Sir Douglas Black
Professor of medicine whose famous report on inequality and health fell foul of the
Sir Douglas Andrew Kilgour Black, emeritus professor of medicine, Manchester University (b 1913; q St Andrews 1936; MD, FRCP), died from pancreatic cancer on 13 September 2002.
Sir Douglas Black was one of medicine’s most important and well loved individuals. His many achievements included a professorship of medicine in Manchester, research on salt and water balance, persuading the profession in the 1940s and 1950s that the NHS was a good thing, and the presidency of the Royal College of Physicians. But he is best known for his 1980 Black report, which spelt out the social inequalities in health and proposed ways of reducing them.
In 1977 the then Labour government’s health secretary, David Ennals, chaired an expert committee investigating why the NHS had apparently failed to reduce social inequalities in health, and he commissioned Black to write a report. The result was published—or, rather, suppressed—in 1980, when the Conservatives had come to power. The Black report was not to Mrs Thatcher’s liking and was never printed; instead, 260 photocopies were distributed in a half hearted fashion on Bank Holiday Monday. However, the report had a huge impact on political thought in the United Kingdom and overseas. It led to an assessment by the Office for Economic Co-Operation and Development and the World Health Organization of health inequalities in 13 countries—though not on UK government policy. Penguin Books later published a shorter version of the report.
Black provided convincing figures that showed what many suspected—that the poorest had the highest rates of ill health and death. He argued that these rates could not be explained solely by income, education, mobility, or lifestyle, but were also caused by a lack of a coordinated policy that would ensure uniform delivery of services. He recommended health goals, tax changes, benefit increases, and restrictions on the sale and advertising of tobacco. Patrick Jenkin, the social services secretary, estimated with a shudder that Black’s proposals, which he hinted were little short of outrageous, would cost an unthinkable £2bn a year.
Thin, gentle mannered, poker faced, and self effacing, Black was deeply moral, always serious, and frequently extremely funny. His after dinner speeches were received with rapt attention, as to miss a moment of that soft Scottish voice was to miss a joke. He could, and usually did, make people laugh till it hurt. His pen nib was pointed: when the Human Fertilisation and Embryology Authority refused Diane Blood permission to use her dead husband’s sperm, he wrote: "People banded together are capable of follies and excesses beyond what the same people, acting as individuals, would perpetrate on other individuals. Such activities may be termed corporate tyranny . . . Medical ethical principles are made for people, primarily for patients, and not the other way round." Of his postgraduate training: "We learned by the principle of Wackford Squeers, a somewhat underrated pedagogue."
Black was born in the Shetlands, a son of the manse, which, he said, gave him the twin advantages of poverty and culture. "We didn’t even have a radio but we had plenty of books, so I was able to read and think," he said.
During his house jobs Black was enjoined by the abdominal surgeon Walter Campbell to leave a pint of saline in the peritoneal cavity as this would, in those pre-antibiotic days, greatly increase the patient’s chance of survival—but Campbell didn’t know why. A couple of years later, when Black was offered a research fellowship at Oxford ("this was wealth, in the purely academic sense, beyond the dreams of avarice"), he followed up Campbell’s injunction, studying salt and water loss. He often experimented on himself and demonstrated that even moderate dehydration caused muscle weakness and disorientation, which could rapidly cross unseen thresholds and thus escape the body’s natural capacity to control its internal milieu. Black then set about the difficult task of establishing these thresholds, work that was to prove particularly useful in the second world war.
He served in the Royal Army Medical Corps from 1942 to 1946, studying fluid and salt balance in surgery, infectious diseases, and emergencies. He found that soldiers and sailors, when driven by extreme thirst, would drink sea water, or their urine, both of which were desperately harmful. He caught hepatitis from a contaminated yellow fever vaccination ("Plato suggests that the best doctor is the one who has had most diseases himself"). On VE day, when he was running a laboratory in a field hospital in Poona, the officers’ mess laid on a celebratory meal, and he was made to dine outside on the lawn as he didn’t have full mess kit.
In 1946 he took his demob suit and became lecturer in medicine at the Manchester Medical School. Manchester was noted not just for its academic excellence but also for wit, in the best 18th century, Dr Johnson sense of the word. Black could exchange bon mots with the best of them. He also continued his research, which was enhanced by new techniques for biochemical measurements. In 1959 he became professor, by which time he had welcomed in the new NHS and done much to make his colleagues overcome their antagonism towards it. His research was prolific and diverse; for example, in 1972 he drew public attention to the increased incidence of heart disease in soft water areas. He also become noted for his social conscience and egalitarian views.
In 1974 he was seconded to the Department of Health as its first chief scientist, a post he hated. The mandarins blocked his work. The Rothschild report had urged the Medical Research Council and other funding bodies to sponsor only that research with immediate practical benefit and his explanation that this policy was short-sighted fell on deaf ears.
His two anti-heroines were Barbara Castle, who forced private patients out of NHS hospitals, thus depriving them of facilities and forcing doctors to waste time and energy on finding outside facilities; and Margaret Thatcher, for charging so called realistic fees to overseas students, thus cutting off what was once a remarkably cheap way of spreading British influence around the world. He also abhorred her materialistic view of society.
Black was appointed to the Medical Research Council in 1966, three years after the Royal College of Physicians had published its report on smoking and health, and found that more than half his fellow members smoked pipes or cigars. In 1977 he was elected president of the Royal College of Physicians, a post he held for six years. He was the college’s most successful and popular president, greatly enhancing the college’s standing. Black is the only person to have given every eponymous lecture—such as the Harveian, Lumleian, and Linacre—at the RCP.
He was knighted in 1973 and created a Knight of St John in 1989, but is the only former president of the Royal College of Physicians not to have been made a KBE. Thus the establishment took its revenge.
While president of the RCP he gave evidence for Dr Leonard Arthur, a paediatrician who had allowed a Down’s syndrome baby, with no hope of survival, to die—having nursing care only—at its parents’ request.
He chaired the committee that investigated the clusters of leukaemia near Sellafield, and found the evidence of causation wanting.
Black has held high office in the General Medical Council, British Medical Association, British Association for the Advancement of Science, Medical Protection Society, and many others. He enjoyed chairing committees, and tolerated neither waffle nor prevarication. He had the rare knack of stopping conference speakers from overrunning their time. He was a fellow of most of the Royal Colleges, and of colleges overseas.
His many publications include Sodium Metabolism in Health and Disease (1952), Essentials of Fluid Balance (four editions from 1959), The Logic of Medicine (1968), and Recollections and Reflections for the BMJ’s Memoir Club. He was a man of immense learning, for example reading all three volumes of Ruskin’s The Stones of Venice during spare moments in the Athenaeum library. He had to climb up a ladder to get them and blow the dust off first.
Black’s book reviews and other occasional writing continued to please a medical audience, mainly in his column, "Black Looks," in the Royal College of Physicians journal, and in the BMJ. Of J K Galbraith’s The Good Society he wrote, "Brought up in Scotland in the same tradition as Galbraith was raised in Ontario and, like him, nourished for decades on alien corn, I should warm to this book. And warm I did."
He opposed euthanasia but advocated advance directives ("living wills") to be made while still in good health, and practised what he preached. At a talk in the 1980s he said he wanted to live till 90 and die young. He enjoyed his life and career, even the frustrating bits ("my respect for politicians had ample room in which to grow.") He made it to 89, dying from pancreatic cancer two years after diagnosis, and after refusing parenteral nutrition after an unsuccessful operation. He remained active and clear minded to the end; his talk to doctors in Wolverhampton in May was packed.
He leaves a wife, Mollie, whom he married in 1948, a son Andrew, a psychiatrist; and daughters Teresa, a medical psychotherapist, and Alison, a teacher.