, “that servants having no regard to the ordinance, but to their ease and singular covetousness, do withdraw themselves from serving great men and others.” So there’s all this hyperbole about the working people basically wanting to work for higher wages, but not really wanting to work for less.

Sarah: If you’re on the side of the peasants in this conflict…and think “these people shouldn’t have had to put up with wage suppression after all they’d just been through with the plague,” you’ll want to hear the next chapter of this story, which you can find in an earlier episode of On the Record called “Revolt: The Story of England’s First Protest.”

And actually, Euan, you were the guest historian on that episode. Would you give us a one-line preview of what happens thirty years down the road in 1381?

Euan: Only one line? Ok, well basically, people are angry, they storm the Tower of London, the Chancellor gets beheaded, and the peasants get slightly fairer system of taxation.

Sarah: And on that lovely note [sarcasm], I’ll turn it back over to you Euan to introduce our next story in this brief history of plague and pandemic in Britain.

Euan: Next we are going to jump forward in history to the early 1800s for a look a Britain in the age of cholera, and to help us understand our records from this pandemic, we’re calling up our colleague Chris Day.

[outgoing ringing tone]

Chris Day: There we go. So, my name is Chris Day. I’m Head of Modern Domestic Records at National Archives and I work to try and enhance the understanding of the records we have of domestic government departments in 1782 to the present day, and I’m really interested in sort of records to do with public health really in the sort of 19th and early 20th centuries…and riots. But that’s another thing altogether.

Euan: Not every podcast can be about riots, Chris. And we already let you talk about them back in our series on Protest, so I don’t want to hear any complaining.

Now, I’ve been told you’ve got a story to start us off that paints a picture of cholera’s impact. So, who was Henry Sibbeth, and why is he in our records?

Chris: So, Henry Sibbeth is a 39 year old sailor from Gateshead in Northern England, and he dies from cholera in 1832 and it’s a pretty brutal case. He’s come off a ship, he’s been to see some friends. His surgeon, who’s the guy who’s described his symptoms, a guy called Simon Bullen, says that maybe he drinks too much, but he’s not unhealthy.

So, this is Bullen’s description of Sibbeth’s demise. So, he says “At 2 o’clock on the 12th of January, he became attacked with a sudden purging and an extreme coldness. The surgeon attended him at nine in the morning. The eyes were then sunken. The countenance had assumed the deathly character and was changed to the blue colour. The pulse could scarcely be felt; it was 70 in number. The tongue was cold, the extremities cramped. He had considerable pain in the epigastric region. He died at 12 o’clock the same morning, retaining his senses to the last. This was a marked case of the cholera, no essential symptoms of the disease was wanting.”

So Sibbeth dies, and he takes 10 hours to die without reporting any symptoms beforehand. And Bullen writes up his account of the disease and it’s pretty harrowing. But the reason he does it is he sends it to the government to publish. And they’ve been publishing accounts by lots of medical professionals of the sort of symptoms of cholera and how to treat it because it’s a new disease in Britain. So, doctors need to know how to spot it and how to try and deal with it because it’s spread so rapidly.

So, if you look at the World Health Organization’s fact sheet, data sheet on Cholera, we can probably say with a fair amount of certainty, as sort of historical sort of investigators, that that definitely was cholera because the symptoms are incredibly consistent with the ones we see now in the sort of modern medical practice. And when we talk about that deathly character and the sunken eyes and the blue colour, this is classic of the way that it’s described at the time. People because they’re so dehydrated and so sort of withered by it, their skin tightens and their skin turns blue because you can start to see the blood vessels through…it’s a horrible disease.

Euan: wow, yeah that’s a horrible way to go. Throughout the 19th century we see Cholera outbreaks happening all over the world. How do these outbreaks in the UK fit into the global context? And how hard was the UK hit?

Chris: So, cholera is a bacterial disease in the small intestine, as many people will know and the symptoms are as above with Henry Sibbeth in very severe cases, but they do vary. It’s spread by unsafe water a majority of the time and by unsafe food, both of which have been contaminated by the faeces of humans who have been themselves infected with the bacteria. And the risk factors as a result of this are things like poor sanitation, lack of clean drinking water, and what goes hand in hand with both of those things is poverty.

So, in the 19th century you see quite a few cholera pandemics ravage the globe. The first, begins in the Indian subcontinent around 1817 and then Britain’s first hit during the second pandemic. So, when cholera arrives in Britain via Russia and the Baltic in late 1831. While Britain isn’t as badly hit as other countries, up to about 55,000 people died in England and Wales between 1831 and sort of early 1832. And Ireland and Scotland also suffered many, many deaths.

England gets hit again by cholera in 1848 to 1849. In that period as well, a million people die in Russia from cholera, and it’s not as bad in England, but still very bad. 52,000 people died in England and Wales across those two years. And the registrar general with the official report on the outbreaks said that the death toll was if a” foreign army” had invaded the country. And then again in 1853 to 1854, 10,000 people in London alone die from cholera. And there’s another outbreak in the East End in 1866. which killed 5,000 people. But since then, cholera hasn’t been epidemic in England, although it continues to cause devastation elsewhere in the globe to this day.

Euan: And those huge numbers, are those mainly lower status, those who experience poverty who are affected?

Chris: So, what’s really interesting about cholera is it doesn’t really take distinctions of class that easily because all of these poor districts and rich districts are next to each other and they often draw from the same water supplies. So, whereas the majority of deaths are coming from the lower classes, richer people are getting sick. And what’s a really interesting thing about cholera and also the sort of change it has on society, is the fact that it hits very hard, it’s very visible and very devastating. So, it scares people and it pushes them towards action because it’s so visible and so horrible.

Euan: And there’s a lot of mystery and debate at the time about what causes it, isn’t there? Which leads to a lot of different remedies, both individual things you can do to avoid getting cholera and at larger scale. Can you tell us about some of those theories and solutions that are being devised?

Chris: Yeah. So, I think when a lot of people hear the words cholera in England they think of a Dr. John Snow who discovered through sort of investigation during a cholera outbreak in Soho in 1854, that the water pump was the source of infection as far as he could work out. And he sort of hypothesised the germ theory infection that we still use today as a result of his investigations, that the cholera was caused by people drinking water infected with these sort of tiny little pathogens. But the thing is Snow’s ideas are not immediately credited as true and most people are operating under the assumptions of what’s called the miasma theory, that disease was caused by a poisonous vapor in which it was some suspended, particles of decaying matter, which is characterised by a foul smell, a bad smell. And that’s really what reigns supreme in this period.

Like a Kent medical officer in 1866, when I asked about it, says to an audience, “The cholera is in the air.” And we can get a real understanding of how the theory gets taken to sort of quite a stupendous sort of ends through the sort of remedies that are put forward by various people in these outbreaks.

So, in 1831, a Dr. Barnes sends a pamphlet on his sort of cure or preventative of cholera, also cures what he refers to as the pestilential jungle fever, which I think might be malaria. And basically, he provides a five step solution. So, basically you start with a hoop bath, which is basically a sort of DIY steam room using some wooden hoops and some grease proof paper. Then you have the emetic, which is basically a medicine to cause you to vomit uncontrollably. Then you have what he calls the aperient, which is a laxative, just to clear you out fully. And then you have the stimulant mixture, which is basically brandy and sugar. And then you have the foot bath, which is basically like a Babyliss foot home spa, but 19th century style. And he says, if you do these you have no cause to fear any attack of cholera, which just goes to show that they believe it’s about sort of purging your humors–like a medieval sort of medical idea–and purifying your sort of airways because that’s where the bad smells are coming from.

We also see a Devon surgeon called Thomas Calley contacting the home office in early 1832 with a really bizarre solution to save London from cholera. And he basically wants to have packets of gunpowder fired from large pieces of ordinance, from cannon, above all the principal streets in London. He says this would produce a general purification of the atmosphere and fill the element with vital air. [Euan: that sounds like a good idea] And then, he … Yeah. Well, he goes further than that as well because he’s not just worried about the streets. He says, recommends the gunpowder pastilles, like little tablets, be distributed to people to ignite in their own homes. And his reasoning is that, “Every man knows who has been in the habit of shooting that not only are his clothes impregnated with the gas, but that it passes through every channel of his body and my opinion is that it offers a good preventative against contagion as anything yet known. An infant may inhale it.”

But it’s not to say that it’s all sort of quackery and insanity in this period as well. People realise as a result of the shared drinking supplies and sort of looking at the correlation in poorer areas, that sanitation is important and start to campaign for it. And we have people like Snow who invents epidemiology and then we’ve got some various surgeons around the country who really work very hard and sort of share information on how to treat these cases, even if they don’t know how they’re caused.

Euan: So that miasma theory, that’s the same thing that medieval people thought brought the plague about… is it the same idea in the 19th century?

Chris: Yeah, very much so. So, I don’t think it’s changed too much, but just the language changes slightly and gets this like, with sort of scientific trends, but Snow’s germ theory, about in late 19th century it’s starting to be accepted. In 1866 as well, William Farr, who is the closest thing that registrar general at the time has to sort of chief epidemiologist or though they wouldn’t have called him that in the 19th century. He, having dismissed Snow’s work in the 1850s, actually then uses it in 1866 and discovers that the waterworks are the source of the East End cholera outbreak and uses it to sort of quell it quite quickly. So, these ideas start to pick up and it’s cholera that gets the research really, but they by no means take over the miasma theory until the late 19th century. And it’s very medieval, sort of relatively unchanged.

Euan: One interesting thing about the cholera outbreak in the UK is that government officials know that it’s coming, don’t they? So do we know anything about how they prepared and responded?

Chris: Yeah. So, we’ve got a lot of evidence of both of these things. Britain in the 19th century is a very important part of a very, very globalised world. As you can see by the spread of cholera through the shipping lanes. And it’s an Imperial power as well, which takes on another aspect in the sort of way cholera can be spread and also the way it can gather information. So, with the coming of cholera it takes some steps to try and understand it better and some ways to prepare. So, in 1831 we can see the government has sent medical professionals to Russia, where there was an outbreak, knowing that it will come to England, to Western Europe sooner rather than later, to study the cholera cases there and to report on them. And then they published these findings and these reports so that medical professionals in the UK can gain a better understanding of the disease and how to treat it.

And they’re also collecting information from foreign governments. From 1848 onwards we have thousands of letters sent by admiralty, by the Foreign Office, by the Colonial Office, back into London and other government departments as well, writing as well, reporting outbreaks of cholera and other infectious diseases around the globe and also on the sort of methods people are taking to try and prevent them or treat them.

But they also set up in response to these outbreaks sort of government agencies to try and deal with the fallout from the cholera outbreak. So, in 1831 to 1832, we get an organisation called the Central Board of Health. It’s a very temporary organisation. It mostly distributes the sort of information they gather about treating cholera cases, like the report of Henry Sibbeth’s death, but also sort of draft regulations or sort of little local boards of health that get set up in communities. Model regulations for cleansing streets and so forth. But the thing is there’s little political possibility of making such practices permanent because the idea of using sort of local taxation to clean people’s streets, calling people to pay for something which isn’t their private property in early 19th century Britain is like sacrilegious.

But then in 1848 with the Public Health Act of 1848, which sets up a General Board of Health to oversee permanent local boards. And they could do quite a lot to make their communities cleaner and therefore safer, but there’s still a culture against it.

So, if you take the instance of a place called Clitheroe which is a small town in Lancashire, they set up a local board because they’re shocked by cholera. 17 people die in five days. And they’ve only got a population of 12,000. So, it’s a big thing there. So, they said they needed a local board because despite all their efforts they say it’s unavailing because we don’t have the power to do what we need to do. But as soon as the deaths stop, they go, “Actually, no. This is far too expensive, we don’t want to do this anymore. It would actually kill more people to have the expense then it would to have these regulations.”

And so, they do nothing for years because they can’t be forced to. They say “This is centralisation, at its worst terrors and tyranny”. And their death rate remains really high. But you can see again, the sort of scientific debate that’s going on, the resistance to these new ideas because they dismiss those who claimed that Clitheroe’s water is infected with disease and that’s going to cause things as pseudo chemists and they blame the district’s really very, very high mortality on intemperance and falls and drowning with no evidence whatsoever.

Euan: What’s the significance of these outbreaks in the larger, the wider, history of public health?

Chris: So, I think it comes back to the fact that this disease is so shocking, it’s often called a shock disease because it spreads fast, it strikes victims fast and it kills people fast if they have a severe case. And it’s why it’s really important in the history of public health, particularly in Britain as far as I’m concerned, because it’s not the sort of slow toll of death or disease you get from things like typhus or smallpox; it really is very, very dramatic. And that forces politicians and government to do new things because they’re reactive creatures I suppose in the 19th century and possibly in any age. And they set up things that they were considered to be too expensive or politically impossible.

If you take the example on a small scale of Clitheroe, they’re obviously very against the idea of any sort of government intervention or sort of advanced local government that would cost money. But in the heat of a cholera outbreak, they reach out for anything which can try and help them. When the government sets up a national framework of public health bodies in 1848, despite the fact that this was so hard to get through parliament, which is why it’s so watered down because the disease is so mysterious and so deadly, it makes people react in strange ways, but it also, because it’s in people’s minds, it means that doctors and people like John Snow start to investigate it and make discoveries.

So, the real legacy of these outbreaks as far as I’m concerned is what we would now call environmental health. So, cholera outbreaks convince people who are in charge of things that the cleanliness of where people live, even very poor people who live near rich people, affects the health of everyone. And by 1875, you can start to see that the British government is legislating to provide the population with a basic sanitary standard in their communities, like a guaranteed one. It doesn’t always happen, but it’s there.

And also, the big legacy of it is that John Snow and people like him, William Farr, the registrar general, they really start to sort of put together what we now call epidemiology, that study of infectious disease outbreaks, they and other surgeons and medical professionals across the world. But, it’s that this globalised pandemic and spread is so brutal, basically forces people into action they hadn’t necessarily taken before.

Euan: The second cholera pandemic…the 1852-60 one when Jon Snow made his discovery…ultimately killed around a million people worldwide. And a third cholera pandemic in the early 1900s was almost as deadly, claiming roughly 800,000 lives globally, although it didn’t reach Britain. That’s an enormous loss of life, but it pales in comparison to the subject of our next story, the deadliest pandemic to reach Britain since the Black Death.

Sarah: And for this story, we called up Laura Robson-Mainwaring.

[outgoing ringing tone]

Laura Robson-Mainwaring: I’m Laura Robson-Mainwaring and I’m the health records specialist at the National Archives. So I delve into the collections that we have and promote our health collections to a wide range of audiences, whether that’s family historians, researchers, students, just everyone who’s interested in our health records.

So just over a hundred years ago, the worst ever recorded outbreak of influenza took place. It took the lives of an estimated 50 million people worldwide. Although, many estimates actually go quite a lot higher than this. And Britain was struck by three separate waves of the virus, between around mid-1918 to around the spring of 1919. It was unusual, in that the virus killed people in lower age brackets. So, people in their twenties and thirties, people seem to be in the prime of their lives. This was not the normal pattern of the seasonal flu, which tended to kill more vulnerable age groups.

Sarah: Okay, there’s been quite a bit of renewed interest in the 1918 influenza recently. But otherwise, it’s probably gotten relatively little attention when you consider that the virus killed around 225,000 people in Britain alone. Why do you think that is?

Laura: So it does seem odd that its impact is not more well-known, especially considering the death toll.

However, at the same time as the outbreak was also something we may all be more familiar with. And that’s the First World War, which really has just overshadowed the pandemic in history books and within collective memory. And undoubtedly, the First World War aided the spread of the disease. There was an unprecedented movement of people, whether that’s via steam boats and trains, or to and from war zones across the globe. And soldiers also lived in communal camps and trenches where sanitation and overcrowding could be a problem. And this helps the influenza to spread effectively, unfortunately.

Sarah: We’ve got a story in the archives that highlights the interconnectedness of the First World War and the 1918 influenza. So what can you tell me about William Leefe Robinson?

Laura: So, William Leefe Robinson was Britain’s most famous pilot during the First World War. And The National Archives hold some records from his military career. And he received the highest military honor, the Victoria Cross medal, for being the first pilot to shoot down a German airship over Britain. And as a result, he effectively became sort of famous overnight for this act of heroism.

However, his luck was fairly short-lived following this event. So, a few months later, he went to serve in France and was shot down, captured, and then imprisoned for the duration of the war. He made a number of escape attempts, which led him to being placed in notoriously harsher prisons. And this is where he appears again in our records. So we have a letter from his fiancé, Joan Whipple, dated from May 1918. And she expresses concern that her husband to be was being maltreated and had spent too long under solitary confinement.

And she wrote, “Nothing would matter so much if he was still cheerful. But since Christmas, his letters had been written in a melancholy and depressed frame of mind. His own family tells me that he is certainly not at all normal. I would not worry you in this way, but I feel that knowing my fiancé’s sensitive disposition so well, he may become thoroughly ill, if he is not taken away from his surroundings, which have made him so morbid.” So, following the declaration of the end of the war in November, 1918, he finally came home to join his fiancé over Christmas, but tragically Joan’s worries end up coming true. And after surviving the rest of the war, after he returned home he succumbed to the influenza in December, 1918, on New Year’s Eve, aged just 23. Which was sadly the fate of a number of soldiers returning from the front.

Sarah: Oh no, that is such a sad story. But he did make it home to his sweetheart, so at least they were able to see each other before he died.

So, I’m wondering, how preventable was this fate?

In our story about cholera, we talked about how the government knew that cholera was coming, but how prepared was Britain for the 1918 influenza. And how did the government and the public try to stop it from spreading once it was here?

Laura: So the first wave of the influenza would have taken Britain by surprise. However, this wave was fairly mild, not really unusual compared to other strains of the annual flu. So it was the second wave in the autumn that really caused alarm and the government and local authorities tried a number of public health measures to try and mitigate it. Britain’s public health system had been greatly improved in the late 19th century, yet the country was vastly unprepared for a pandemic on this level.

So infection at the time caused the usual cough, fever and aches. But during the second wave, it was more likely to lead to a deadly form of pneumonia. And medically, nothing could really be done to prevent or cure it. There was however, a public health response, which happened on a local level. And this sort of predominantly focused on limiting public gatherings. So there were attempts to control entry to theaters, dance halls, churches, and other places of public gathering, and to isolate those who were ill. Which was really their sort of only real ammo in stopping the spread of the disease.

And across the country, local medical officers of health who were employed by the local government boards were engaged in organising information campaigns and enforcing regulations.

Sarah: So Laura, do we have any records in The National Archives that offer the unique perspective or information that’s not available anywhere else?

Laura: Yeah. So during the war, many medical practitioners were engaged abroad or at military camps as part of the war efforts. And people wrote to the government calling for local GPs to be recalled from service as the situation was just so dire at home. So for example, Edwin Cornwall of the National Insurance Joint Committee wrote to the Cabinet Office on the 29th of November, 1918, requesting that the War Office immediately release a number of doctors to meet the needs of the civil community.

And he included in this an anonymous letter from a GP in Nottingham, which sheds light on the experience of medical practitioners at the time. So, in the letter, the GP stated, “I am personally near the limit of my physical endurance after working for a long period from 14 to 18 hours or more occasionally, Sundays and weekdays.” And he goes on to say, “We’re being grossly misused and our patients are literally dying neglected and insufficiently tended.” So sort of certainly the combination of the war and the pandemic really put a strain on health services at the time.

So I’d say that a unique point of our collection is looking at how the pandemic was dealt with by central authorities and government departments at the time. So for example, the Ministry of Munitions was a very large employer during wartime. And our records show the level of care taken to abate the disease at their premises. So floors were sprinkled with disinfectant every morning, windows were left open at night, a solution containing disinfectant was available for gargling in the sick room. Telephones were sprayed down. And members of staff were sent home when they presented symptoms.

Sadly, it was reported that in one case, one member of staff, a woman who had the influenza very mildly, was sent home. And sadly three members of her family, her father, mother, and brother, all died within one week from the disease while in her own case the attack was very slight. And these files also showed that the Ministry of Munitions recorded statistics of how many employees were being affected on a regular basis.

Sarah: So finally Laura, what would you say are some of the short and longer term impacts that the 1918 flu had on Britain?

Laura: So short term, on the surface and in sort of day-to-day life, I would say not much changed. As even after the pandemic subsided, no one knew what caused it. So really Britain’s only defense in the face of another pandemic was trying to keep everything disinfected and to isolate the healthy from the sick and just stop public gatherings. But one short term impact can be seen to be the creation of the Ministry of Health in 1919. So a Ministry of Health as a more streamlined system of health governance was on the cards before the war. And it was part of an idea of reconstruction after the war.

However, newspaper articles from the time show that calls for the new ministry were given more impetus by the onset of the pandemic. So The Times, for example, reported that the time was ripe for a new ministry because the influenza had aroused public interest in health matters.

And then sort of long term, a significant change is perhaps the level of research into the causes of the influenza. So research is undertaken in earnest during the pandemic, and in its aftermath from across army medical services, universities, and the Medical Research Council. And they’re all trying to find out how it was caused.

And research continued throughout the 1920s, mainly looking at something called Pfeiffer’s Bacillus, which was a bacteria widely thought to be the cause of the influenza. And that’s even after reports that it was not present in all cases. In fact, it wasn’t until 1933 that it was proven that the flu was caused by a virus rather than by a bacteria. So quite some time later.

And one of these researchers was called Alexander Fleming, who would go on to profoundly change the course of history. So Fleming worked on the influenza throughout the 1920s, researching at his laboratory near Paddington. And in 1928, he would discover penicillin, the world’s first antibiotic. So yeah, long term research in the area of influenza really helped to advance medical science.

Sarah: And now, our final story of this episode brings us up to the present, as we look at a disease that has led to an estimated 35 million deaths over four decades and continues to affect 39 million people worldwide as of 2019.

Euan: We’re talking about HIV & AIDS. This is potentially a huge story, and we only have 15 minutes, so we’re going to be focusing on one set of records from two years early in the fight to stop the spread of HIV. Our colleague and fellow National Archives historian Mark Dunton has been doing quite a bit of research on these records, so we’re calling him up to learn more about a very specific story within the larger global context of HIV and AIDS.

[outgoing ringing tone]

Mark Dunton: I’m Mark Dunton and I’m a contemporary specialist at The National Archives. An important part of my job is helping the public track down what they’re looking for. So normally that would be either in person or by the chat service or by email. And I specialise in 20th century British political, social and economic history. It’s a great job. Yeah.

Euan: So Mark you’re going to be talking to us about AIDS in Britain today. Can you give us a bit of context? What is AIDS, to get us started?

Mark: Yes. I mean, that is a really good question because confusion often arises over the sort of terms that are used. So AIDS actually stands for acquired immune deficiency syndrome, and it was given that description back in 1982. AIDS is a name for a collection of illnesses which are caused by the HIV virus. HIV stands for “human immunodeficiency virus.” So immunodeficiency is really referring to the fact that the virus weakens the immune system, it makes it more prone to infections, and that includes cancers. So AIDS is like the final set of symptoms caused by the HIV virus.

Sarah: A quick note on terminology: HIV and AIDS are not the same thing, as Mark has explained. Because AIDS describes symptoms caused by HIV, it’s important to note that only HIV can be transmitted, and only through intercourse, contaminated injection tools like needles, or breastfeeding. HIV was only discovered in 1983, and in this episode, we’re speaking about a time when most people with HIV eventually developed AIDS. So you’ll hear Mark referring to AIDS more than HIV. Today, we speak primarily about HIV, because medical advances mean people living with HIV can live full and long lives. Ok back to our conversation.

Euan: How big of an issue was AIDS in Britain. What kind of time period are we looking at here?

Mark: Yes. Well, I think the first known case of AIDS in the UK was 1981. The period that I’m particularly keen to talk about is 1986, 1987, because that’s when it really kind of rocketed to the top of the national agenda in Britain. These were difficult years, there were no effective treatments either. Not really anything much in the way of palliative treatment. It had a kind of shocking effect on the population. This was something new that had arrived a bit out of the blue, the first reports had come over from America, particularly American gay men, and then talk of a kind of gay cancer that was affecting them. Yeah, it was a chilling sort of development really.

By the end of April, 1989, there were just over 2000 cases of AIDS in Britain in total, with just over 1000 deaths. Then by the end of 1993, World Health Organization figures show just over 8,000 cases of AIDS in Britain.

Euan: And do we have any evidence or records about what the government’s reaction is?

Mark: We certainly do. There’s a lot of documentation at The National Archives. There are lots of bulging files on this. In 1986, 1987, there was a real concentration on this by government. There was widespread fear, actually, it gripped society as a whole, and that includes government and the media. What you get in these years is a sort of wartime emergency feel.

So what was the government response? Well, the government launched a direct advertising campaign, and this was on an unprecedented scale to the British public. And for a time, the issue just soared to the top of the national agenda.

It’s an interesting time because when this occurred there was also a good deal of homophobia around at the time, and the AIDS threat got kind of caught up with this.

There was a great deal of hysteria and panic about AIDS, particularly in the years, 1984, 1985. The Sun ran a headline, “AIDS is the wrath of God, says vicar.” AIDS was described as “the gay plague.” There were other headlines like, “AIDS, it’s catching like wildfire.” There was quite a lot of stoking up of fear and hysteria. That period didn’t necessarily last a long, long time, but it did create fear.

But it’s important to note that the government health campaign was based squarely on medical advice. And, as Virginia Berridge has pointed out, it was based on a liberal consensus. So the government’s campaign was emphasizing safe sex. You could still have sex, but it’s got to be safe sex rather than no sex. We’ve got masses of records about this: Prime Minister’s office files, Department of Health files. And they kind of show the thinking behind the campaigns. Very interesting stuff.

Euan: And there is a driving force behind the campaign? Is there someone who is leading the charge on this?

Mark: Yes. And that person is Norman Fowler. Now he’d been Health Secretary since 1981. And actually he is on record as saying that when he first knew about AIDS as a serious problem, he knew very little about the gay community and he had very few gay friends. But he could not understand why there was opposition to gay people purely on the grounds of their sexual orientation. And he believed passionately that prejudice should not stand in the way of a great campaign to prevent HIV and AIDS from spreading. So Norman Fowler was very earnest about this. He showed a great deal of drive and determination in the whole matter, as did the Chief Medical Officer, Donald Acheson, who was also instrumental. But yes, Norman Fowler is central to this.

Euan: So tell me a bit about his campaign. What was he hoping to accomplish and what methods did he use to try and do that?

Mark: Well, as I’ve mentioned, at this time there were no effective treatments to counter the AIDS threat. Rising numbers of people were dying from it. So the only weapon the government had was prevention through education. So Norman Fowler’s national advertising campaign, it was really explaining how the virus was contracted and how to avoid catching it. The key messages were “The greater number of sexual partners you have, the greater the risk. So protect yourself, use a condom.”

And that campaign, it started with newspaper adverts. That was in 1986, early 1986. Then there was a leaflet drop with this leaflet headlined, “AIDS, Don’t Die of Ignorance.” And that went to every household in the country. And then the campaign kind of peaked with a truly portentous television advert, which had a chilling effect. Many people who were around at this time will remember this. The advert featured the voice of the actor, John Hurt.

You can see this on our website with our government information films that we’ve got. So it had the voice of the actor, John Hurt. It began with explosions in what looks like a rock quarry. Then there’s a drill and a hammer cutting out the words AIDS on what becomes a gravestone. Then a bunch of white lilies is thrown on top of this gravestone. Very chilling advert.

[45 second audio of government advertisement featuring the voice of John Hurt] “There is now a danger that has become a threat to us all. It is a deadly disease and there is no known cure. The virus can be passed during sexual intercourse with an infected person. Anyone can get it, man or woman. So far it’s been confined to small groups, but it’s spreading. So protect yourself, and read this leaflet when it arrives. If you ignore AIDS, it could be the death of you. So don’t die of ignorance.”

Mark: There was another one featuring icebergs as well, with the implication that this is only the tip of the iceberg in terms of the problem, you know? So yeah, these campaigns had a big impact.

Euan: And did he face any resistance within government or in the media?

Mark: Yeah, I think resistance is probably too strong a word, but certainly strong concern was expressed at times by the Prime Minister, Margaret Thatcher, and some other ministers, including Lord Hailsham. It was really concerned about the level of explicitness about sexual practices in Fowler’s proposed newspaper adverts and the household leaflet. Indeed, in fact, the whole notion of leafleting, every household in the country on this subject was questioned by some. So Thatcher’s concerns really focused on the language used to explain about sexual practices which could lead to HIV infection, specifically unprotected anal sex. Fowler circulated a memorandum giving details of the planned publicity text, and Thatcher wrote on this, “Do we have to have the section on risky sex? I should have thought it would do immense harm if young teenagers were to read it.”

Euan: So we actually have those handwritten changes and notes in our records?

Mark: We do. It is fascinating. It’s always fascinating to see the comments written in the hand of the Prime Minister, their gut reaction to things, their initial reaction to things, always fascinating to see.

And after a good deal of toing and froing on this, they finally agreed a text which read, “Anal sex [rectal intercourse] carries the highest risk and should be avoided.” Mrs Thatcher said that she would have preferred a kind of wartime approach as with VD, venereal disease, where notices were placed in surgeries and public lavatories, but Fowler felt this view was old fashioned given the range of modern communication techniques that were available by the mid-eighties. But, having said all this, as Fowler wrote in his book, AIDS: Don’t Die of Prejudice, ‘Margaret Thatcher may have grumbled, but with the exception of the canceled ministerial broadcast, she did not veto our efforts’.

Also it’s important to note, the media were really supportive, particularly television, which ran a series of programs in February, 1987 dealing with the use of condoms in a frank manner. Perhaps the tabloid press didn’t always, well, they didn’t always play a very positive part in the story, but certainly television did take a responsible approach.

Euan: So what’s the impact of all this publicity and this campaign? Does it make a difference to how the disease is being spread, at all?

Mark: Yeah. I mean, I think it’s a fair claim to make that the campaign was effective, because the government commissioned, I think there was a Gallup report in 1987. Well over 90% of the public had seen the advertising. 94% of people thought the government was right to be doing the advertising they had seen. Only 7% found elements of it offensive. These are pretty impressive figures.

Euan: especially considering a British Social Attitudes Survey from the same year found that 75% of the population agreed with the statement that homosexual activity was quote “always or mostly wrong” unquote…which suggests wide-spread homophobia.

Mark: So knowledge about AIDS, they found, had increased dramatically. Condom use increased, and there was a marked decrease in sexual disease generally. They found this is also markedly true for gay men. So there was a dramatic fall in gonorrhea and syphilis.

It’s also interesting to note that the Terrence Higgins Trust, the campaigning body that was so much in the forefront of spreading education about AIDS to gay men, they noted that France, Spain and Italy was slower to react to the threat of AIDS than the UK. The level of HIV infection in those countries was considerably worse in comparison with Britain.

And I must just say that it’s important to remember that many charities and activists in the gay community played a significant part in the fight against AIDS, whether it’s helplines or their own publicity, the Terrence Higgins Trust.

Euan: 1987 was also the year that scientists developed the first drugs for slowing the progression of AIDS. Research and the search for a cure continued into the mid-90s, when another breakthrough development led to drugs that could prevent the onset of AIDS entirely for people living with HIV. Today, the National AIDS Trust estimates that there are about 105,000 people living with HIV in the UK. There is still no cure, but with treatment, the HIV viral load can be suppressed to such a low level that it cannot be transmitted. 97% of people living with HIV in the UK are receiving this treatment.

The challenge of Norman Fowler’s time was education and prevention. Today, the focus is on safer sex, widespread testing, early diagnoses and treatment, and importantly….the destigmatisation of testing and treatment for men who have sex with men and for heterosexual men and women. The Terrence Higgins Trust hopes to see the end of new HIV infections by the year 2030, but meanwhile, people living with the virus who receive treatment can live full, long lives, participate in loving intimate relationships, and have children.

Euan: So, Mark, what does the response to AIDS in the mid-80s tell us about the human response to epidemics and disease?

Mark: There is perhaps a tendency that when a new infectious disease suddenly comes into being, this touches on very deep human fears which I think are buried in our subconscious. There’s something about ‘plague’ in inverted commas that really tends to strike terror and fear. So it can lead to a kind of emotional overreaction. But this thing about the danger of overreacting is an interesting theme, because it’s that difficult balance between being seen as crying wolf over some new threat and not taking it seriously enough. It’s that delicate balance that you see with health scares over the years. So there’s an awful lot, actually, I think that we can learn from looking at the files and reflecting.

Sarah: Thanks for listening to On the Record, a production of The National Archives at Kew.

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Euan: Thank you to all the experts who contributed to this episode. This episode was written, edited, and produced by Hannah Hethmon for Better Lemon Creative Audio.

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