Horace Joules

Horace Joules LRCP, MRCP, MRCS, FRCP (21 March 1902 – 25 January 1977) was a British physician, health administrator and health campaigner, who played an important role in promoting public health and preventative medicine; particularly the link between cigarette smoking and lung cancer following the work of Richard Doll, Austin Bradford Hill, Ernst Wynder and Evarts Graham, and the adverse effects of air pollution.

Horace Joules was born at Woodseaves, High Offley Road, Newport, Shropshire, on 21 March 1902.

He was the son of Richard Edgar Joules, a master grocer, and his wife, Emily Ann (née Hyatt), and one of ten children.

His family were Primitive Methodists and his father was politically radical and a strict teetotaller.

Joules was educated at Newport Grammar School before studying medicine at University College Cardiff and at Middlesex Hospital Medical School.

He passed his medical degree in 1925, and in 1928 he achieved Membership of the Royal Colleges of Physicians and was awarded a Medicinae Doctor (MD) with a gold medal from the University of London.

After completion of his studies in 1925 Joules took up the posts of house physician at the Middlesex Hospital and Brompton Hospital.

He was then appointed medical officer and registrar to the City of London Maternity Hospital and Middlesex Hospitals.

In 1929 he left London to become resident physician to the Selly Oak Hospital, Birmingham.

While at the Middlesex Hospital, Joules had been inspired by Somerville Hastings, surgeon in charge of  the Ear and Throat Department, who was also chairman of the London County Council and subsequently became a Labour MP for Barking.

It is likely that Somerville Hastings influenced Joule's socialist views, although Palladino has also suggested that Joules' left-wing politics also grew out of the strong Christian Socialist tradition in Britain.

In 1930 Joules became a member of the newly formed Socialist Medical Association (SMA), and was influential in its subsequent development.

In 1935 Joules was appointed the first senior physician at the Central Middlesex County Hospital in north-west London.

He remained active in political causes supporting the Spanish Medical Aid Committee to help the Republicans in the Spanish Civil War.

Following the outbreak of World War II in 1939 Joules arranged for medical students from the Middlesex Hospital to be sent for clinical teaching at the Central Middlesex Hospital, and in 1940 he was made its Medical Superintendent.

He was elected a Fellow of the Royal College of Physicians in 1943.

During and after the war he was a strong supporter of the creation of a National Health Service (NHS), and in 1948 he was appointed member of the North-west Metropolitan Regional Hospital Board and chairman of its medical committee.

Richard Doll had joined the Social Medicine Unit at Central Middlesex Hospital in 1948 to work with Francis Avery-Jones on peptic ulcer disease, but by 1950 he was working with Austin Bradford Hill at the London School of Hygiene and Tropical Medicine on the possible link between cigarette smoking and lung cancer.

Joules had been a heavy smoker for 30 years but after seeing Doll and Hill's results he became entirely convinced of the harmful effects of smoking.

His father had died of lung cancer and he immediately stopped smoking himself and became a strident voice in the campaign against tobacco.

Since Joules was a member of the CHSC, SAC(CR) and SMAC he was ideally placed to press the issue with the Ministry of Health.

Still, he was often a lone voice speaking against tobacco and was opposed by many inside and outside of government.

In the same year he was also appointed to the Central Health Services Council (CHSC), the main professional advisory body for the National Health Service, and two Standing Advisory Committees (the Standing Medical Advisory Committee (SMAC) and the Standing Advisory Cancer and Radiotherapy Committee (SAC(CR)). In 1950 he was also appointed to the Nursing Council. These positions gave him significant influence on health policy-making. Joules also played another indirect but important role in British Public Health at that period - in 1948 he invited Jerry Morris to base the Medical Research Council's Social Medicine Unit at the Central Middlesex Hospital, where it went on to undertake seminal studies on infant mortality and the role of physical exercise in heart disease. The unit was dissolved upon Morris's retirement in 1975 but by that time it had assembled a very influential team of epidemiologists and undertaken extensive research into chronic diseases and social medicine.

Joules' clinical specialty was lung disease.

Tuberculosis (TB) was a major problem in the post-war period and Joules lobbied extensively to improve clinical services and was instrumental in opening two new hospital wards for tuberculosis at the Central Middlesex Hospital.

This was at a time when many general hospitals refused admission to TB patients due to the perceived risk to staff.

Joules instituted meticulous procedures of care that minimized the risk of infection, such that levels of TB were no higher in staff at the Central Middlesex than in other hospitals that refused to admit TB patients, and lower than the London teaching hospitals.

He was also particularly concerned with dust disease (pneumoconiosis) in miners, especially those who developed chronic bronchitis but had no radiographic evidence of pneumoconiosis.

In the absence of X-ray evidence of disease, miners received no compensation, an injustice which he fought hard to correct; however, it still remains a problem today.

This was highly topical since the Great Smog of December 1952 had only recently happened and was estimated to have caused at least four thousand avoidable deaths in London.

Around the same time, in 1952, Joules became aware of the evidence linking cigarette smoking to lung cancer.

In 1952 an anonymous civil servant in the Ministry of Health wrote that:[Joules] ‘is as you know the main protagonist against smoking - on the CHSC, on the SAC(CR) and in the Press.’ Nevertheless, despite opposition from Sir Ernest Rock Carling, chair of the SAC(CR), he persuaded the Central Health Services Council to make the first official statement in Britain on the harmful effects of cigarette smoking.

It is likely his contacts with the Labour Minister for Health, Hilary Marquand, and the recent death in February 1952 of King George VI, a heavy smoker, from a heart attack after an operation for lung cancer helped his case.

Joules also energetically lobbied the Press, the Chief Medical Officer, and the Royal College of Physicians.

In 1953 in a letter on Chronic Bronchitis to the British Medical Journal he wrote:‘The air we breathe is as important as the water we drink.

It must be uninfected and unpolluted.’ He urged the government to take action to control air pollution.

Sir Hugh Beaver, chairman of Guinness Brewers and a member of the management committee of the Central Middlesex Hospital, was appointed to lead a parliamentary inquiry into the problem.

Pressure from Joules helped provide evidence for the Beaver Committee.

Joules was also interested in the adverse effects of air pollution on health and, as vice-president of the SMA, established a special committee on 'Clean Air and Diseases of the Lung' in 1954, which included medical experts on industrial diseases, and representatives of the trade unions.

The Clean Air Bill that resulted became law in 1956 and smog gradually diminished in London and other British cities.