"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Sunday, 19 August 2012

Healthcare on a budget

My grandfather moved to Shanghai in 1928 to escape the rising unemployment and industrial unrest in Britain. Like most people at the time he had basic schooling, but he had taken evening classes to train as a plumber. This meant that he was slightly higher than most in the British class system because he was a tradesman. His passport says that his occupation was "plumber" and the contract for his job in Shanghai said that he was "foreman class".

The class system in Shanghai was more complicated than in Britain and was heavily influence by empire. Inevitably the Chinese were at the bottom, but the British were resolutely at the top. The city that the Britons knew as Shanghai was the International Settlement, and formally it was the amalgamation of the British Settlement and the American Concession granted by the Chinese after the Opium Wars (Shanghai also included the French Concession, which was separate to the International Settlement). Nominally, the International Settlement was run by 12 countries (the Shanghai Municipal Council flag  had the flags of 12 countries: Great Britain, US, France, Germany, Russia, Denmark, Italy, Portugal, Norway and Sweden, Austria, Spain, and Holland), however, in practical terms, the city was run by British businessmen. Even the Americans recognised this, taking a subservient role to the British, and it was only after liberation by the Americans in 1945 that this changed, perhaps most symbolically by the change on the 31 December 1945 to make cars drive on the right, whereas up until then cars drove on the left, as was the case in Britain.

Within the British community there was a complex class system. For example, at my grandfather's company the senior staff were engineers and university educated, but significantly they were educated in Britain. The important point was that they had been employed from Britain. This was the case with my grandfather, he was skilled with evening classes qualifications, but because he applied to a job advertised in Britain and emigrated to Shanghai, he was regarded as being a rung on the class ladder above a similarly skilled European man who was employed locally.

Shanghai between the world wars was extreme capitalism, the city existed to make money. There were no passport controls, so anyone could move there, and it was well known for gamblers and gangsters. There was also a large population of "white" Russians who emigrated there after the Russian revolution and there was a large Jewish population of stateless refugees who emigrated from Europe in the 30s after the rise of Nazism. However, if you had no employment, you did not eat and life was cheap. For example, during the Winter of 1938 one hundred thousand "exposed corpses" were removed from the streets of the International Settlement (up to 400 a day), these were the bodies of the homeless who had died in the extreme cold and some were the casualties of the 1937 war between the Chinese and Japanese.

The capitalism continued even during the war. In 1941 the Japanese occupied the International Settlement (they had occupied the much larger Chinese city surrounding the settlement since 1937). In 1943, fifteen months later, civilians from the countries at war with the Axis Powers were interned in prison of war camps. There were about 6,000 "British" (a term that included Australians, New Zealanders and South Africans as well as people from the United Kingdom). These were not people "sheltering" from the War, indeed, Shanghai had suffered terrorism (bombs and shootings between rival gangs and attacks from Nationalists and Communists) throughout the thirties. When the Second World War started many of the British (particularly the younger men) tried to join the British military, but were refused. Churchill, realising the importance of Chinese trade on the British exchequer, told the British firms in the city not to allow their employees to leave. This may seem to us, in a modern world where people change jobs frequently, to be an ineffectual decree , but before WWII this was an important statement. My grandfather's contract says specifically that the employee - my grandfather - could not break the contract. He could only leave the job if he was dismissed, retired or was "invalided out of service". No employer would employ someone who had broken their contract of employment with another employer. Indeed, when he was interned, my grandfather obtain a letter from his employer to state that he was no longer working for the company because of internment and not because he had broken the contract.

In the internment camp the Japanese provided little food and what food that turned up had a poor provenance. The internees had intermittent deliveries of Red Cross parcels. These were not provided by the Red Cross, the organisation was simply used to deliver the parcels and to ensure that they only contained permitted items. The parcels came from friends of the internees. The internees were given several weeks notice before they were interned and so they deposited some money with a friend who was not going to be interned (in my grandfather's case, it was a Rumanian employee at the company where he worked, someone who was described as "stateless"). The friend would then put together the parcel and when the Japanese authorities allowed it, the parcels were delivered to the camp by the Red Cross.

The internees were also allowed to buy food when it was available. The British government provided funds which were administered by the Swiss Consul. These funds were euphemistically called "comfort allowances", but were used to pay for basic necessities like food and clothing. My grandfather kept a notebook and it appears that the "comfort" payment he received was $18,000 per month. Inflation was rampant in the camp, so on the 23 November 1944 six eggs cost $192, eight months later, on the 23 July 1945, the same number of eggs cost $3000. It is important top note that these "comfort" payments were loans. The civilian internees clearly had no employment, but were expected to pay for their time in the internment camp, and when they were finally liberated after two and a half years, each one was handed a bill from the British government. My grandfather returned back to work after liberation, and after a couple of months of negotiation, his employer agreed to pay his bill for his "comfort" payments while he was interned.

My father was born in Shanghai in 1932. When the war started my grandfather tried to persuade my grandmother to move with my father to Australia, but she refused to go because my grandfather could not leave his job. So my family, my grandparents and my father, were interned by the Japanese authorities. In early 1945, after two years in the camp, my father fell seriously ill. He had a tumour on his elbow. He was treated as much as was possible in the camp hospital, and also made trips to Shanghai to have x-rays in one of the hospitals there.

My grandfather's notebook lists him getting sicker. On the 12th of April it says that my father's arm was in a sling and on the 18th he had aspirin. On the 2nd my father had an x-ray and his arm was put in plaster (this must have been in a Shanghai hospital), and he was admitted to hospital on the 3rd (possibly the camp hospital). On the 28th of May the entry reads that my father is "sick". On June 27th and July the 4th he had more x-rays, and was admitted to hospital (possibly the camp hospital?) on the 6th of July. On August 8th he was admitted to hospital in Shanghai and on the 9th and 10th he was x-rayed again. On the 19th my grandfather notes that he "spoke to Dr Byson" and then on the 20th he writes a letter to my father in St Lukes Hospital Shanghai (I have the letter). My father appears to have returned to the camp by the end of the month, and then within a couple of weeks he was sent on a hospital ship back to England.

In my grandfather's notebook there are also notes of the hospital costs. The cost for my father's hospital care for the month of May 1945 was $11,300 (in comparison, the following week gave the cost of one egg at $410), for June it was $14,500 (80% of the monthly "comfort" allowance) and in August it was $200,000. The last payment would presumably cover the cost of the two x-rays and the time my father stayed in St Lukes Hospital. Most poignant was the entry on the 28th August 1945. My father was in great pain and someone in the camp had made a brace to support his arm. This cost two and a quarter million Shanghai dollars. (Unfortunately, I cannot find a comparison figure for eggs, but the hospital bill for August of $200,000 was noted in the following week.) I assume that there must have been a separate loan for this, but there is no paperwork to indicate this.

Reading through this I cannot help but wonder how these medical costs can be managed on a small, fixed budget that has to cover basic needs like food and clothing. My grandfather managed it, but it must have been a strain. I know that my grandfather suffered mental ill health a year later, but this was when my father and grandmother were in England and their letters say that they are unsure that the doctors in England could save his arm (in the event, they did, although my father's arm was disabled for 40 years until eventually it was amputated when he was 51).

This is something that we do not experience now, since we are so used to getting high quality care, free at the point of delivery. Soon, however, when personal Health Budgets are introduced, we will be in the same situation my grandfather was in: a fixed monthly budget, and regardless of the vagaries of ill health, we will have to stick to our budgets or find some other funding source. Personal Health Budgets are a return to the 1940s and it is a Conservative government that will deliver it.


  1. I found this post both compelling and moving. Sadly experience of the UK healthcare system before the NHS is passing out of living memory. My grandfather, who was born in 1910 and died at the age of 95, also remembered WWII. In his version, millions of soldiers returning from war were not prepared to accept their former servitude, and it was the latent threat of armed violence that persuaded the owning classes to allow the creation of the welfare state. The question for today is 'what can we use instead of the threat of violence'? This type of citizen journalism offers us access to the information that the mainstream press chooses not to investigate, but it needs a corresponding activism to have an impact on policy.

    1. The difference is that the soldiers returning after WWII had the public behind them. The government knew that they could not repeat what happened after the soldiers returned after WWI, where they were just expected to go back to life as it had been before, and the result was revolutions all over Europe and the British losing Ireland. The government in England were damned scared of losing power here too - during the General Strike they moored battleships (serious armaments) off the major ports as a warning that they were still in control.

      But the situation is different now. A threat of violence in 1945 (or even 1920) would scare the government because a large proportion of the population would be on the workers side. These days, the people being hit hardest - the poor and disabled - are a minority and the majority is not yet informed enough to understand what is happening.

      You're right, the mainstream media are not interested in what is really happening, so we have to use the internet to spread the message.