As the USA continues its long-running debate over the proper role of the state in the provision of healthcare to its citizens, historians might be tempted to rehearse what are now well-established arguments about why the USA alone among leading Western democracies lacks a system guaranteeing universal access to medical care.¹ Despite its theoretical and methodological diversity, the abundant scholarly literature addressing American healthcare provision shares to a greater or lesser degree Beatrix Hoffman’s assessment that ‘what did not happen’ – in her work, a failed New York State campaign for compulsory health insurance in the aftermath of the First World War – ‘shaped what did’.² Each cycle of intervention in the provision of healthcare – from reformist innovation to ideologically and procedurally driven political battles to eventual legislative compromise, limited and partial implementation, and consequent, often unintended sequelae – pre-conditions present and future debates, leaving historians to sift the ‘cumulative sediment of negotiated cease-fires between powerful stakeholders’ for glimpses of the future.³

Much has been written in a comparative vein. Responding to contemporary debates, historians and others have analysed the different pathways taken by the USA and Canada.⁴ These accounts lean heavily – and often narrowly – on the close scrutiny of political and economic forces and actors. ‘Political culture’ – once favoured and then contested as an explanatory model for American exceptionalism in healthcare – is again attracting attention in the literature.⁵ Recently, historians of medicine have called for wider recognition that health systems incorporate more than their political, economic, and institutional components; that they include, as Charles Rosenberg has argued, a ‘cultural politics’ consisting of the ‘expectations and norms’ of their host societies in relation to both bodily health and the balance between social and personal responsibility.⁶ However, with few exceptions, even such interpretations focus largely on high politics and elite discourses rather than those intended for, and accessible to, the general public.⁷ Cultural representations of twentieth-century healthcare systems, providers, and user-consumers have certainly captured attention in the last twenty years.⁸ However, these representations, and indeed the beliefs and trends which underpin them, have rarely featured in studies of the marked and persistent diversity of healthcare systems in post-industrial societies.

What might a cultural history of responses to and projections of the National Health Service (NHS) add to our understandings? Here I will show that attending to popular culture in particular allows us to identify and explore the deliberately constructed and meticulously curated meanings of Britain’s NHS for domestic and international audiences at the heart of key debates during the Cold War. At the same time, close scrutiny of popular culture reveals that many of the cultural tropes currently dominating America’s idiosyncratic opposition to state-funded universal healthcare nucleated around the NHS in its first decade. During this period, representations specifically of the NHS became fiercely attacked and hotly defended stand-ins for the post-war British welfare state, and for all state provision of universal access to medical care, eclipsing other emerging models for state-supported healthcare in US debates.⁹

Visions of the NHS – often ‘frankly propagandist’ – functioned in this period as evidence in two key areas. First, for Britain, the post-war delivery of a massive and generous programme of social services directly rebuked both internal and external narratives of national decline. The health service, as an internal British Broadcasting Corporation (BBC) memorandum recorded in 1948, was intended by the UK government ‘to project to the world outside the notion [...] the object lesson that this country, which in some quarters is thought to be economically crippled, can nevertheless plan and execute a large comprehensive scheme of social improvement’.¹⁰ At the same time, the NHS and parallel social legislation represented a direct experimental intervention in polarising debates between the USA and its European allies about whether investment in welfare or in warfare would more effectively contain the spread of communism.¹¹ If for Britain, welfare provision was both a sign of national prestige and a powerful weapon against communist ideology, for the USA – initially bankrolling both reconstruction and re-armament across Western Europe – it drained scarce resources that would be better spent preparing militarily and economically to meet the emerging Soviet threat.¹² Worse, welfare socialism was widely represented in the USA as obscuring the benefits of capitalist economic growth, and even as a dangerous concession to communism. American cultural representations of the NHS, the first and initially the most generous national health system to emerge in post-war Europe, reflected these anxieties. Conversely, the intense early activity of British state and professional actors seeking to shape US perceptions of the NHS indicate its early symbolic role for a nation promoting a vision of successful and ‘equalitarian’ reconstruction and of welfare as a tool of (Cold) warfare.

In the following section I will examine visual and textual representations of the NHS in the US popular press from the 1946 passage of the National Health Act to the tenth anniversary of the NHS in 1958. During this period, Americans experienced heated debates about health and welfare reforms, intensified by media-stoked fears about the spread of socialism and communism in Europe and across the globe. This was the cultural filter through which almost all information about the NHS passed into US public discourse. It was also, I suggest, this moment which naturalised the enduring predominance, at least in popular discussions of health reform, of comparisons between American and British models of health provision. In subsequent sections, I will reflect on British responses to the resultant image of a failing service in a declining and ideologically suspect nation.

Seeing and suspecting the medical state

By the time Britain’s NHS opened its doors on 5 July 1948, US newspapers and periodicals had already demonstrated lively interest in the new service. National papers like the New York Times, the Washington Post, the Chicago Tribune, and the Los Angeles Times covered Beveridge’s proposals and the government’s White Paper with sceptical interest; and Aneurin Bevan’s battles with Britain’s doctors and dentists with zest. As early as 1944, mainstream – and ‘main street’ – magazines like the Saturday Evening Post were already campaigning alongside the organised medical profession against what they characterised as demands that ‘doctors be sovietized’.¹³ Such articles certainly responded to a US political climate in which health reform of some kind seemed inevitable, and to the famous and long-running campaign conducted by the American Medical Association (AMA) against any and all forms of state intervention in the medical marketplace, including the initially popular Wagner–Murray–Dingell and Truman proposals for compulsory national health insurance for workers, retirees, and their dependents funded through payroll deductions.¹⁴ But they were also a part of the wider battle over Europe’s future; it was no coincidence that Britain’s state-funded purchasing of medical services from explicitly independent expert providers was mischaracterised as ‘sovietization’: the AMA’s most effective and most often-repeated slur represented the NHS as ‘socialized medicine’.¹⁵

The AMA’s strategy of using the NHS as a ‘whipping boy’ to influence the US healthcare debate by painting all state welfare provision as a slippery slope to communism dismayed civil servants and politicians in Whitehall.¹⁶ Returning from a 1950 tour of the USA, the Minister of Pensions, Hilary Marquand, complained bitterly to Bevan about the ‘scandalous shame’ of the AMA’s ‘blackguarding of our National Health Service for their own political campaign’ and demanded active efforts to influence US opinion and media coverage both formally and through informal networks.¹⁷ As this chapter will discuss below, such efforts were already underway both within and beyond the Ministry of Health and the British Information Services (BIS), though they never would equal the reach of the AMA’s richly funded publicity machine.¹⁸

What, then, did US coverage of the NHS look like between 1948 and 1958? Portrayals and responses to the NHS in US general periodical magazines varied from the cautiously positive assessments of outlets like the Atlantic Monthly, catering to an educated and relatively affluent readership on the eastern seaboard, to the scepticism and outright hostility of the national middle-brow magazines – perhaps most notably Reader’s Digest, but also Time and Life – serving America’s conservative heartlands. Women’s magazines, interestingly, featured the NHS infrequently, but more positively. The national newspapers (by which I mean those widely available beyond their city or region of origin) took positions that reflected their regional and political commitments. While none welcomed the service with open arms, the New York Times and Washington Post broadly represented the NHS as a popular – if expensive – ‘test tube experiment’ from which the USA might learn.¹⁹ Contrastingly, the Chicago Tribune, based in the home city of the AMA and with enduring editorial links to its leadership, was unremittingly negative in its coverage of the NHS, consistently framing it as ‘socialized medicine’ of low quality and high cost. The Los Angeles Times, operating in a region that pioneered voluntary pre-payment medical plans and in which healthcare featured in hotly contested gubernatorial campaigns, was consistently hostile to ‘socialized medicine’ but fluctuated on the NHS.

Across these national papers, reportage on systems of health provision generally responded to one of two prompts. As Figure 11.1 indicates, by far the more significant stimulus was provided by domestic political debates about health reform, and particularly questions about whether ‘socialized medicine’ was the right health system for the USA. For instance, the New York Times addressed ‘socialized medicine’ as a principal or secondary theme in some 581 articles, reflecting the intense attention provoked by the AMA’s inflammatory campaign against government intervention in the medical marketplace.²⁰ The majority of these addressed the US domestic situation, and explicit discussion of Britain’s NHS was a minor theme by comparison. Nonetheless, the papers did cite international examples, either as cautionary or as aspirational models. A closer review of coverage of ‘socialized medicine’ in the digitised archives of the Chicago Tribune, the New York Times, the Washington Post, and the Los Angeles Times reveals that the British or English system (the terms were used interchangeably) was by far the dominant comparator used to illustrate arguments for or against the introduction to the USA of any national or universal system of state-funded healthcare or health insurance (see Figure 11.2).²¹ For instance, in the New York Times, systems of provision in Europe as a whole received four mentions, and Argentina, Australia, Canada, Chile, China, Columbia, Guatemala, Hungary, Israel, Italy, Japan, Palestine, Scandinavia, Spain, and the Vatican State each appeared once. Sweden was cited eight times, and Russia or the Soviet Union nine. Britain and England, in contrast, drew 128 references, many of them substantive.

Figure 11.1 Press coverage of US healthcare debates, 1948–58.

Less common but more revealing were responses specifically tackling observations, claims, rumours, and myths about Britain’s novel medical system. The New York Times carried more than 200 articles featuring discussion of the NHS from the advent of the NHS Bill in 1946 until its tenth anniversary in 1958, while the Chicago Tribune ran 101. All four of the national papers I surveyed reported the initial spike in demand for medical services and appliances, the return of prescription charges, and other tensions between the Ministry of Health and medical professionals avidly throughout the 1950s. None gave significant positive coverage to suggestions that the USA might simply adopt the UK system or one like it. Indeed, early suggestions from Oscar R. Ewing, the US Federal Security Administrator charged by President Truman with shaping a new US health plan in 1948, that America might reform along British or European lines prompted lively and often angry coverage across the papers, eventually forcing him to publicly recant.²²

Figure 11.2 Comparator health systems in the ‘socialized medicine’ debates, 1948–58.

With the NHS implemented by an explicitly socialist government through the nationalisation of the vast majority of Britain’s hospitals, both its symbolic importance and its specific vulnerability to a US politico-medical discourse that increasingly mobilised fears of communism are clear in relation to the heated debates around healthcare provision that preoccupied American medical professionals, politicians, and the medical media in the post-war years. Britain’s successful implementation of the NHS in 1948 was in sharp contrast to four failed US efforts to pass national healthcare legislation between 1939 and 1947. Following the Democratic President Harry Truman’s unexpected re-election in 1948, many medical professionals, industrial stakeholders, and economically conservative or free-market politicians met his renewed efforts to enact a national insurance plan with enormous hostility.²³ As numerous scholars have observed, their central rhetorical strategy, pioneered by the AMA, was the liberal application of provocative terms like ‘socialism’ and ‘socialized’ to any system of healthcare provision which deviated from entirely private, fee-for-service relations between doctors and their patients.²⁴ With Cold War re-armament exacting a growing toll on US (and UK) resources, this rhetoric successfully drove out alternative language for state-mediated universal health provision, including the initially common ‘nationalized medicine’, which withered to just twelve appearances in the New York Times between 1946 and 1958; ‘government medicine’, which attracted fifteen uses; and ‘political medicine’, which appeared ten times. By 1955, even supplying free polio vaccines to poor children could be tarred as ‘socialized medicine’.²⁵

Lavishly funded and deliberately wide-reaching – the AMA worked tirelessly to recruit local medical organisations and other potential allies including small businesses – this fear-mongering campaign was also richly visual in an effort to reach beyond the active newspaper readership into the media hinterland of less confident or engaged readers.²⁶ Notably, while the AMA occasionally referred to other state healthcare systems, the bulk of its critiques of ‘socialized medicine’ explicitly or implicitly drew upon the British NHS. Indeed, as the historian Jill Lepore documented, the AMA’s political consulting firm, Campaigns, Inc., made strategically linking the English NHS to communism the backbone of its work as a tactic to turn the question of state healthcare provision into one of ‘whether we are to remain a free Nation […] or whether we are to take one of the final steps toward becoming a Socialist or Communist State. We have to paint the picture, in vivid verbiage […] of Germany, Russia – and finally, England.’²⁷ Paint the picture they did, evoking wars both recent and future: ‘On January 1 [1949], American medicine stood virtually alone’, cried its 1949 ‘Campaign Report’ to its AMA funders, as ‘the virus of socialized medicine […] spread from decadent Europe’. The same document included a letter from Elmer Henderson, Chairman of the AMA’s National Education Campaign, predicting a ‘Battle of Armageddon’ to determine ‘not only medicine’s fate, but whether State socialism is to engulf all America’. Profusely illustrated (see Figure 11.3), the report reproduced, among many cartoons, a Chicago Herald-American depiction of a Viking longboat, its sail emblazoned ‘The Welfare State’; sweating as they manned its oars were ‘doctors, lawyers, merchants, etc.’ And fundamental to facilitating the campaign, this document reported, was a fully staffed ‘observation post in London’.²⁸

Like the AMA’s campaign literature, US newspapers and popular magazines included visual representations of the NHS to capture their readers’ attention. These too were carefully selected to reinforce each outlet’s editorial stance on a hotly contested topic. Thus the Ladies Home Journal, generally positive about the NHS, illustrated its 1950 extended feature article ‘Can a Nation Afford Health for All its People?’ with a photograph, covering a page and a half, of children and women with various injuries smilingly waiting in a queue while a nurse takes information from a girl in a wheelchair at the front of the line.²⁹ The New York Times, ambivalent but interested, pictured bored patients in waiting rooms and happy patients receiving (free) spectacles, but also regularly reproduced UK editorial cartoons critical of the NHS.³⁰

The digital availability of Life magazine’s entire photographic archive in conjunction with its published visual and textual content allows some analysis of this selection process and its effects on US representations of the NHS. Throughout the late 1940s and 1950s, Life, steered by its staunchly conservative owner and editor-in-chief Henry Luce, turned a sceptical eye on Britain’s social services, including the NHS. All discussions of the welfare state were framed by visual and textual cues presenting Britain as devastated and grimly impoverished by its hard-won victory, kept afloat only by US aid (‘the famed US loan’) and her ‘stubborn, indomitable spirit’. A 1947 photographic essay and article both lingered on the themes of ‘privation’ and rationing. Hamstrung by ‘great poverty’ and ‘industrial anemia’ (linked suggestively to comments about socialism), the text proclaimed, ‘Britain is no longer a great power’, implicitly adding weight to Luce’s call for a globally active and interventionist America. Britain’s ‘cradle to grave’ socialism meanwhile meant that ‘[e]veryone in Britain must share the misery’, as one heading read.³¹ Readers of the issue were covertly invited to compare these bleak monochrome images of life in Britain with a full-colour article which preceded it, portraying new and luxurious models for ‘the kinds of homes US now can have’.³²

Figure 11.3 ‘1949 Campaign Report by the Coordinating Committee National Education Campaign American Medical Association to the Board of Trustees and House of Delegates of the American Medical Association’, pp. 7–11 (The National Archives, London, MH55/967). © American Medical Association 1949. All rights reserved and permission to use the figure must be obtained from the copyright holder.

In September of the same year, Life ran an editorial officially introducing the NHS to its audience – but actually aimed at undermining the Wagner–Murray–Dingell Bill proposing a compulsory universal insurance system, versions of which had been repeatedly proposed in Congress since 1943. Entitled ‘The Public’s Health: Britain is About to Care for it in a New Way – Not Necessarily the Best for Us’, the editorial spoke of Britons cagily ‘getting it fixed for themselves’ to ‘obtain any kind of medical service available without money changing hands’.³³ The editorial offered to compare Britain’s situation and new system with ‘our own – in effect and in future’, making explicit what would become a common implicit assumption: that scrutiny of the infant British health system could predict the outcome of successive legislative efforts to reshape the US medical marketplace along more equitable lines. According to Life, British doctors had accepted the NHS ‘after some kicking at the traces’ in order to gain an assured income in their impoverished and in any case largely state-medicated nation. America’s more optimistic profession, in contrast, saw ‘state medicine’ as ‘a spawning of the nether pit’, liable to induce corruption among practitioners and ‘malingering and hypochondria’ among patients. Unsurprisingly, while the author admitted that the existing US system could be better, he rejected the British system, which he described as building health services ‘from the roof down’, entirely.

As American commentators and politicians continued to debate the merits of national health insurance during Truman’s second term, Life commissioned two photographic expeditions to document Britain’s new NHS. In February 1949 the photographer N. R. Farbman documented the array of health services offered under the NHS. In January 1950 Mark Kauffman, William J. Summits, and Larry Burrows covered the same territory. Both Farbman and Kauffman’s team took a wide range of staged and candid photographs documenting the reach and scope of the service, the population it benefited, and the facilities from which it operated. The settings for these images included bomb-damaged streets, wards with peeling paint and shabby window frames, dour and dark waiting rooms, and pokey consultation rooms, but also modern operating and diagnostic facilities, dental suites, and boardrooms. If the faces of patients and doctors alike were largely set or anxious, the photographers’ cameras also caught smiles in those waiting rooms and doctors’ consultation rooms (see Figure 11.4). Expressive, often gritty, and shrouded in fog, neither of these photographic collections systematically flattered NHS facilities or the state of British medicine in the immediate wake of the ‘Appointed Day’. Nonetheless, reflecting Luce’s socially conservative and sharply anti-communist views, very few of these images ever appeared on the magazine’s pages.³⁴

Crucially, Life’s editors – staunchly opposed to ‘socialized medicine’ for the USA and committed to a declinist visual and rhetorical narrative of Britain – apparently shunned images that highlighted the universal and comprehensive nature of the new service for its patients.³⁵ They rejected both Farbman’s images of an upper-limb amputee holding his outdated and worn hook-hand in the gloved gripping hand of his new NHS prosthesis (Figure 11.5) and Kauffman et al.’s pictures of men learning to use their prosthetic legs in NHS rehabilitation facilities. Clearly, the editors were not willing to risk showing the NHS, emblem of decadent welfare statism, as part of Britain’s response to war. Kauffman’s shots of an elderly woman being fitted with a new hearing aid (Figure 11.6) amid stacks of devices ready for similar fittings, and another foregrounding the latest audiology equipment and the NHS record card, went unpublished, as did pictures of nursing care for the elderly (a population already seen in the USA as desperately vulnerable to rising medical costs). Photographs of the stately private offices and Rolls Royce cars of Harley Street consultants and of a flourishing commercial pharmacy advertising surgical appliances (newly available to all on NHS prescription) likewise failed to meet the magazine’s editorial standards: they would, of course, have contradicted accusations that socialised medicine was anti-capitalist and forced doctors to give up private practice. While other US news outlets portrayed the NHS through images of full waiting rooms, free spectacles, and doctors at work in their surgeries, at patients’ bedsides, or surrounded by smiling if scruffy urchins between home visits, Life systematically erased the daily routine of NHS care.³⁶

Figure 11.4 N. R. Farbman, ‘Socialized Medicine in England’, 1949. © The LIFE Picture Collection via Getty Images. All rights reserved and permission to use the figure must be obtained from the copyright holder.

Figure 11.5 N. R. Farbman, ‘Socialized Medicine in England’: ‘Englishman with artificial arm obtained through socialized medicine, holding discarded homemade hook he used for 15 years’, 1949. © The LIFE Picture Collection via Getty Images. All rights reserved and permission to use the figure must be obtained from the copyright holder.

Indeed, of the many remarkable archived images from these photographic safaris, I have found only one in print (Figure 11.7).³⁷ Clearly staged, it portrays a poker-faced and bespectacled Englishman, arm in a sling, seated in a wheelchair beside a crutch, a spinal support, and a table filled with medicine bottles. He is liberally bandaged and festooned with medical aids, ranging from a hot-water bottle to an ice pack. This single published photograph was selected from multiple versions of the same subject. Among the rejected images were several in which this English everyman smilingly held a healthy and happy baby on his knee. The visual reference to NHS provision of free antenatal care and childbirth proved a step too far for Life’s sceptical editors in a period when its middle-class American readership was increasingly concerned about the rising cost of private medicine.

Figure 11.6 Mark Kauffman, ‘Socialized Medicine’: ‘Poor English woman being fitted for hearing aid under socialized medicine, United Kingdom’, 1950. © The LIFE Picture Collection via Getty Images. All rights reserved and permission to use the figure must be obtained from the copyright holder.

Figure 11.7 Mark Kauffman, ‘Demonstration of what a subject could get’, printed in ‘Dentures, Specs, and Turmoil’, Life, 7 May 1951, p. 43. © Time. All rights reserved and permission to use the figure must be obtained from the copyright holder.

Eventually printed to illustrate ‘Dentures, Specs, and Turmoil’, an article about Bevan’s resignation from the Cabinet in 1951 after the imposition of prescription charges, the picture played the generosity of the NHS for laughs. Its caption suggested that the picture was a ‘[d]emonstration of what a subject could get under Great Britain’s original National Health Service program inaugurated in 1949’. It added that ‘anyone’ – even a visitor – in Britain was eligible not only for ‘a doctor’s care and hospitalization for as long as necessary, but a wheelchair, false teeth, crutches, spectacles, hot water bottles, ice bags, splints, x-rays, and even a spinal corset if he needs one’, all without charge. By 1951, the editors clearly expected the comic proliferation of medical equipment in this portrait to signify the excesses of ‘socialist’ provision to American eyes.

In bold type immediately below Kauffman’s image, the editors formulated what they saw as the crucial equation: ‘how much socialized medicine = how many guns?’³⁸ It is in this equation that the tensions of Cold War politics in both the USA and the UK are made evident: should the exigencies of warfare – here, the need to contain the Soviet threat on the Korean Peninsula – preclude state investments in domestic welfare, as US commentators clearly saw it, or could welfare be part of the battle, as it would be depicted in UK responses? In the same issue, an article on ‘Baleful Bevan’ hammered home this editorial gloss: ‘Whether the nation can afford such expenses of the welfare state and afford rearmament as well – whether it will not have to choose between guns and hearing aids, between homes and medical centres – is a pressing question.’³⁹ In this context, the image crystallised a prominent strand of the wider journalistic response to the NHS in US media, one that characterised the free wigs, spectacles, and dentures as needless (and for an aid-dependent UK, unaffordable) fripperies rather than essential and economically effective medical appliances.⁴⁰ A 1949 Los Angeles Times editorial, for example, re-purposed a speech from the visiting former NHS Chief Medical Officer Dr Leslie Banks (intended, among other things to debunk claims that ‘American loans are paying for the British experiment’) to equate ‘high taxes’ with ‘poor health’ and ridicule ‘the luxury of state medicine’ for a nation in decline.⁴¹ This was not an uncommon perception, even among American experts. The historian Almont Lindsey, regarded by most contemporary reviewers as a reliable if sympathetic witness, called it a ‘luxurious necessity’ in his 1962 account of the scheme.⁴² Of course, it equally demonstrated the comprehensive benefits provided to the British public by the new service. Life’s editors were clearly confident that it would convey their satirical message, but in the absence of readers’ responses (Life published no letters addressing these particular articles), we can only guess how they interpreted it.

In fact, only after the comprehensive defeat of Truman’s efforts to create a national health insurance system in the USA did Luce and his magazine empire begin to address the problems in US healthcare, and in particular its steeply rising costs. In 1953, for instance, with a conservative president in the White House and the spectre of any national programme of health reforms apparently banished, Life ran a cautionary editorial warning that the combination of rising medical costs and AMA intransigence threatened America’s resistance to state medicine. ‘Watch It, Doc’ claimed to speak for ‘the millions of us ordinary mortals who worry ourselves sick’ about medical bills.⁴³ Yet even in this critical vein, the editors were careful to note that the public were ‘bitter’ only about the AMA, not about the US system as a whole. Some change, they concluded, was both necessary and inevitable, but they envisioned a ‘middle way’. Tellingly, it was explicitly not British medicine:

Media, medicine, and the Marshall Plan

Throughout the NHS’ first decade, with Life and other US media outlets regularly invoking Britain’s example to inform domestic debates, British civil servants and visitors to the USA often found themselves addressing hostile enquiries about the NHS. In a nation deeply concerned about the perceived dangers of communism, some US commentators were enraged by the idea that American capitalism was apparently funding the more attractive features of British socialism. The mechanism they blamed was the Marshall Plan, which between 1947 and 1951 funnelled some $13 billion in financial aid to Western Europe, initially in the form of shipments of food, fuel, machinery, and other staples from the USA, and later in the form of industrial investment. The resolutely anti-NHS Chicago Tribune, for example, trumpeted that ‘Marshall Plan Paves Way for Reds’ and was ‘accelerating the spread of socialism’ in response to a barnstorming speech by the conservative Senator Kem of Missouri. It gleefully quoted Kem’s assertions that ‘[i]t was American money – it was your money that saved Britain […] from the inevitable lower standards of living which would otherwise have come under the socialist program’ and that the Marshall Plan in Britain operated as ‘a great slush fund to keep the British socialist party in power’. Paradoxically, in Kem’s view, ‘[t]he United States is spending billions of dollars in an effort to stop Marxist communism, but at the same time is spending billions of dollars to subsidize Marxist socialism’.⁴⁵

While few national news outlets adopted the strong stance of the Tribune, even the more liberal papers presented their readers with milder versions of this ‘paradox’. The New York Times reported a speech by William Allan Richardson, editor of the conservative journal Medical Economics, under the provocative headline ‘US is Seen Paying for British Health’. Richardson argued that only Marshall Plan funding enabled the British government to operate the NHS. He based his assertions on a two-month survey of the NHS, during which time he requested and was granted five interviews with different members of staff at the Ministry of Health. The Ministry also provided him with ‘a considerable amount of material’ from its own records and those of the Ministry for National Insurance. It was a source of some disappointment for staff in the Ministry that their efforts had not borne riper fruit; they had ‘devoted a good deal of time to him’, not least since Richardson had promised them an article in the publishing behemoth Reader’s Digest.⁴⁶ But in fact, Richardson’s claim – like Life’s singular image of the NHS – was as much an implicit acknowledgement of the breadth, scope, and scale of NHS provision and a complaint about the attractive light it shone on socialism as it was a criticism of Britain’s use of US funds.⁴⁷ A year later, Harper’s Magazine irritably acknowledged the popularity of the NHS, its ‘slightly better than expected’ success, and the ‘bumptious health’ of British babies under the new regime, but described Britain, and especially post-war socialist Britain, as utterly dependent on ‘repeated blood transfusions from the United States – lend-lease, Marshall Aid, and loans that will never be repaid’.⁴⁸

In absolute terms, Britain did receive more Marshall Aid than any other European nation: just under $3.2 billion between 1948 and 1952.⁴⁹ In return, British governments agreed to operate with balanced budgets and fixed levels of currency reserves and to contribute ‘counterpart funds’ in Sterling to the Marshall pot, both to pay the costs of the US administering agency, the Economic Cooperation Administration (ECA), and to boost economic development. Britain also faced (and accepted) considerable pressure from the USA to maintain and increase its levels of defence spending.⁵⁰ Across Europe, the ECA and the bilateral negotiations that enveloped Marshall Aid in any given nation profoundly influenced social policy, not least because the structural demands imposed on recipients severely limited the funding available for social services. As the historian Daniel Fox has documented, this was certainly the case in the UK, where by 1949 even ECA officials were happy to testify to the US Senate that the Attlee government was at least restraining the growth of health and other social spending.⁵¹ Moreover, the ECA was not above threatening cuts to Britain’s allocations of aid when feeling in the USA ran high against subsidies to socialism.⁵²

In fact, it seems unlikely that any Marshall Aid money reached the NHS directly. The vast majority of dollars received were spent on either industry capable of generating foreign exchange, re-arming Britain, or imports of basic raw materials and foodstuffs.⁵³ Indeed, spending on health centres and hospitals was reduced in 1948, just as Marshall Aid began to flow.⁵⁴ Thus, far from subsidising the NHS, evidence suggests that the ECA strings with which Marshall Aid was packaged operated to constrain it. Nonetheless the plan’s founders and early administrators were eager to avoid charges that the USA exercised, in the words of the British ambassador to Washington in 1950, ‘dollar dictatorship’ over recipient nations’ duly elected governments.⁵⁵ British health policy was officially tolerated on these grounds, though, as Fox has shown definitively, never uncritically or without efforts at interference.⁵⁶ From 1948 to 1958, across the US press, the NHS features alongside more visibly international topics including re-armament, relations with China, European unification, and the Korean War as a topic of special sensitivity.⁵⁷ Equally, American representations of the NHS throughout this period and beyond it lived up to the characterisation of the service by the Director of Public Relations for the Ministry of Health as ‘the plaything of politics’ – both the domestic politics of the US healthcare marketplace and the international politics of Cold War re-armament.⁵⁸

What is perhaps more surprising and interesting, however, is the degree to which British authorities were deeply invested in US responses to what was, after all, a strictly domestic social service. Why did it matter so much? Of course, as the discussions of Marshall Aid suggest, in part US perceptions mattered pragmatically. Introducing BIS to staff at Britain’s Washington embassy in 1948, the director, Bill Edwards, explained its mission bluntly:

Unfortunately, the NHS fell very far short of achieving that status, having rapidly become a catalyst for resentment and attacks whether in its own right or as a proxy in US debates. Edwards’s successor would add, several years later, that ‘If the United States is far and away the most important country to us, then there seems to be no choice but to consider the possible reactions of American opinion to all our policies and statements.’ Moreover, he noted that American foreign policy was ‘much more sensitive than ours to short term movements of public opinion’. So when Americans attacked the NHS as a stand-in for Truman’s national insurance proposals, ‘even if all the British press were unanimous in presenting the British National Health Service as a success, the B.I.S. would still have to be careful in publicising that fact or they would be denounced again as bolstering the [Truman] Administration’.⁶⁰

British authorities, experts, and citizens therefore responded actively, even anxiously, to the many and varied charges levied against their NHS in the USA. To official eyes, misconceptions about the uses of Marshall Aid were in part due to ‘virgin innocence’ or ‘muddleheadedness and ignorance’ on the part of vocal and influential Americans.⁶¹ However, they also reflected clear political agendas, including ‘the dislike of American owners of media of publicity for British “socialistic” practices’ and the practice in US ‘business and Republican circles’ of attacking their own government ‘through us’. For BIS, operating on the frontline of the battle for American public opinion, US reactions to the NHS in particular exemplified this strategy: ‘e.g. British “socialised medicine” is allegedly a disastrous failure; therefore [...] more cautious public health proposals in the United States are deeply sinister steps towards similar disaster’. For it, as for the Foreign Office generally, efforts to correct such prejudices in relation to the NHS were also intended to address deeper problems in Anglo-American relations. It was imperative, as Britain struggled for survival and influence during its economic recovery from the effects of the Second World War, to obtain what Paul Gore-Booth, Director of BIS in the USA from 1949 to 1953, termed ‘a fair and favourable view of British conditions, achievements and policies’.⁶²

British figures, both official and voluntary, moved quickly to deny all claims that US aid funded NHS generosity, particularly as US–UK relations around the ECA deteriorated in the later months of 1949 and beyond. Stella Isaacs, the well-known founder of Britain’s million-strong Women’s Voluntary Service during the Second World War and a friend of Eleanor Roosevelt, made this a central plank in her personal campaign to support Anglo-American relations.⁶³ Writing to T. Fife-Clark in the Ministry of Health’s publicity division in 1949, she was adamant about the need ‘to debunk from the consciousness of foreigners that the whole of the Health Service is run on E.C.A. money’. The traditionally leak-averse British Treasury supplied Britain’s Washington embassy with early information on the expanding NHS budget in 1950, stressing the role of long-frustrated health need, rather than overpayment, in its growth.⁶⁴ A British Member of Parliament touring the American Midwest on vacation gave, impromptu, two radio broadcasts, a television interview, and three press meetings to address ‘tremendous anxiety on the part of the press and every kind of society and organisation for reliable information [...] in particular about the Health Scheme’.⁶⁵ Even ordinary citizens travelling in the USA reported on the confusion and the hostility it provoked: ‘I met many types of Americans – from the millionaire class to the shop assistants who served me – and they are ALL of ONE opinion – They are being taxed to support us!’, and called on the British state to correct such assumptions.⁶⁶ Communications between the Foreign Office, BIS, and other actors on Whitehall all illustrate the perceived importance of clarity on this point in the wider Anglo-American relationship. Prompted by the British Board of Trade to address ‘accusations of the mis-use of Marshall Aid’ in another regional newspaper, BIS wrote to insist:

Austere, disciplined, equal: welfare as warfare in post-war Britain

Despite its evident importance, pragmatism alone cannot explain the strength of British responses to US attacks on the NHS, particularly after the Marshall Plan ended in 1951. We must look elsewhere to understand fully what was at stake. A key factor here is ideological, reflecting the strong sense that the burgeoning Cold War battle against the spread of communism in reconstructing Europe could be won only if the longed-for return of economic prosperity was tempered by a degree of equality. In Britain, scarred by war but also alert to the risks of any return to pre-war levels of social inequality, this view was widely shared and actively propagated. Addressing a restricted session of the Committee of Ministers of the Council of Europe in August 1951, Herbert Morrison (then Deputy Prime Minister and Foreign Secretary in the last days of the post-war Labour government, and in his pre-war role as leader of London’s County Council, a key player in its expansion of health services) insisted that the ‘main emphasis’ of all negotiating parties ‘should be unity [...] between the different groups and classes of our free society’. Only by creating ‘a balanced, just and contented society in which communism will find no appeal’, he argued, could Europe be safe.

Morrison’s anxieties were not unfounded; a July 1951 Cabinet memorandum reported a dangerous ‘state of mind’ among the people of Western Europe: ‘over a quarter of the population of France and Italy still vote Communist either for social and economic reasons or because of Soviet peace propaganda’. Moreover, they were ‘restive’ under ‘American pressure’ to commit at least some of the resources they were purchasing with US aid to re-arming, and anxious that the US policy of demanding re-armament at the cost of reconstruction ‘would be playing into the hands of the Communists’.⁶⁹

Moreover, the area of social and economic justice was one in which British politicians and policymakers felt that the nation could demonstrate its continued global leadership and importance. Morrison asserted, ‘it is in the redefinition of equality that […] Great Britain to-day has something to offer. [...] [W]e are giving a very definite lead which we invite – indeed are challenging – all to follow [...] in the elimination of communism at home by the creation of conditions under which it will not flourish.’⁷⁰ Intriguingly, traces of a similar view were visible in the Indian medical press, where the NHS was positioned as the ‘logical conclusion’ of ‘new concepts’ of equality established in the last war. This ‘great experiment in social legislation’, eagerly watched around the world, had become ‘a service available as a right, and the nation has accepted good health as a national responsibility’, spending on health almost as much as on defence.⁷¹ An editorial written for the same issue of the Indian Medical Journal (mouthpiece of India’s general practitioners) in 1951 suggested that from a global perspective too, the NHS looked like a frontline in the Cold War. As its author observed, ‘England has set an example to the world of accomplishing revolutions by peaceful methods’ – but that example was not universally loved:

This sense of the NHS as a symbol of national values, a battle front, and as an ‘experiment’ attracting a global gaze was a crucial motive for the UK to react strongly against American critiques and hostility towards the NHS. As we have seen, key staff at the BBC felt certain in 1948 that the inception and success of the NHS, like that of National Insurance, was seen by Britain’s new Labour government as a matter of ‘prestige for the Ministry and for the country’. Aggressive challenges to that prestige through hostile US representations of the NHS either as analogous to communism or as medically inadequate or backward were consequently equally dangerous and unwelcome.

To pursue and protect the NHS as a vehicle and emblem of national prestige, even an incomplete list of meetings between the Ministry of Health and US media organisations between 1948 and 1949 documented briefings to over twenty-six different US media outlets.⁷³ These local efforts were supported by Britain’s Information Services bureaux in the USA and by interested individuals with personal connections to American society. Medical professionals in contact with US colleagues and acquaintances, and travelling officials like Dr J. A. Charles, then Deputy Chief Medical Officer and temporarily based at the Rockefeller Foundation in New York, were also active missionaries for the NHS. Charles’s letter begging the Ministry to send factual information about the new service to a specific press contact in order to address the fears of the US public and medical profession was fairly typical. He grumbled, ‘It is interesting how little is known about the N.H.S. and that little is usually confined to wigs, dentures and spectacles, the suppression of research and the deterioration of the medical schools. [...] The ignorance is woeful even among doctors.’⁷⁴ While UK visitors pursuing other ‘medical missions’ had ‘done something to correct these errors and shed a better light’, their ad hoc efforts could not alone turn the tide.

Of course not all such travelling commentators were positive, even when the Ministry expected their support (or at least their silence). In fact, the views of dissatisfied UK medical professionals and organisations, including the Fellowship for Freedom in Medicine under its founder Lord Horder, were often amplified by the AMA and featured prominently in the US press and periodicals.⁷⁵ As later observers would note, ‘the American press devoured such reports with pleasure’ in a climate that was ‘unfriendly’ to the NHS from the outset.⁷⁶ Mollie A. Hamilton, head of the American Information Department in the Foreign Office, wrote to her counterpart at the Ministry of Health to complain about another culprit, the British journalist Cecil Palmer, who was ‘doing a great deal of harm’ through lectures offering ‘a distorted account of the Health Service’.⁷⁷ Hamilton urgently demanded material that would allow her, and BIS in America, to counter such ‘malicious distortion’.⁷⁸

From 1949 onwards, information flowed from the Ministry of Health specifically intended to counteract such ‘poison’ and to correct the most frequently repeated misunderstandings of the British system in the USA. Intelligence officers inside the Ministry generated briefing packets and commissioned articles to ‘deal with some of the main American misunderstandings and resistances’:⁷⁹ that the state intervened in doctor–patient relations, or violated their privacy; that nationalisation had eradicated voluntarism within British medicine; that private practice was forbidden to doctors and patients alike; that mortality or morbidity or medical migration was rising; or that enthusiasm for medical education had declined. As well as attending to errors of fact and opinion, respondents in the Ministry paid exceptionally close attention to the rhetorical flourishes of US NHS discourse – not least, the ‘rolling flood of rhetoric and propaganda’ sponsored by the AMA.⁸⁰ In particular, they repeatedly rebutted the idea that the NHS was in fact ‘socialized medicine’, resisting this terminology not just when it appeared in the national press, but even in personal letters and enquiries from students, individuals, and British citizens in the USA who were eager to present the NHS in the best possible light.⁸¹

Ministry of Health civil servants, aided by BIS, responded individually to a blizzard of information-seeking correspondence both from Americans and from Britons travelling in or to the USA. Indeed, the sheer volume of such queries indicates the degree to which the NHS was –and was popularly recognised in Britain to be – a topic of current interest in the USA. They also hosted and addressed US citizens’ groups in the UK. ‘Mary Foster’s Women’s Tour of Europe’, for example, visited the Ministry in 1948, while the fifty-seven influential members of the long-running progressive Sherwood Eddy Travelling Seminar – all required as a condition of membership to be ‘persons in public life’ dedicated to promoting internationalism – benefited from the attentions of a Ministry intelligence officer while sailing to the UK, and from an additional lecture from the Minister for Health, Hilary Marquand, on their arrival in London in 1951.⁸²

Clearly, the authorities charged with burnishing the image of Britain’s welfare state were not the only ones who cared: members of the general public also sent the Ministry of Health letters expressing concern and even anger at how the NHS was portrayed in US publications and by individual Americans. Others wrote directly to US newspapers to share their views.⁸³ They were eager to rebut unfair criticism and ‘grotesque ideas’ about the service among Americans, even seeing it as ‘a national service’ to do so.⁸⁴ Medical professionals are well represented in these files, responding furiously to what they regarded as inaccurate or ‘tasteless’ critiques in the US professional press. Pro-reform doctors and politicians in the USA too were concerned; J. A. Charles later reported from Boston that ‘medical circles’ there felt that the Ministry was ‘letting [...] the A.M.A. get away with any lies, distortions or caricatures that they care to put forward’.⁸⁵

The Ministry of Health was a conscious curator of US images of the NHS. While compiling and distributing point-by-point rebuttals to negative US news reports on the service (especially to ministers and others planning to speak in the USA), the Ministry actively sought positive US press coverage. Such responses evinced clear and direct pride in the service’s uniquely ‘comprehensive’ approach and a strong sense of ownership. A briefing document prepared for the health minister’s 1951 visit to the USA, for example, boasted: ‘What does the country get for its money? The National Health Service is comprehensive – it covers all medical services for the patient [...] our National Health Service is quite different from [...] American schemes in so far as it alone covers all treatment and is free of charge [...] to the person using it.’⁸⁶ Americans, the briefing crowed, paid more for their healthcare, and fewer were able to access it. It spoke too of ‘achievements’ quantified in terms of the millions of prescriptions filled, and hundreds of thousands of spectacles, hearing aids, dental treatments, and dentures supplied at no or low cost to patients from across the social spectrum. The service was, by 1953, characterised in exactly the same terms as the British nation more broadly, ‘calmly, quietly going ahead’, and was under no threat of repeal or failure.⁸⁷

Encounters between US citizens and the NHS, both planned and unplanned, also generated consistently positive individual impressions and, more grudgingly, coverage of the NHS in the US press. In a letter addressed to Bevan, a US exchange teacher who had recently returned from a year in England wrote to ‘express to you and your people my gratitude for excellent care’ on the NHS. He would, he assured the minister, ‘bring home the highest praise for the Health Service’, and evidence of this kind did gain traction particularly in regional papers.⁸⁸ The system’s generosity in fully incorporating foreign visitors prompted a mixture of admiration and incredulity, even among experts. Almont Lindsey, for example, described the case of an American child who was in Britain with her military father. Terribly burned in a fire, she received state-of-the-art skin grafting treatment in the NHS, treatment that would require constant revision until she finished growing. Her father, Lindsey reported, ‘dreaded the prohibitive cost that would be entailed when he returned to the United States. In England, there was no charge.’⁸⁹ Journalists like Carroll Binder, reporting for the moderately conservative Minneapolis Sunday Tribune while on a two month tour of Western Europe in 1950, viewed such largess sceptically. While he acknowledged that American recipients of free NHS treatment were pleased, Binder was no fan of the system: ‘I do not set down these first hand reactions to show that the health scheme is good and worth of imitation [...] I think it is significant however, that the scheme should be viewed by its beneficiaries in this light.’⁹⁰ And even stern US critics were forced to admit that the NHS represented an enormous improvement in access for the industrial poor, perceived by many experts as the most susceptible to communist persuasions.⁹¹

Conclusions

As the prospect of a US national health programme diminished from the mid-1950s, the NHS lost much of its immediate political saliency. Further, as the US Committee for the Nation’s Health commented tartly in 1951, ‘[a]s the Service began to operate more smoothly, its news value dropped’.⁹² Instead, the baton for ongoing investigation of the NHS passed largely to experts, whose reports either in monographs or in the scholarly and professional journals received little direct coverage in the US media. By 1953, when the NHS celebrated its fifth anniversary, US popular coverage was both less frequent and less polemical, if still mixed. Newspapers covered the service’s popularity with the public and acceptance by medical professionals and all political parties at that milestone in tones ranging from mild surprise to moderate disapprobation.⁹³ As one BIS officer noted, ‘It seems a far cry from 1948.’⁹⁴

After its first five years, changing levels of US interest in the British NHS correlated directly to the relative prominence of healthcare reform on the US political agenda. Thus, when the House Ways and Means Committee launched its first consideration of access to medical care by American retirees with the Forand Bill in 1958, for example, or during the Medicare and Medicaid debates of the 1960s, US magazines and newspapers returned their gaze to the NHS. Importantly, despite the spread of state-run or state-funded healthcare systems of various kinds across Europe in the intervening years, it remained the NHS specifically that attracted the lion’s share of such comparative attention, even when other systems more closely resembled those proposed in the USA (see Figure 11.8).

While US interest in the British NHS followed the ebb and flow of its own healthcare debates, British responses to that interest followed a rather different pattern. After the fervour of the service’s first five years, when efforts to project a positive vision of the NHS in the USA were intense, British concern about the image of the NHS abroad declined. At the same time, there is evidence of increasing confidence, in the Ministry of Health and the British medical profession more generally, that the highly regulated, tightly funded, and universally available NHS was economically and medically valuable – perhaps even superior to the larger and richer US system. This confidence is apparent in the greater volume of critical commentary crossing the Atlantic, this time from east to west. In 1960, for instance, the Lancet editor Dr T. F. Fox observed that because of lax US standards for specialist practice, ‘at present, one’s chances of dying quietly in a hospital bed with the wrong diagnosis are higher in America than in Britain’. As the Atlantic’s editor noted, ‘tit-for-tat’ played some role in this: ‘the British have smarted under our criticism of their National Health Service’.⁹⁵ But it also reflected the widespread conviction that the NHS was in Britain to stay, that it was improving, and that it was also improving British health and society. ‘Even with its faults’, the Washington Post observed in 1962, ‘most Britons seem proud of their National Health Service. Almost never is anyone encountered who wants to […] return to the old system.’⁹⁶

Figure 11.8 Comparator health systems in the ‘socialized medicine’ debates, 1959–68.

As early as 1958, Bruce Cardew, General Secretary of the Medical Practitioners’ Union, had proclaimed, ‘The Health Service was not a money-consuming service; it was a wealth-producing service.’⁹⁷ Cultural responses to and representations of Britain’s health services during their first ten years suggest that the NHS became a symbol and a touchstone, for both the USA and the UK, in debates over more than how best to provide medical services: would affluence or equality best protect societies from absolutism? Could welfare be a form of warfare in the rugged ideological terrain of post-war Europe? During this period, the NHS was actively constructed (in the USA and the UK) as a potent symbol of national values. The flood of media programming celebrating the service’s seventieth anniversary in 2018 suggests that the NHS remains – perhaps problematically – totemic even to those most critical of its practical merits and everyday achievements. This extraordinary persistence speaks volumes about the importance of exploring the agency and power of cultural productions to enduringly shape public opinion and political discourse alike.