Class Inequality and Public Health Reform

Class Inequality and Public Health Reform is a central concern in Poor Things: medical care is not presented as a neutral service but as a practice shaped by wealth, working conditions and social power. Godwin Baxter challenges a system that treats poor people as material for medical training while reserving safer, private care for the prosperous. The novel extends that criticism from hospitals to preventive health, reproductive medicine and the struggle to educate women as clinicians.

Hospitals, Class and the Art of Care

Baxter argues that public hospitals teach doctors to earn money from rich patients by practising on poor ones. In his account, the poor dread and hate the institutions, while patients with money can arrange operations privately or at home. His family history supplies a counterexample: Sir Colin Baxter operated in the family’s town house in winter and country house in summer, and took precautions against infection when hospital boards were still rejecting or denouncing aseptic medicine. The contrast is not simply between competent and incompetent surgeons. It exposes how access to money can insulate some patients from risks borne by others, while medical authority can conceal the consequences of unsafe practice.

Baxter’s account of Ignaz Semmelweis sharpens the conflict between evidence and institutional power. Semmelweis used antiseptics in a Viennese maternity hospital and reduced its death rate from 12 to 1¼ per cent, but his superiors rejected his conclusions and forced him out. He later died in a mental hospital after deliberately contracting the infection he had fought. His fate makes public health knowledge itself a contested resource: evidence that might protect patients does not guarantee that institutions will accept or apply it.

Baxter also contests the prestige accorded to doctors. He credits nursing with making hospital care effective, arguing that patients would often recover if nursing continued even in the absence of doctors and surgeons. The claim shifts attention from the celebrated practitioner to the sustained work of care. It also challenges a hierarchy in which professional status and medical technique can obscure the practical conditions on which recovery depends.

Prevention and the Industrial Economy

For Baxter, medicine should prevent illness rather than make money by treating its effects. He lists sunlight, cleanliness, exercise, fresh air, pure water, good food and roomy houses as basic protections, and calls for a government ban on work that poisons health or prevents people from securing these conditions. His argument places disease within the organization of everyday life: a clinic can treat an individual patient, but it cannot by itself remedy the circumstances that make people ill.

Archibald McCandless replies that Britain’s industrial position depends on profit. If social legislation restricts industry, he argues, Germany and America could take its markets, while workers might starve; he also notes that nearly a third of Britain’s food is imported. Baxter’s answer is that medicine consequently gives a charitable appearance to a plutocratic order without challenging its foundations. His voluntary work in an east Glasgow clinic soothes his conscience, but he doubts that it can resolve the contradiction. A complex transplant could take thirty-three hours to perform, preceded by at least a fortnight spent finding and preparing a compatible body. In that time, poor patients might die or suffer because conventional surgery had been delayed. The technical possibility of saving a life therefore sits beside the immediate costs of diverting time and resources from people who already lack care.

Poverty, Death and Discarded Lives

Baxter connects social inequality to the deaths of women and infants. He says that hundreds of young women drown themselves each year amid poverty and social prejudice, and describes how babies with severe conditions may be unable to live without artificial assistance. Some infants, he observes, are born without digestive tracts and would starve after the umbilical cord is cut; in practice, a kind hand may smother them, although no doctor would formally order it. In Glasgow, which he describes as Britain’s second-largest city and foremost for infant mortality, some parents cannot afford a coffin, funeral and grave for every child they lose. The account makes poverty visible not as a distant social statistic but in the material costs attached to death and mourning.

This argument shapes Baxter’s response to the drowned woman whose body becomes the basis of Bella Baxter. He says that he could clear her lungs and remove the foetus, then use electrical stimulation to return her to self-conscious life, but did not do so. In a society where suicide is treated as lunacy or crime, he fears that revival would force her into a madhouse, reformatory or jail against the life she had chosen to leave. He keeps her body alive at a cellular level instead. Baxter then describes his plan to unite a discarded body and a discarded brain, presenting Bella’s creation as a response to lives and remains that society has cast aside. The episode links scientific possibility to an ethical question about who has the power to define care, consent and a life worth preserving.

Reproductive Care and Medical Authority

The novel carries its critique into the treatment of women’s sexual and reproductive health. In Paris, Bella tells Millie Cronquebil that she can no longer work at the establishment where Millie is employed. She objects that medical examinations are unfair and inefficient when they scrutinize the women workers rather than the male clients who spread disease. When Millie replies that the clients would not agree and France has too few doctors, Bella proposes training the women to examine each client before the sexual encounter. Her intervention relocates responsibility from the women whose health is policed to the men who may expose them to infection.

A later confrontation over the proposed clitoridectomy for Lady Blessington exposes another form of medical control. Dr. Prickett says that Lady Blessington wanted the operation, while Godwin Baxter challenges the cultural assumption that women’s sexual pleasure is pathological and their desire for contact with a husband is evidence of illness. He points to the different origins of that belief, from ancient ideas that women existed to produce men to religious suspicion of sexual pleasure. Medical treatment thus appears within a wider struggle over who gets to interpret women’s bodies and whether distress should be answered with care or surgical suppression.

Bella’s later medical ambitions turn these criticisms toward professional practice. Baxter discusses the scarcity of women doctors in Britain and the opening of medical education to women, while proposing that Bella begin as a trainee nurse in an east Glasgow infirmary and, if she succeeds, assist him as a theatre nurse. He argues that doctors and surgeons should begin in nursing or be recruited from it, and that manual work should form the basis of professional training. Bella wants to help little girls, mothers and prostitutes, and intends to teach women effective contraception. Baxter and McCandless advise her to keep that intention private until she is qualified, and to wait before advocating birth control publicly; Bella agrees only when they acknowledge that the length of the wait must be her choice. The exchange shows both the barriers women face and the limits of even sympathetic advice when it seeks to manage their decisions.

Reform, Opposition and the Limits of Change

The later fate of Victoria McCandless’s medical and political work shows how reform can be attacked from opposing directions. Her book A Loving Economy proposes birth control, but clergymen of every Christian church denounce it, while birth-control advocates object to its claim that commercial contraceptives are unhealthy. Victoria argues for a broader understanding of sexual intimacy in which affection need not be reduced to a separate, marketable act. The controversy makes clear that reformers do not necessarily share a single program, even when they challenge established sexual and medical conventions.

Victoria’s prosecution ends with a Scottish verdict of not proven. She is not struck off the British medical register, but she is not declared guiltless either. In 1890 she and Archibald McCandless had opened the Natal Clinic using all of Baxter’s money for its fund; by 1920, a weakened managing committee gave way to hostile publicity, dismissed Victoria and transferred the clinic to Oakbank Hospital as an outpatient department. After spending her savings on publishing and promoting A Loving Economy, she retained only 18 Park Circus. She let its upper rooms to university students and continued a much smaller version of the Godwin Baxter Natal Clinic in the basement. This contraction gives the novel’s reformist vision a material ending: ideas and medical commitment persist, but the institutions and resources needed to sustain them can be withdrawn. Public health reform remains bound to the distribution of money, authority and access—not only to the knowledge of how illness might be prevented.