In 1940, diphtheria became the first vaccine of the bacteriological age to be offered free to British children on a national scale. It achieved impressive results in its first years, reducing the case load from over 46,000 in 1940 to just 962 in 1950, and deaths from 2,480 to 49.1 Medical authorities celebrated this success, but were mindful of the paradox they had created. With diphtheria no longer a common disease, would parents stop immunising their children? And if they did, would a disease that should be eliminated make a deadly return?
These fears appeared to be realised in 1950. After solid progress in immunisation of the child population throughout the 1940s, there was a sudden decline in the number of children being presented for immunisation. While a number of causes were investigated, the main culprit, in the eyes of the Ministry of Health, was apathy. A publicity campaign began and was maintained throughout the 1950s, coordinated through the Ministry of Health and Central Office of Information (COI) and supported through direct interactions with the public by local medical authorities.
This chapter discusses how “apathy” acted as an explanatory model and call to action for health authorities seeking to improve uptake of immunisation services among the population. It played a key role in constructing the public in the minds of policy makers, built out of long-standing paternalistic attitudes towards the working classes, particularly mothers. The Ministry considered apathy a problem because it threatened the successes achieved by public health policy up to this point. Immunisation had reduced the burden of diphtheria on the health services and, it was hoped, could eventually eliminate the disease entirely. The risk was that this apparent progress might stall – or, worse, the disease would return to higher levels. By defining apathy as low uptake of immunisation, the problem could be identified and quantified. In turn, apathy tells us how these authorities viewed the public and their relationship with them. The Ministry of Health focused on encouraging individuals to immunise their children in order to minimise the risk of diphtheria's return. Its campaign ran on the basis that parents no longer feared diphtheria and therefore were unmotivated to present their children for immunisation. Nevertheless, authorities also understood that there were many reasons why parents might not vaccinate. At the local level, medical officers worked with the public and responded to their needs. That is to say, the public was not simply lectured to; rather, policy makers consistently monitored the public through various systems of surveillance for signs that could be interpreted. Apathy actively guided policy in ways that often made immunisation more convenient for parents and children. It was a form of communication; a translation of the diffuse behaviours of the public into a language which administrators and policy makers could understand.
Apathy is an amorphous concept. Indeed, the imprecise nature of the term in itself gives us insight into the motivations and thinking behind local and national policy. This chapter therefore attempts not to deconstruct how the concept was experienced by parents in 1950s Britain but, rather, to explore how it was used – often without precision – by various authorities. Apathy was often invoked to explain public behaviour, and attempts were made to combat it. It was a rhetorical device, one without an objective basis, yet still built into the longer history of British public health practice.
This chapter begins by outlining how the national anti-diphtheria programme came into being during the Second World War. It shows how this continued after 1945, and through the formation of the new NHS. In 1950, however, the Ministry of Health became concerned at declining vaccination rates. The reasons for this are explored, in terms both of changing patterns of behaviour and of the ways in which the statistical indicators available to the Ministry allowed it to “see” (or construct) apathy among parents. The chapter then goes on to explain what national and local government did to combat apathy over the course of the 1950s.
Diphtheria immunisation before 1945
If the decline in immunisation rates suggested that the British people had become complacent about diphtheria, this was not always the case. After some initial difficulties, take-up of diphtheria immunisation was high throughout the later war years and into the late 1940s. Diphtheria immunisation developed out of the work in the emerging science of bacteriology at the turn of the twentieth century.2 As Claire Hooker and Alison Bashford have argued, ‘diphtheria is ideally placed for thinking through the historical connections between bacteriology and applied public health precisely because it was so strongly associated with laboratory medicine and the new capacities to understand and therefore control disease’.3 The condition itself was discovered to be caused by a bacterium, Corynebacterium diphtheria, and tended to attack through the larynx and the tonsils. Complications could include heart disease and paralysis, sometimes leading to death. In Britain during the 1930s, before the introduction of immunisation, an average of 58,000 cases were seen each year, with 2,800 deaths.4
However, Britain had not always been so enthusiastic about the procedure. British public health authorities had come to adopt immunisation relatively late, compared to those in other Western nations. Toronto and New York City, for example, had run successful interventions during the inter-war years to significantly reduce morbidity and mortality.5 Despite this, and although some local authorities had used immunisation prior to the Second World War, Britain was rather conservative with regard to new immunisation technologies. The anti-vaccination and anti-vivisection organisations were still relatively powerful in the 1930s, and the experience of resistance to compulsory smallpox vaccination in the nineteenth century still loomed large.6 There was also a widespread belief among medical authorities that the well-established public health system in Britain functioned perfectly well without the use of prophylactics. The main example cited was the much lower rates of tuberculosis in Britain as compared to France, despite the latter's use of BCG. Sanatoria and health education were therefore seen by medical authorities as at least as good as BCG, if not better, and so they were not willing to risk introducing a new public health measure that might go wrong.7 There was no guarantee of vaccine safety, as evidenced by the poisoning of children with contaminated diphtheria toxoid in Bundaberg, Australia, and contaminated BCG in Lübeck, Germany.8 While the national government stayed clear of providing the toxoid or centrally funded advertising to promote immunisation, local authorities had been permitted to use it before the war. However, they had to pay for supplies and manpower themselves.9 Thus, it was embraced with varying levels of enthusiasm and administered with varying levels of competence, resulting in very uneven coverage.10
The war provided an impetus to adopt immunisation as a mass public health measure. Mobile populations as a result of evacuation, bomb damage and general dislocation made traditional public health measures more difficult to maintain. Combined with the need to keep the home population healthy for industrial output and morale, diphtheria immunisation was belatedly accepted.11 From late 1940, a campaign was initiated to immunise all school children. The minimum school leaving age was fourteen, and the school system provided a useful site for vaccination before leavers entered the world of work. The prophylactic was supplied to local authorities free of charge, and the government estimated that around a third of school children up to the age of fourteen had been immunised by September 1941.12
After the war
Although in many ways the war-time experience might be seen as atypical, given the number of controls imposed on public life and economic behaviour, immunisation had been shown to be invaluable. Parents thus understood that it was an effective tool and they were keen to have their children protected. If apathy was a problem, authorities were at no great pains to stress it. Indeed, they saw parents’ enthusiasm as a sign that modern preventative health care would be seen as a civic duty – states would be obliged to provide services, and good citizens would actively use them.13 While the British political classes had committed to the social rights of a comprehensive welfare state based on the war-time Beveridge Report, they also came to expect certain behaviours in return.14 These trends were common in the West during the twentieth century, and accelerated after 1945. Dorothy Porter has argued that it would become increasingly unacceptable for people to be unhealthy and that citizens would be under pressure from the state and from their peers to avoid ill-health.15 As diseases became “vaccine preventable”, not vaccinating became an unacceptable practice. In a speech to the Council for Education and World Citizenship in 1946, Labour Minister of Health Aneurin Bevan cited immunisation as an example of what centrally coordinated health services backed by modern medicine could achieve. Morbidity from diphtheria had effectively halved from its pre-war levels; mortality had been reduced to a third. Bevan further argued ‘that in working for a better health service [the Labour Party was] not looking forward to a nation of hypochondriacs, enjoying bad health, but a nation whose members understood and practised the laws of health’. This encompassed a range of health technologies and lifestyle changes, of which immunisation was one. But it would require the ‘energetic cooperation of every citizen’ to achieve its full effects.16 Citizens were both the users of services and, through taxation, the funders. Government imposed moral and legal conditions on citizens in return for services, but through democratic channels also could claim to represent citizens. These inherent tensions in health care systems, between individual liberty and collective responsibility, were not new to this period, but they were recast.17 Indeed, later in the century, as the focus of welfare provision began to shift from a broadly social democratic model to one based more on markets and individual choice within a public-private framework, the relationship between public or preventative health and citizens would change.18
This interplay between citizenship and risk management is explored in greater detail in Chapter 4. What is important in the immediate post-war era, however, is that citizens also demanded health protection from the government. The most obvious example of this is the creation of the NHS. T. H. Marshall would describe the coming of the new welfare state as an expression of social rights, a new age in which protection from hardship would be as important as equality under the law and the right to vote in previous decades.19 If there was a will for greater protection, state planning and modern science appeared to offer a means for its provision. Although much would later be made of the “technocratic age” of the 1950s and 1960s, it was in the 1940s that the British state would begin to take greater control of once-private industries in the name of efficiency and accountability.20 Indeed, it was through the establishment of monitoring statistics during this time that the Ministry of Health was able to monitor the apathy that it would see in the 1950s and how it would come to see problems within the rest of the vaccination programme, as described in the later chapters of this book.
Throughout the period discussed in this chapter, the government recommended an initial immunisation of children under the age of twelve months. Young children were at the most risk of death, and early immunisation was considered necessary to increase the efficiency of the programme. This was initial immunisation was “boosted” with a reinforcing dose as the child entered primary school.21 A combined prophylaxis was also available in some areas, offering protection against both diphtheria and pertussis (whooping cough), which complicated this picture as the 1950s progressed, as authorities could run slightly different programmes to those of their peers. Where the combined vaccine was used the schedule was amended to find a practical and epidemiologically sound compromise between protecting children from pertussis as early as possible and maintaining safety standards. Trials had begun on the pertussis vaccine in 1942, and the combined vaccine was trialled from 1951.22 By 1957, almost all local authorities had applied for and been granted permission to vaccinate against whooping cough, and many chose the combined immunisation.23 Because whooping cough was even more dangerous for very young children, this dose was given to children at around six to nine months old. The relationship between the two vaccines – and indeed the two diseases – had implications for the campaign against apathy. The Ministry considered the public much more fearful of whooping cough, and therefore the combined prophylactic was seen as an administratively convenient way of reaching otherwise-apathetic parents. Separate injections may have led parents to “choose” one form of protection over another, further reducing the diphtheria immunisation rate.24 These are discussions to which this chapter will return.
The use of schools as sites for vaccination was significant for two reasons. First, since attendance was compulsory, schools were historically important as a surveillance tool for health authorities. Height, weight and other measurements were taken in schools to track malnutrition and neglect, primarily to ensure that children grew up healthy enough to work in factories, fight in the army and bear children.25 Through them, local MOHs could reach almost all children and produce records about their immunisation statuses for routine monitoring and follow-up. Second, this greater efficiency in school-age surveillance meant that there was a significantly higher rate of immunisation among children over the age of five than those of pre-school age.26 Infants were immunised at clinics held at specific times, usually led by the MOH. This reflected the administrative arrangements for public health at the time, as well as practical considerations with regard to diphtheria toxoid. Immunising from local authority clinics made it easier to store the vaccine, order in bulk and keep track of usage statistics. Clinics could see more patients in a shorter period than general practitioners, who, before 1948, were not contracted to a national health service.27 Supplying the vaccine to individual surgeries and collating the statistical returns demanded by the Ministry would also add an extra layer of administration. Parents could make arrangements with their own doctor if they wished, with the general practitioner then being compensated by the local authority, but this was less common than attendance at a clinic.28 This meant that most parents had to make a specific trip to the clinic to get their children immunised, rather than having the procedure done at the same time as a routine visit or check-up at the doctor's surgery.
Through the statistical data available, the Ministry was well aware that uptake among children of different ages varied significantly. This was a cause for concern from the early days of the programme. Pre-schoolers were specifically targeted in 1942, and again after the end of the war, in an attempt to combat the discrepancy.29 By the birth of the NHS, local authorities were tasked with immunising 75 per cent of children before they reached their first birthday.30 But uptake rates did not vary just by age. Geography was another major dynamic. Immunisation was managed at the local level under the direction of local MOHs. Local authorities had traditionally enjoyed a good degree of autonomy from central government, meaning that they could often be resistant if the Ministry attempted to interfere too much with regional matters.31 However, the use of MOHs was administratively convenient – smallpox vaccination had been the responsibility of local authorities before 1948, and this was maintained and formalised by Section 26 of the National Health Service Acts.32 There was an inherent tension, therefore, between national targets and local circumstances. The attitudes of parents and priorities of MOHs could vary considerably from council to council, and local difficulties could suspend or severely derail efforts to immunise children promptly. For example, in 1946 in London alone the diphtheria immunisation rate of children under five years old ranged from 68 per cent in one borough to just 28 per cent in another; and the figures for five- to fourteen-year-olds ranged from 20 per cent to 86 per cent.33
That “convenience” had an effect on immunisation uptake was significant. Indeed, it would be a central part of debates about apathy. For while a parent's unwillingness to surmount inconvenience could be criticised as apathetic behaviour, it could also be seen a reasonable response to failures on the part of public health authorities, in terms of both service provision and education. Regardless, this was something that needed to be tackled. If indeed the problem was one of willingness to act over convenience, the Ministry believed that this could be overcome through education and persuasion. In this sense, apathy was bound to long-held liberal concepts of public health based on individual freedom and the capacity of informed people to make rational (and therefore “correct”) choices.34 Human behaviour was a contributor to the spread of disease, giving moral authority for medical officers to intervene for the good of national productivity and military power.35 As societies became more reliant on technologies and complex administrative systems, these risks were considered to be manageable. The state's role was therefore to ensure that individuals behaved in ways that did not expose the state or fellow citizens.36 However, such actions could not unduly interfere with the rights of private citizens. Thus, education was seen by English practitioners as a sign of the nation's democratic values, especially when compared to states like Germany that employed a coercive medical police.37
During the inter-war years, national and local health authorities expanded education as a preventative strategy.38 The creation of the COI from the war-time Ministry of Information also showed that such tactics would become even more important in the NHS era.39 Apathy was therefore seen as something that could be eliminated, much like sewerage and other public health measures had rid the streets of other “nuisances”. Educating the public through “propaganda”, as it was termed by public health officials at the time (without the modern negative connotations), was a key tool in the MOH's arsenal.40 And yet, this also gave rise to the possibility of “victim blaming”. Once education and information were put out to the public, only the stupid, obstinate or wilfully neglectful would not follow the “rational” path set out by public health campaigners.41 The experience of the 1950s shows that this was not always the way apathy was used as a rhetorical tool. Many people who had been exposed to “education” and were still non-compliant could still be depicted as “apathetic”. Similarly, the Ministry accepted that lower immunisation rates were a predictable and rational response to the decline of the disease. Moreover, interactions between authorities and the public showed that there were other costs and risks associated with immunisation that informed parents’ decisions about their children's health.
Despite this subjective and vague notion of apathy, the Ministry of Health felt that it would undermine the immunisation programme and see the return of thousands of cases of a deadly illness.42 This attitude reflected a belief that citizens had a duty to be engaged in their own health care – to avoid illness and so not put strain on health resources or harm national productivity. The immediate post-war era was one in which citizens demanded health care as a right from their governments; but it was also one in which governments and fellow citizens demanded mindfulness of those who used those services.43 As a result, the government identified apathy as a problem and sought to “measure” it, primarily through tracking immunisation rates and commissioning studies from the Social Survey (both of which will be explored in this chapter). Yet as we will also see, publics responded in other ways which showed that they were not as disengaged as headline figures and official thinking might have suggested. This, in turn, affected the ways in which local and national authorities sought to engage the public. It had a major impact in the way in which the 1950s anti-diphtheria campaign would be run.
The 1950s campaign
All the evidence suggested that the immunisation campaign since 1940 had been a public health success story. Local authorities were required to return statistics on the number of immunisations performed, and diphtheria was a notifiable disease. Case load and death rates dropped significantly over the period up to 1950. To celebrate ten years of the NHS, London County Council's Annual Report for 1957 showed the significant decline in mortality in different age groups in an informative chart (Figure 1.1). A trend line was plotted to show just how successful public health provisions had been in the 1940s by comparing actual death rates to a projection based on data from the 1930s.44 Other graphs produced in MOH reports in the 1950s also included a line plotting ‘percentage of population (5–14) not immunised’, which further demonstrated the correlation between immunisation rates and declining notifications in London County.45 Further proof of the impact of immunisation came from official statistics. Those who had been immunised were four times less likely to develop the disease, and if they did, they were twenty times less likely to die of it.46
Figure 1.1 England and Wales: diphtheria deaths, 1931–48. Source: J. A. Scott, MOH Report, 1957, p. 65. Reproduced from the digitised Medical Officer of Health Reports by the Wellcome Trust under Creative Commons licence (CC-BY 4.0).
However, the Ministry became concerned at the sudden drop in the number of young children being immunised. In 1949, the government had achieved its target of 75 per cent uptake. Yet, preliminary figures for 1950 suggested a significant decrease, and in 1951 fewer than 30 per cent of children less than a year old were immunised.47 It was clear that the Ministry had a problem. The question was, what had caused it and what could be done? Very quickly, “apathy” among parents was identified as the main culprit.
The choice to focus on apathy seems at first glance to be a strange one. The decrease in the number of vaccinations was caused primarily by a lack of opportunity. Owing to a national epidemic of poliomyelitis, the campaign had been suspended in areas of particularly high prevalence.48 This meant that parents’ appointments were cancelled, and local authorities could not follow up on young children who had not been immunised.49 The reason for the suspension was that medical authorities had received some evidence that immunisation (against any disease) might exacerbate the onset of paralysis in the limb in which a person was injected during a poliomyelitis outbreak. Some medical professionals and commentators argued that the act of injection may actually cause polio, reflecting the gaps in knowledge about the disease at the time.50 A. Bradford Hill and J. Knowelden at the London School of Hygiene and Tropical Medicine performed an analysis on government data and case reports from J. K. Martin,51 B. P. McCloskey52 and D. H. Geffen.53 They concluded that people who developed poliomyelitis within one month of being immunised were much more likely to experience paralysis in the limb in which they were injected. Despite this, it was found that the risks of a recently immunised person developing paralytic symptoms were no greater than those of an unimmunised person – i.e., immunisation did not cause paralytic polio.54 In subsequent years, this allowed the national immunisation campaign to continue, with suspension occurring only in local areas with significant polio outbreaks. National propaganda was, however, suspended during the summer months, the “polio season” in which most cases developed.55 Despite the clear decline in the percentage of children being immunised, the second biggest reason for the decrease in absolute numbers of immunisations was the lower birth rate of 1949 as compared to the following year of 1950.56 If the polio season and declining birth rates explained most of the drop-off, then why was the Ministry of Health so concerned with apathy?
Part of the answer lies in how public health authorities monitored and identified public health problems. They concentrated on the areas of low uptake that they could combat directly – that is, the risks that could be managed. Convinced that rates were low even when one made allowances for polio and the birth rate, the Ministry surveyed parents to ascertain their attitudes towards immunisation. It hypothesised that apathy could be a problem; and sought to find it through its new research department, the Social Survey.
The Social Survey had emerged out of the war years and was the successor to the Wartime Social Survey, which was established by the Coalition government as a way of monitoring public attitudes and experiences of government departments so that policies could be more efficiently tailored to the conditions of war-time Britain.57 Building on sociological and survey methods developed in the earlier period by social research pioneers such as Charles Booth and Joseph Rowntree, and mass participation projects such as Mass Observation, it represented a shift towards technocratic solutions to social problems and an increasing faith in the state to be able to provide rational responses.58 As Lord Moran showed in 1952, surveys were seen by many in the medical establishment as an excellent tool for judging the public's mood and, in Moran's words, ‘persuading them to fall into line’ by developing ‘new methods of interesting and educating the public’ against ‘prejudices and old wives’ fears’.59 The Ministry had used the Wartime Social Survey and its successor to assess the impact of its original propaganda campaign during and immediately after the war, interviewing mothers about their knowledge about diphtheria and where they had heard about it.60 In combination, they suggested that by 1945 most mothers knew about immunisation and almost all had adequate access to clinics. Rates of immunisation were much higher than they had been in earlier years, and apathy is mentioned only as a side concern. By taking those parents who said that they ‘have not bothered, not had time yet’ and those who had incorrectly believed their children were too young, it estimated ‘about 12% of mothers have not had their children immunised owing to ignorance or apathy’.61 Nine per cent were considered to ‘have a positive resistance’ through not believing in the procedure, spousal objection or fears the child would be hurt or frightened.62
While the 1942 and 1945 surveys had specifically investigated the level of knowledge and effects of propaganda on parents, the 1951 report focused more heavily on the reasons for declining uptake. Many of the questions were similar, to allow comparison across time, but the final report spent much more time analysing the reasons for non-immunisation from mothers of young children. The Ministry hoped to find the extent of apathy and the deeper reasons for parents’ reluctance to immunise. Yet, it did not appear that – statistically – apathy could be considered a much larger problem than it had been six years previously. Indeed, direct resistance to immunisation appeared to be much lower than in 1945, with only 3 per cent of mothers considered to be opposed to the procedure.63 Thirty-five per cent of children who had not been immunised were ‘accounted for by apathy and ignorance on the part of the mother’. This, the report concluded, was a similar overall proportion to that identified in 1945.64 Even the new problem of poliomyelitis did not appear to have had much material effect. The Chief Medical Officer had claimed that the suspension of the programme in some areas had ‘naturally aroused apprehension among parents’.65 But while this was the greatest cause of the lower immunisation rates in 1950, there was little evidence that it had affected parents’ decisions about whether to present their children. Very few mothers who had not immunised their children gave the fear of polio as a reason. The debate had received some coverage in the Manchester Guardian and Daily Express,66 but despite ‘a whole series of questions enabling them to reveal their knowledge on the subject … only 4% of mothers were even aware of the possible association’.67
Identifying apathy was not solely an exercise in statistical and sociological methodology. Even if the Social Survey suggested that apathy had not increased, some MOHs and commentators at local and national levels continued to report that they had seen or felt its effects within their communities. Apathy was not, necessarily, something the Social Survey could adequately and objectively capture. It was emotional, identified as a lack of fear among parents. While less tangible than objective survey results, it was no less real to medical officers at the national and local levels. Professional experience and intuition told them that apathy was a bigger problem than it had been in the past; and this perception guided action as much as any material reality. For the Ministry, this was confirmed by their interpretation of uptake statistics. For MOHs, interactions with local citizens confirmed their suspicions. The decline both of parental fear and of the efficacy of public health's ability to communicate risk was reported in multiple forums. The COI had received a lot of praise for the cost-efficiency and positive effects of its campaigning in the 1940s,68 but the feeling was that the tactics that had been used in previous years were no longer sufficient. The Chief Medical Officer argued that it had become ‘less easy to bring home to parents the vital importance of protecting their children than it used to be when most of them had first-hand knowledge of this disease among their own and their neighbours’ children’.69 Others in the press and medical establishment agreed. The Times’ medical correspondent wrote of ‘a sense of false security’ that had tended to ‘spread throughout the community’.70 The London County Council MOH added that ‘the low incidence of diphtheria … whilst itself resulting from the successful measures of immunisation, tends to produce apathy in parents to whom the old days of diphtheria scourge were unknown’.71 Newspaper editorials also reflected concerns after the war that apathy with regard to health care extended beyond diphtheria. ‘All the efforts which are being made to improve the health of the nation will come to nothing if people, ignorantly or selfishly, neglect the precautions that are offered them free,’ argued the Daily Mirror.72 The Manchester Guardian was particularly scathing. The uptake of free orange juice and cod liver oil in schools was at less than half of official targets. Child dentistry, too, was often neglected, despite its availability on the NHS. The public, it argued in an editorial, were apathetic about prophylaxis in general, and neglecting their civic duties.
We are being kept alive longer, we are surrounded by expensive welfare systems, and yet many of us are too lazy or ignorant to give our children the safeguards to a healthy life that the State is ready to provide, and too dirty or slovenly in our personal habits to escape outbreaks of food poisoning that should never occur at all. …
We should be a far healthier nation if we turned as readily to free preventative medical services as we clamour for free aspirin and barbiturates. … It is a sad indictment of our society that we let free health go begging and then demand money in hundreds of millions to spend on “free” medicine.73
These observations, even if they were not borne out by the statistics, dominated the official narrative. They reflected contemporary concerns about good health citizenship in the post-war era, and (at least in the case of the Manchester Guardian editorial) appeared to project wider anxieties about other welfare programmes onto vaccination. While good health had come to be seen as a right across economically developed countries after the Second World War, there was also a sense that citizens had a duty to behave in way that did not put their health at risk.74 Good health meant fewer hospital visits, meaning lower direct health care costs and better productivity owing to fewer work days lost to sickness and disability.75 This meant citizens making use of welfare schemes that were provided for their own good. Parents ought to want immunisation, and they ought to present their children. If they did not do so, this apathy needed to be eliminated. The national government continued to remind the public of its obligations, but also appealed directly to parents about their own children's health and wellbeing. It stuck to its original premise of attempting to educate parents about the dangers of diphtheria and the benefits of immunisation, in the hope of increasing immunisation rates so that the disease could continue its decline throughout the country. If such tactics had worked in the past, reframing them in the wake of declining fear of diphtheria ought to work again.
The national campaign
The campaign that followed borrowed heavily from posters and tactics that had been used to establish the diphtheria programme during the war. However, the emphasis turned away from simply extolling the virtues of immunisation and towards a concerted effort to explain to parents just why they should still fear the disease, in an effort to combat apathy. The Ministry aimed ‘To persuade parents to have their children immunised against Diphtheria before they reach the age of twelve months’, and ‘To raise the level of children immunised to 75% thereby eliminating Diphtheria as an epidemic disease’.76
The justification was three-fold. First, the Ministry warned that while morbidity had continued to decline in 1951, so had the immunisation rate. Second, preliminary figures showed the 1952 was on course to be the first year since immunisation began in which mortality had not decreased. Third, the impending introduction of nationwide whooping cough vaccination led the Ministry to worry that parents would choose to ignore diphtheria altogether unless they were made aware of the risks of the disease.77
At the national level, the Ministry of Health prescribed propaganda to treat the ailment. It hired billboards for large sixteen-sheet posters, as well as initiating a targeted press campaign. The message throughout the 1950s was that ‘diphtheria still kills’ and ‘diphtheria is deadly’.78 However, resource constraints limited what the Ministry could do. For 1953 it had wanted to run a nationwide poster campaign costing £21,700. This was denied by the Treasury, who instead allowed a budget of £10,000.79 The Ministry ‘fully agreed that [this] amount … was insufficient to counteract existing apathy, make parents fully aware of the dangers of diphtheria, and emphasise that the elimination of the disease is conditional upon the maintenance of an adequate level of immunisation’.80 But what could be done? The Churchill government had placed limits on expenditure – referred to by the Ministry as the ‘Salisbury ceiling’ – and this was a time of austerity for a number of departments.81 To make best use of resources, the national campaign was targeted at those areas where the total immunisation coverage in children under five years old had dropped below 50 per cent.82
The Ministry of Health acknowledged that such efforts would be in vain without the cooperation of local authorities, showing that the diphtheria programme was not entirely “top down”. The Chief Medical Officer explicitly praised MOHs for their work, explaining that the national publicity operation could only help, not replace, the tried and tested campaigning techniques at the local level. This included further targeted advertising, but was also dependent upon the aid of voluntary organisations and efficient use of face-to-face contact between local authority medical staff and parents during the first years of their babies’ lives. Thus ‘the health visitor, midwife and clinic doctor constitute[d] the joint spearhead of the attack on smallpox and diphtheria’.83 The campaign was aimed at ‘those mothers who have been lulled into a false sense of security’, but would ‘depend, more than ever, on local initiative’. ‘If local authorities make effective use’ of the materials provided, ‘there will be fewer mothers saying “if only…” this year – and perhaps in future years too.’84
Elements of this campaign were universal in tone, seemingly targeted at all parents. We can see this quite clearly in the centrally produced propaganda materials. The 1951/52 campaign led with a striking and stark poster. It contained no images, but was a simple black typeface on a white background. It read, ‘if you had seen a child with diphtheria you would have yours immunised now’. The word ‘if’ (all in lower case) was larger than the rest of the text, and emphasised by being picked out in red.85 A later version of the same poster used white text on a black background, but kept the red colour of the opening word.86 Many leaflets and posters led with (or at least contained) the line ‘diphtheria still kills’, with emphasis often placed on the word ‘still’. Another common line was ‘diphtheria costs lives – immunisation costs nothing’.87 Having been armed with these facts, and being made aware of the real risks of diphtheria, it was argued, parents would make the right choice: ‘The wise parent knows … that with the best care in the world any child, and particularly a baby, may fall ill’, after all.88 The only way to insure against this was via immunisation.
Another universal approach was to send postcards to houses where a child was about to reach their first birthday. Decorated like birthday cards, the imagery of celebration helped to present the Ministry's central message. First, it reminded parents of the need to get children immunised before they turned one; and second, it reinforced the idea that immunisation was a gift, and one that both parent and baby would appreciate in time. Local authorities in London found this a particularly helpful tactic, one that was both universal and, by physically entering the homes of potential contacts, in some ways personal. Not everyone could be met by a health visitor, but almost all could be reached through the Royal Mail.89 It played to the very personal relationship between parents and their young children. ‘Only if parents are wise enough to give their babies protection can this deadly disease be held in check,’ declared one leaflet.90 Such rhetoric also emphasised that central tenet of the liberal British public health tradition: immunisation, while clearly desirable and implored by the government, was still a choice.
Despite the universalist overtones, the government was clearly selective in where it targeted its messages. It made very deliberate choices in how and where these messages were sent, telling us much about just whose “apathy” was considered a danger. In doing so, it focused on the group in whom it felt apathy was the most dangerous. As had been made clear from the Social Survey, investigations into parental responses to diphtheria and immunisation had questioned only mothers.91 Here it had found only a small number of families where immunisation had been refused on the basis of the father's disapproval. These were not further sub-divided in the published statistics, though the report mentioned that about half of those questioned about the father's objection noted bad experience of (smallpox) vaccination in the armed forces and among other parents. All other reasons for non-immunisation were attributed to the mother. Apathy was measured through four categories of response considered to be ‘unsatisfactory excuses’. These were ‘father does not agree’, ‘does not believe in it’, ‘never heard of it’ and ‘not bothered’. All placed the blame on the mother.92 This in itself is quite illuminating. ‘Never heard of it’ would imply a lack of knowledge rather than a lack of care. Yet clearly the authorities were willing to conflate the two. In the midst of a long-running national and local campaign, ignorance was not an excuse. Similarly, ‘does not believe in it’ and ‘father does not agree’ would imply positive objection rather than apathy. At face value, only ‘not bothered’ would constitute indifference. In all of these cases, however, the assumption on the part of health authorities would be that these issues could be cured through education and persuasion. If, in the British liberal tradition of public health, apathy were overcome through giving rational actors the correct facts about health care, then, once mothers (and, in some cases, fathers) were properly educated, these problems would cease. For the Ministry of Health, apathy could cover a range of public responses, so long as they were surmountable through good education.
The focus on mothers can in large part be attributed to mid-century visions of the role of mothers within the family, with women traditionally being seen as the primary – and, at times, only – caregivers.93 This had been a common theme in public health from the late nineteenth century, the point at which ‘motherhood’ became an ideological and political state rather than simply a descriptive term for being a mother.94 But it was not inevitable that fathers would be side-lined. During the interwar years, the role of fathers in the care and raising of children began to gain importance.95 An agony-aunt column in the Daily Mirror clearly felt that fathers had a role, with Sister Clare telling dads to ‘put [their] foot down firmly here and insist’ that the mother agree to immunisation.96 The original survey in 1942 did investigate whether ‘husbands’ were consulted in the decision to immunise the child. Fifty-four per cent of mothers said that they did consult their husband, with 40 per cent declaring that it was their ‘own decision’. Husbands from more affluent backgrounds were more likely to be involved, but even in the ‘D’ social classes, there was an equal split of ‘own decision’ and ‘consulted husband’ from those who gave a positive response to the question.97 The Social Survey did not follow up on this in 1945 or 1951. Since husbands did not appear to be a barrier to immunisation, and wives had shown their capacity to immunise unilaterally, it seems resources were moved to mothers, where they might achieve more immediate results. Apathy among fathers was hence viewed as largely irrelevant; and indeed, their place within this decision-making process was discussed only in relation to their refusal to immunise.
Only one press advertisement in the COI file on the diphtheria campaigns specifically spoke to ‘father’; and this had effectively the same content as a contemporary advert showing a picture of a mother with her child.98 This was a long-running theme. Of the thirty-one magazines listed in the 1942 campaign information brochure, nineteen contained words related to women readers, with none aimed at men.99 Other actors within this process expressed similarly gender-imbalanced views. The press and local authorities both focused on the sensibilities of the mother. One secretary at a north London town hall objected to the ‘ghastly’ ‘if’ posters, sending them straight back to the Ministry. She noted that the mothers in her area would be disturbed by the messages and the imagery, and made a request for the ‘pretty’ baby posters of previous years.100 In this specific case, at least, it was felt that apathy could be overcome through a more overtly feminine message rather than through fear. Immunisation messages could also be integrated into pre-existing public health schemes. For example, some local authorities had special film screenings for women, which included other “mothercraft” messages such as disseminating techniques for teaching young children how to walk.101 Patricia Hornby-Smith, the Minister for Health, gave a speech warning against apathy at press events organised at a new maternal welfare clinic.102 As for the press, The Star, a London-based, populist newspaper, ran a number of stories during 1955 in favour of the immunisation scheme.103 It was far more explicit about the role of women than the official national propaganda. And far more judgemental. An editorial written by the paper's own ‘Harley-st Doctor’ put the blame for low immunisation rates on ‘Silly Mothers’ who ‘after all the proofs of its value … raise silly objections’.104 Even those with less judgemental tones highlighted the example of the ignorant mother. The Bristol MOH was quoted in a Bristol Evening World article recounting a conversation with ‘a young mother at a Bristol clinic’ after seeing a ‘Diphtheria Still Kills’ poster: ‘ “But,” she said to the Sister, “I thought it meant only a few spots and Johnny would be over it in a few days. I didn't know it was so dangerous.” ’105 If apathy was a problem with parents in general, it was clearly the responsibility of mothers to overcome it.
The 1951 Social Survey indicated some class divide in the uptake of immunisation, as shown in Table 1.1. Sixty per cent of children (of all ages) whose mothers had left school before they turned fourteen were immunised, versus 85 per cent of those whose mothers had been educated beyond the age of fifteen. Similarly, 61 per cent were immunised in households where the main wage earner took home less than £5 per week, as compared to 80 per cent in households where the main weekly wage was more than £10. There was little variation among those outside of the poorest families. The core of the campaign, however, was focused on increasing the immunisation rate in children younger than one year – and here, rates were more even. Fifty-six per cent of children were immunised before twelve months in the lowest earnings bracket, with between 61 and 63 per cent for the higher incomes.106 Using the ‘unsatisfactory excuses’ noted earlier, apathy was measured at 36 per cent among least-educated parents, versus 28 per cent for the most-educated. There was a bigger divide across income brackets, ranging from 45 per cent among the poorest to 24 per cent among the better-off.107 As also shown earlier, in 1942 a greater number of higher-income parents had made a joint decision on whether their child would be immunised.108
|Proportion immunised||Proportion of immunisations before first birthday||Proportion of mothers’ reasons taken as ‘unsatisfactory’||Proportion vaccinated [against smallpox]|
|Left school before 14 years||60%||60%||36%||28%|
|Left school when 14 years old||73%||59%||31%||37%|
|Left school when 15 or over||85%||64%||28%||61%|
|Weekly income of head of household|
|Up to £5||61%||56%||45%||39%|
|Over £5 to £7 10s||73%||61%||31%||39%|
|Over £7 10s to £10||80%||63%||27%||43%|
|Number of children in family|
|Four or more||55%||50%||35%||26%|
|All children aged 6 months to under 5||74%||60%||31%||42%|
The Ministry acted upon this information with its propaganda campaign. Although this is not made explicit in the literature, advertising space was bought in papers such as the Sunday Express, News of the World and People, but not in more middle-class papers such as the Mail on Sunday, Sunday Times or Observer.109 By 1951 the number of national titles targeted had contracted, but there were still two explicitly mentioned categories of publications: ‘the more widely read national Sunday and weekly papers and the most suitable women's weekly magazines’.110 There was a prima facie case for using these periodicals. The more “populist” the titles, the larger the audience, and the more people who would see the advertisement. Local authorities also tried to promote immunisation uptake in traditional “black spots”, often in more deprived areas. Manchester used a mobile immunisation van in the 1940s and gained press coverage in the Manchester Guardian for it.111 ‘Division 3’ in London (covering the boroughs of Finsbury, Holborn and Islington) used a similar vehicle that toured busy shopping centres, hoping to reach children who had not yet been immunised.112
Class was not as explicit in the national campaign as gender was. The government had targeted specific locations for increased advertising or epidemiological intervention, but these areas were identified based on their aggregate immunisation rates and not specifically the class composition of local authorities. Partially, this reflected the mass nature of propaganda campaigns. The national government's concern was to tackle apathy by generally raising awareness of diphtheria and the associated risks through a coordinated use of media that would reach the most number of people with the greatest impact. By definition, this would have to be broad and largely “populist”. It was the job of local authorities, with their knowledge of the peculiarities of their unique circumstances and demographics to further target the specific populations and families that were non-compliant.113
In the press and in the justification for national campaigns against diphtheria, apathy made sense as a central narrative. On the ground, medical authorities presented a different picture of the reasons for non-immunisation and ways of tackling it. A more complex interaction between the public and the immunisation programme emerges, in which the government adapted to parents’ concerns. To begin with, the rhetoric of apathy did not necessarily make sense with the data coming back to public health authorities. This was evident even from the way in which the Ministry of Health targeted those local authorities with lower immunisation rates. The Ministry was limited in the direct action it could take, as each authority ran its own public health schemes through its MOH. While the MOHs were empowered or compelled to act in certain ways, prioritisation was a local matter. One direct intervention the Ministry could make was advertising. Originally the plan had been to treat all areas equally, but expenditure limits forced greater selectivity. Instead, the government paid for advertising only in the counties and county boroughs with the lowest immunisation rates.114 The use of advertising as a public health measure relied on the assumption that lower rates in those areas were due to a lack of knowledge or apathy (in comparison to the better-performing authorities) rather than to any other local peculiarities.115 Even so, the Manchester Guardian noted that the results of the 1945 Social Survey suggested that parents in the northern region knew more about the nature of diphtheria and facts about immunisation, and yet had a lower immunisation rate than the national average.116 Of the 26 areas targeted due to low immunisation rates in 1952, only 7 were outside the industrial Midlands or the North.117 Education did not appear to be the problem; the issue was persuasion. As with the ‘unsatisfactory excuses’, the Ministry's conception of apathy appeared to conflate the issues of ignorance, indifference and disbelief. Despite this contradictory feedback, the government continued to centre its actions on parental apathy.
An outbreak in Coseley, in the Black Country, appeared to justify this approach and confirm judgements about apathy in mothers from certain areas and from certain backgrounds.118 At the same time, it exposed failures in the logic that education and fear of the disease would be enough to make parents comply with official advice. The town had gone through a diphtheria epidemic in 1951, with 66 cases. Despite an intensive immunisation campaign, there were a further 20 cases in 1952 and 38 in 1953. In 1953, Coseley accounted for almost a third of all cases in England for the year.119 The intensified immunisation efforts by the local medical authorities succeeded in immunising 78.5 per cent of school children in the district. However, 60 per cent of pre-schoolers remained unimmunised, despite the clear evidence that diphtheria was endemic.120 According to the Chief Medical Officer's report for 1953:
In Coseley, as elsewhere in the country, it was found in most instances the parents of unimmunised young children had no objection to the procedure. They were merely indolent and quite apathetic concerning the matter … Later, when the child could be immunised at school, without any inconvenience, they readily consented. Nevertheless, there was the odd instance of the obdurate parent who could not be persuaded to have his children protected, even though other members of the household had contracted the disease. In several instances in recent years, in Coseley and elsewhere, this refusal has brought tragic consequences – the child not only contracting the disease but succumbing to it.121
One of the striking things about this passage is how the Chief Medical Officer repeatedly draws parallels between Coseley and the rest of the country. What happened in Staffordshire could happen anywhere. The tone, however, is far less sympathetic than the content of the national propaganda campaigns. The parents in Coseley were wilfully choosing not to immunise their children. Parents knew that diphtheria was still a menace, yet they were unwilling to make the effort to present their children to medical authorities until the medical authorities came to them. Even then, it could be a struggle. An official from the Staffordshire Health Department despaired, ‘we send them forms and tell them of the dangers … but they don't bother to return the forms’.122 This interpretation relied on a contradictory definition of apathy. Much like the ‘unsatisfactory excuses’ in the 1951 Social Survey, the unwillingness or inability to assimilate official advice and make the “correct” decision about immunisation could at once be attributed to wilful resistance and apathy. And yet, the education campaign continued. Local Alderman George Newham's response to parents who had fears about immunisation was thus: ‘They haven't been educated … We are still having to teach them.’123
Coseley further showed the way in which a number of phenomena could be attributed to apathy. It also highlighted the difficulty of effectively monitoring and intervening in the lives of children without the full cooperation of parents, especially in pre-schoolers. Apathy could therefore also apply to parents who were unwilling to make sacrifices to the greater good. This could include: consent to the procedure in principle; taking the child to the clinic; waiting for the doctor; and having to deal with any potential consequences of the procedure, from irritability to other more serious side-effects. With all these costs and risks, the government was asking a lot of mothers – and it was almost always mothers – with young children. For some, this was part of civic duty, echoing Bevan's words about the ‘energetic cooperation of every citizen’.124 As early as 1946, a coroner in Stoke-on-Trent accused the parents of a child who died of the disease of ‘grossly selfish humbug’ because ‘they had not bothered to have their child Theresa … immunised’.125
Most authorities, however, were much more restrained. For example, the MOH for Camberwell reacted to an outbreak of diphtheria in his borough in 1959 by imploring parents to ‘do the right thing’ by the country. ‘Public apathy and complacency have grown concomitantly with the diminution of a disease, the ravages of which are unknown to the young parents of today,’ Chalke wrote.126 The outbreak served ‘as a dramatic reminder … of the damage that can follow unbelief in the efficacy of immunisation’. Aside from the school absences and risks to the individuals, it was a drain on the time and resources of health workers and hospitals.127 Despite the moralising tone, there is no evidence in his report that parents were being actively blamed for wanton ignorance or refusal to submit to reason. But there was a sense that some parents were ‘lacking a communal health consciousness’.128 Immunisation was not simply an act for personal protection. It was part of a wider citizenship, both for protecting the “herd” against disease and ensuring that medical resources were not spent fighting a disease that should, but for apathy, be eliminated from British cities. Once again, health care was not only a right of the new, technocratic welfare state; it was the duty of citizens to help themselves and others by availing themselves of these facilities.129
Apathy could exist as a general narrative, but this did not have to dictate the specific courses of action taken by health authorities to improve immunisation rates in their local areas. As Jane Seymour and Luke Blaxill's work on the London MOH reports shows, local officers had become less judgemental of citizens as the inter-war years progressed, instead focusing on service provision and understanding of local structural factors to improve health outcomes.130 London's immunisation rates for children under the age of five remained poor. Only 55.4 per cent of children aged 0–4 had been immunised in 1950. That figure rose to 67 per cent when children under one year of age were discounted.131 Despite this, apathy was rarely blamed when the disease hit. An outbreak of diphtheria in West Ham had led to an intensified immunisation campaign.132 Fourteen cases were reported in 1955, and a further two in early 1956. This was the first time since 1948 that the borough had experienced more than five cases in a single year.133 From 1955 to 1956, the number of children of school age being fully immunised rose from 52 per cent to 87 per cent. Yet the number of pre-school children being immunised remained lower – rising from 56 per cent to 76 per cent.134 The West Ham MOH reports made no mention of apathy, nor any judgements on the behaviour of parents during this period. The only hint we can find is in the 1956 report, when the Officer makes reference to the number of parents who fail to keep their appointments for the new polio vaccination. He assumed that with this specific vaccine parents ‘still had doubts about [its] safety’.135 A similar picture was found in Finsbury. Blyth Brook, the borough's MOH, mentioned nothing about the behaviour of parents and described a 1959 outbreak as having little more than ‘nuisance value’.136 This may well have been a case of public relations management, downplaying the significance of an infectious disease so as not to stir panic. It was the first time that there had been so many cases of the disease in the borough since 1941, and the first time since 1945 that more than six diphtheria notifications had been made. However, there is no evidence of resistance to this line of reasoning, and no major panic. Blyth Brook's report focused instead on the specific steps that his inspectors and immunisers made in bringing the disease under control. The blame lay in the diphtheria bacillus itself, and was dealt with like any other public health ‘nuisance’.
The national government had focused on a publicity campaign partly because this was an area of activity over which it had some control. Local authorities, however, had the advantage of being able to reflect on micro-level issues such as practical access to services. They could, and would, act independently of the Ministry in order to meet their own public health goals. The government acknowledged this in its campaign materials, encouraging MOHs to use their local knowledge, social workers and voluntary organisations to help spread the message about immunisation and raise acceptance rates.137 Rather than solely blame parental apathy, MOHs did what they could to target black spots and bring immunisation services to parents, rather than waiting for children to come to them. The immunisation vans in Manchester and northern London show this most clearly.138 Education could also be better targeted according to local custom. R. J. Donaldson (Rotherham's MOH) wrote to the Ministry in 1955 asking for help with locating a film van that he could take around the town. ‘I do feel many people fail to read … advertisements,’ he lamented.139 On top of this, traditional services were strengthened. New clinics were set up, and hours extended. Immunisers went to day nurseries and infant welfare sessions to meet parents directly. In one borough, the medical authorities organised an exhibition in which the immunisation session was open to the public to see just how efficient and desirable protection against diphtheria could be.140 Health visitors were another key tool. These had been used first by voluntary and then by statutory organisations in the field of infant welfare since the late nineteenth century.141 Their role had become more formalised and professionalised over the twentieth century, and in the post-war years was more akin to that of the social worker as we now know it.142 From the beginning of the anti-apathy campaign, the direct contact that they enabled with families was considered vital.143 London County Council considered health visitors along with clinic staff and doctors as the reason why their immunisation programme had been a success.144 Midwives and health visitors were made aware of every birth in the county and, as part of their other tasks, would press upon parents the need for immunisation.145 It was always known, then, that propaganda (in the form of posters, press advertisements and film) would not be enough on its own to combat apathy. The government, through its local administrative machinery, had to go to parents and ensure that immunisation fitted in with their lives. As the 1951 Social Survey had found, children in larger families and with poorer parents were less likely to be immunised (see Table 1.1). Better provision of services and direct communication were needed to make parents believe that immunisation was a high-enough priority for them to seek it out. Apathy did not just require a change in parents’ attitude, it also needed compromise and cooperation from health authorities.
Indeed, there was an inherent acknowledgement in the 1950s campaign, even in central government, that parents’ responses to declining diphtheria rates were rational. While the ‘false sense of security’ was worrisome,146 it was ‘understandable’.147 The immediate risk of diphtheria was less obvious to parents, and therefore managing that risk at the individual level was less of a priority.148 Clearly, parents had concerns over other diseases that felt more immediately threatening – even MOHs themselves had to deal more with outbreaks of poliomyelitis and whooping cough.149 In another attempt to meet parents’ concerns and leverage these to increase diphtheria immunisation, local and national authorities began to use the newly available pertussis vaccine as a way to entice parents to the immunisation clinic and, proverbially, kill two birds with one stone. The 1951 Social Survey had found that parents still found diphtheria to be the most dangerous child illness by some margin, followed by whooping cough.150 Yet MOHs continued to assert as the decade progressed that they found it easier to convince parents to present their children for pertussis immunisation.151 In 1953, the Ministry had feared that this would leave diphtheria under-appreciated.152 But widespread use of the combined immunisation just a few years later meant that local MOHs could protect children against both diseases at the same time. Another positive for the Ministry was that whooping cough immunisation was recommended at an earlier age than diphtheria, meaning that there was more time to administer prophylaxis against diphtheria before children turned one year old.153 In London, protection against diphtheria in children from one to five years old rose from 63.1 per cent in 1953 to 74.1 per cent in 1960 and 94.7 in 1964.154 The vast majority of these injections came from the combined prophylactic.155 There were other ways to overcome apathy than education and persuasion. Restructuring of services and response to local circumstance were perhaps more effective in some ways than national propaganda.
The campaign appeared to be a success. As the combined vaccine and other localised public health measures continued, the overall immunisation rate across the country did improve. Immunisation among children under the age of one grew from 28 per cent in 1951 to 44 per cent in 1956.156 Perhaps more importantly, diphtheria did not make a resurgence. Morbidity and mortality continued to decline, and in 1959 nobody died of the disease (Table 1.2).157 In the later 1950s, talk of apathy continued in the national press, but at a much lower level than at the beginning of the campaign. This made the occasional outbreak newsworthy rather than a routine occurrence. One major example of this happened in September 1960, when a girl died in Derby. V. N. Leyshon, the city's MOH, sent details of the case to the national press and it gained widespread coverage. It was seen as a warning that parents could not give into complacency – or apathy – and that immunisation against the disease was still necessary. Leyshon reported some days later that the publicity had achieved its objective. His clinics had been inundated with requests, and the city's immunisation rate improved dramatically.158 Even after the relative successes of the 1950s campaign– and despite the experiences of MOHs on the ground over the decade – apathy could still be invoked as a criticism of and warning to parents across the nation.
The anti-apathy campaign had started from the premise that the main issue stopping parents from presenting their children for immunisation was declining fear of diphtheria. In the British public health tradition, the Ministry of Health trusted the power of propaganda, education and persuasion to convince rational citizens to make the right decision for their own and the nation's benefit. In practice, “apathy” served other purposes. It was a convenient scapegoat for local and national authorities attempting to explain their inability to maintain high levels of protection among the public. Local MOHs had to justify their progress (or lack thereof) in their annual reports. The government, too, had clearly assumed responsibility for the health of its subjects and needed to explain how and why outbreaks of a preventable disease had been allowed to happen. Apathy allowed the medical establishment to outline the need for personal responsibility and good health citizenship. It was also clearly a concept that could incorporate a number of different public behaviours and still maintain enough coherence to persuade the Ministry, local authorities and the press that it was a clear danger to public health. Ignorance, indifference, disbelief and unwillingness to perform civic duties were all used in various ways to justify the central narrative of the campaign.
Apathy was also an appealing explanation because the Ministry already had multiple tools and administrative structures with which to combat it. It was a manageable risk. If indeed the issue was one of education and persuasion, the Ministry was in a position to utilise the COI and could build upon a long history of local public health campaigning with voluntary organisations, press cooperation and medical clinics. Citizens could be reminded of their obligations and the Ministry could appeal to parents’ self-interest. While this was the main thrust of the campaign, however, in practice national and local authorities realised that “propaganda” alone would not tackle root problems. The government adapted its own tactics in response to the various ways in which parents’ apathy spoke to the medical establishment. Through the Social Survey, statistical analyses and contact with parents on a number of levels, health authorities were able to modify their administrative and medical arrangements so that they were better attuned to the public's needs and concerns. It allowed MOHs to see both what was attractive and unappealing about diphtheria immunisation. Longer clinic hours, health visitors, mobile immunisation vans and the use of combined prophylactics were combined with existing propaganda arrangements to make immunisation against diphtheria a more attractive proposition. In other words, to rectify a national public health problem, local service provision had to be improved.
Apathy was a construct, then, that was created by local and national public health bodies as a form of communication: a translation of the diffuse behaviours of the public into a language which administrators and policy makers could understand. It was a framing device that could incorporate elements of public behaviour that were not precisely quantifiable or identifiable. As such, it kept many of the paternalistic elements of 1950s society and attitudes toward women and “the masses”. It could simultaneously see resistance, disbelief and indifference as part of the same phenomenon, because all indicated that the public had not yet realised the “facts” on immunisation. But it was not an entirely one-sided conversation. The public could be seen to react and respond to changes in policy through the myriad administrative surveillance tools developed over previous years. In the end, apathy was the overall concept employed by government to justify its propaganda campaign; it was the more nuanced local interactions with the public, though, that made it a qualified success.