The Citadel, a 1937 novel by A. J. Cronin, is thought by many to have “paved the way for Bevan’s NHS.”1 Previous work in BJGP Life examined Cronin’s life and career, and his reminder of the realities of British healthcare before 1948.2 Cronin explores the themes of social and health inequalities, drawing from his personal experiences working as a doctor in Britain’s pre-NHS era; Jones has pointed out the striking resemblance between the history of the main character and the author himself.2
The protagonist begins his medical career in a small Welsh mining town and observes first-hand the close marriage between social inequalities and health inequalities.
The title of Cronin’s novel, The Citadel, is interesting — its symbolism is open for interpretation. The word “citadel” originated in the mid 16th century from French citadelle, or Italian cittadella based on Latin civitas or “city”3. Modern English defines a citadel as a “strong castle, in or near a city, where people can shelter from danger, especially during a war.”4 And in maritime terminology a citadel is a designated room aboard a vessel especially designed for the crew to seek refuge during pirate attacks.5
Cronin may therefore be using the citadel to represent the seemingly impenetrable fortress that was the British medical elite of the early 1900s. With towering walls and on high ground, the citadel might represent a professional status to which many including Manson aspire, but only a select few succeed. Throughout the novel Manson struggles to gain acceptance into elite medical circles, hindered by his relenting morals, his lack of casual materialism, and his affection for many of his poorer patients. Through his protagonist Cronin highlights the value of respect and candour as key qualities in a doctor and, by contrast with the disagreeable elite, he emphasises the dangers of losing such qualities in unregulated and unscrutinised privatised medicine.
Drawing upon the function rather than the appearance of a citadel, perhaps Cronin’s choice of title symbolises his view of an idealistic healthcare system; one less focused on providing day-to-day care, but on providing safety and protection during crises, not of war, but of health.
Cronin’s choice of title symbolises his view of an idealistic healthcare system focused on providing safety and protection during crises, not of war, but of health.
If this is Cronin’s intended significance, do we currently regard health crisis management as a key purpose of the NHS? Does the NHS currently meet these expectations? The emergence of the SARS-CoV-2 pandemic exposed shortfalls in crisis preparation, most starkly publicised by shortages in personal protective equipment for healthcare workers6. The NHS’s response to the current pandemic shows that a more robust model is needed for crisis preparation. However, “crisis” might be interpreted less literally. Cronin may instead be alluding to the ongoing British crises of social and health inequalities, the themes underpinning his novel. Bevan’s founding principles, comprehensive treatment, universal access based on need and free at point of care,7 undoubtedly exist to address crises of health inequality.
Cronin may have used the citadel as a metaphor to describe Britain’s dire healthcare situation of his time, but a more optimistic interpretation is that he saw the grand citadel as a vision of what healthcare in Britain could aspire to become.
1. Watt G. The Citadel: A Potent Reminder of Life Before the NHS. BJGP Library: Br J Gen Pract. 2015;65(638):480
2. Jones R. AJ Cronin: novelist, GP, and visionary. Br J Gen Pract. 2015;65(638):479. doi:10.3399/bjgp15X686629
3. Online etymology dictionary. https://www.etymonline.com/word/citadel. Accessed 31 May 2020.
4. Cambridge Dictionary. https://dictionary.cambridge.org/dictionary/english/citadel. Accessed 31 May 2020.
5. Michael McNicholas. Maritime Security: An Introduction (2nd edition). Elsevier, 2016. pp 358.
6. Daniel Boffey. The Guardian: Health Policy. Timeline of UK’s coronavirus PPE shortage. (13 Apr 2020).
7. Aylward, M, 2011. Are Bevan’s principles still applicable in the NHS? 1000 Lives Plus.
Featured photo by David Misselbrook