Cronin A J. The Citadel UK: Gollancz; 1937. 446 pages. ISBN: 0-450-01041-4

Set in Great Britain in the inter-war years, A J Cronin’s The Citadel is often credited with sparking off the movement that led to the establishment of the National Health Service. The novel begins in 1921 with the arrival of a young doctor, Andrew Manson, to Drineffy, a Welsh mining town. It tells the story of his rise from a young physician’s assistant to a successful consultant in London. It is an interesting and enlightening document of the medical system existing at that time. At the same time, it is a romance, beginning with his falling in love with Christine, a primary school teacher, and moving on to their marriage and, then, as he moves up the social ladder, his liaison with Frances, a married woman, who teaches him how to be successful. The novel ends with an idealistic coming together of Andrew, his surgeon friend Denny, and a maverick pharmacist, Hope. The three decide to set up a type of polyclinic in a moffusil town, moving out of avaricious and overcrowded London to deliver medical care where it is most needed and on sound scientific principles.

The Citadel is strangely familiar; the picture of poverty in the mining town could well be set in Dhanbad or Bokaro in our present times, where a young doctor struggles against malnutrition and illness caused by hunger, want and bad working conditions. Much like our own fresh medical graduates, when thrust into rural practice without the backup of a team, Andrew realises how little of medicine he actually knows. He is forced, as many of us are, to substitute good public health practice with ineffectual personal hygiene measures because the system cannot be made to do its job. However, Andrew and his friend do succeed in obtaining a new drainage system-by exploding dynamite in the sewage lines and surrounding the councilor’s bungalow with filth.

And yet, as Andrew moves ahead in life, his zeal for practising good medicine is diminished by the compulsions of success. His research on lung disease in anthracite mine workers yields him an MD but also takes him away from the mining communities that nurtured his work. He becomes a bureaucrat, tangled up in mindless paperwork. His original research is used by politicians to further their own careers while he is left with only the consolation of knowing that his work will help miners file claims for compensation. He achieves personal success as a clinician, setting up first as a general practitioner and then as a private consultant, his idealism and vision getting lost along the way. His personal life parallels his professional growth, as he drifts away from Christine, his conscience keeper, and gets attracted to Frances, a suave upper class woman who is more enthusiastic about his pursuit of wealth and fame.

The Citadel chronicles almost all the problems with our own medical system-cronyism, red-tapism, kickbacks, negligence, and corruption bred by the unhealthy overcrowding of doctors in big cities, even while the rural areas have no doctors to serve their needs. The book ends with a climactic speech in his own defense by Andrew at a hearing before the medical council, where he has been charged with collaborating with an American TB expert, who is not a qualified doctor, in conducting surgery on a friend’s daughter.

The Citadel does not rank as an artistic masterpiece. Its message is delivered without much subtlety, but nonetheless with a great deal of passion and conviction. Andrew is a loveable character, human in his frailties, his quick temper and petty jealousy and yet noble in his capacity to do his duty as a doctor. Andrew is a middle class hero with no family support or privilege, struggling against peers who have the medical profession in their grip due to their social standing and wealth. His struggle is that of establishing a fairer and more just, though not revolutionary, order where he can practise as a good professional. He flirts briefly with life as a high society consultant but returns eventually to the joys of family life and friendship. His vision of healthcare is typically individual, with the enlightened doctor at its centre. Although the book offers detailed insight and description of the poverty both in the Welsh mining towns and the London slums, very little of it translates into a political reflection on the causes of ill health. Not unlike most doctors, Andrew tries to find meaning in the work he can do as an individual practitioner.

And yet, the characters of The Citadel stay with you for a long time. Andrew is memorable. His dream of a happy domestic life in a small town practising sound medicine with a group of likeminded colleagues is endearing. His encounter with the widow of a former patient, who died as a result of a botched surgery, is remarkable: unsentimental and yet poignant. You read with dread and anticipation as he amputates a miner’s trapped leg, down in a mine shaft. Christine, whose life is partly eclipsed by her husband’s ambition, is still a woman who knows her own mind and who sticks to her principles, regardless of the pressure she may come under. And then there is Sir Robert Abbey, a kindly, though remote father figure, who watches over the career of the earnest Andrew Manson.

The book is filled with numerous other minor characters-miners, doctors, patients, bureaucrats, and businessmen – who give us a taste of what life would have been like in the Britain of that time. The Citadel has no real villains, quite unlike Cronin’s other books, except a faceless system which exploits patients and doctors alike. The alternative is, therefore, to look for an arrangement where doctors don’t have to live off the misery of patients but can actually act in their interest while fulfilling their own. In the present context, where even this modest idealism is so severely compromised and the faith and trust between doctors and patients has almost disappeared, The Citadel is a reminder that our problems are not unique or new. And with its undefeated optimism, despite the odds, the vision of The Citadel is still to be cherished.