In the mid-1960s Richard Titmuss, the leading British figure in the field of social policy and adviser to the Labour Party, described the National Health Service (NHS) as ‘one of the most unsordid and civilised actions in the history of health and welfare policy’. Around the same time his sparring partner, the Conservative politician Enoch Powell, described two things that any incoming minister of health had to take on board immediately – that the demand for medical care was infinite and that all doctors wanted to talk about was money. Although coming from very different political standpoints (including over immigration in the 1960s), their comments tell us a number of things about the NHS and its history. Titmuss alerts us to the notion that the service's creation was (and still is) seen by many as the high point of Britain's simultaneously created ‘welfare state’. It was an expression of social solidarity manifested by its commitment to provide health care that was universal, comprehensive and free at the point of delivery. Powell's more cynical comments nonetheless remind us of the extraordinary revolution in biomedicine after 1945 alongside the idea that doctors (and, in the context of this book, medical scientists) were not necessarily disinterested pursuers of objective scientific proof motivated by altruism. Titmuss and Powell thus foreground the highly politicized nature of health care.

Historians have, at least in principle, long understood this, but as Roberta Bivins remarks in this closely researched and subtly argued volume, the ‘meaning of this enormous institution [the NHS] has yet to be fully explored, and existing historical accounts … capture snapshots rather than the broad panorama of its impacts’ (p. 369). She thus seeks to locate Britain's post-war health services alongside, and interacting with, the contemporary processes of the end of empire and the subsequent immigration from Britain's former colonies. And in due course many of these immigrants were to prove crucial to NHS staffing at nearly all levels. The era under discussion – the late 1940s to the early 1990s – was also that of Cold War when Western democracies sought to convince their own citizens (and others) of the virtues of welfare capitalism. So how did medicine and health care respond to, in particular, Commonwealth immigration and how did they interact with each other? The author's aim is to ask ‘how the ideas and ideals of the post-war Welfare State have played out in terms of political and practical responses to the key challenges of racialized migration and medicalized embodiment’ (p. 4). More specifically, Bivins focuses on ‘discourse, policies, and practices that represented and responded to migrant bodies as pathological, pathogenic, or vulnerable’ in the context of a social settlement which ‘predicated health(care) as both the marker and the earned reward of active citizenship’ (p. 12).

The book is organized as follows. An introduction, ‘Medicine, migration, and the afterimage of empire’, sets out its aims and methods, and reviews how existing NHS historiography deals with the question of how immigration has been engaged with (hardly at all). There is also a brief, but useful, discussion of how historians and other social scientists presently deal with issues around ethnicity and race. The book is then divided into three parts, roughly chronological in order. The first, ‘Tuberculosis in black and white’, deals with the period from the creation of the NHS through to the mid-1950s, and consists of two chapters. In the first Bivins seeks to ‘sketch the relationship between tuberculosis and immigration’ in the NHS's early years while the second analyses the responses, which were not uniform, to immigrants purportedly bringing in disease in the context of ‘a social and political battle over Britain's national and international identity’ (p. 22). The second part, ‘Immigration, identity, and “control”’, moves into the racially tense atmosphere of the 1960s. Its first chapter examines the impact of outbreaks of ‘imported’ smallpox in the early 1960s while the second, one of the book's most important, looks at the complex interactions which resulted in a discourse of ‘control’ with three components – control through eradication (in the case of tuberculosis), control of immigration itself (over which Titmuss and Powell became increasingly agitated), and control through integration. Part Three, ‘Chronically ethnic’, engages with, first, ‘Asian rickets’ from the early 1960s to the early 1980s, while the subsequent chapter looks at genetic science with a particular focus on blood disorders such as thalassaemia, a condition generally associated with the Greek Cypriot population. A short (perhaps too short) conclusion rounds off the volume.

As will be evident, Bivins set herself a huge challenge but she has risen to it admirably. One major finding is that her work, while undoubtedly revealing individual and institutional cases of racism, has nonetheless ‘illustrated a more complex genesis for health policy and responses than racial antagonism alone’ (p. 375). To put it another way, health care staff and medical scientists operate in specific social, historical and individual contexts – something which should be self-evident in histories of institutions like the NHS, but is often ignored. For this reason alone, the author's work has added immensely to our understanding of post-war health care. The case studies, too, are models of historical analysis and will be of interest to historians of science as well as to those of medicine. Two quibbles, though. This volume is as much about medical science as it is about the NHS, and only about parts of the latter. Nor does it have much to say about immigrant staff. On one level this is simply evidence of the author's point that the NHS is a vast, complex organism whose history needs to be approached from a variety of angles. But while the volume is not quite what its title proposes this should in no way detract from a remarkable achievement which sets a whole new agenda for historians of British health care.