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George Orwell’s essay How the Poor Die makes for grim reading. It was first published in the magazine “N�Ƿ��� in 1946. The periodical had been founded 6 years earlier “for publishing literary matter and also as a forum for controversial writing��, so it must have been the perfect vehicle for this essay. Also, significantly, even though How the Poor Die had been written a decade or more before, it was first published in the very year when the British National Health Service (NHS) Act became law.

The NHS was part of a social welfare policy under Clement Atlee’s Labour government, and stated:

“It shall be the duty of the Minister of Health to promote the establishment of a health service to secure improvement in the physical and mental health of the people and the prevention, diagnosis and treatment of illness.��

The fine details were sorted out and the National Health Service started 2 years later, on 5th July 1948. The Minister of Health, Aneurin Bevan, was given the task of introducing the service. Its aims were to provide universal and free benefits to all those in need. Britain was on the cusp of arguably the greatest change in social policy there had ever been; an incredibly exciting time full of optimism, looking forward to a hopeful future, when all would have access to the best healthcare possible, irrespective of their means. (So far, in Britain, this is still the case, and honoured by all governments, whatever their political party.) Two years earlier then, keeping the public’s mind on the issue, and focusing on what the alternative might be, must have seemed crucial.

George Orwell had probably written How the Poor Die between 1931 and 1936, when his work revolved around the unemployed, tramps and beggars. For example “Down and Out in Paris and London��, had first been published in 1933. It has been suggested that he may have reworked it between summer 1940 and spring 1941, and he had certainly submitted it to “H�ǰ������Dz��� magazine a few years later. However, it had been rejected at that time, probably because readers would have been unwilling to read about “how the poor die�� in the middle of World War II. A decade on from its creation, the timing was now critical. This then is the background to the publication of George Orwell’s essay.

George Orwell expresses his concerns about hospital and medical care, and exactly pinpoints the preoccupations and worries of the public at that time, when he says:

“The dread of hospitals probably still survives among the very poor, and in all of us it has only recently disappeared. It is a dark patch not far beneath the surface of our minds.��

George Orwell does not write about conditions in English hospitals, instead recalling a public hospital in France. In 1928, he had gone to live in Paris, and had stayed there for 18 months. In early 1929 he began to feel unwell and spent two weeks in a public ward in “Hôpital X�� from 7th to 22nd March 1929. In fact this was the Hôpital Cochin, rue Faubourg Saint-Jacques, in the 15th arrondissement of Paris. The hospital still exists, although with a much improved reputation.

George Orwell was 25 years old, and although he was very ill, he continued writing, giving the hospital address to a publisher. Presumably it was notes from this time which he worked into the essay later. George Orwell was subject to bronchial conditions throughout his life. He had been admitted suffering from influenza or pneumonia—it was never established which—and describes vividly the squalor and primitive treatments he received:

“You got very little treatment at all, either good or bad, unless you were ill in some interesting and instructive way.��

On admission, George Orwell was interrogated dispassionately and at length by a clerk, and then given a bath:

“a compulsory routine for all newcomers, apparently, just as in prison or the workhouse.��

He was marched without slippers along the frosty path, while shivering from a high fever. He was not alone in this; it was standard practice. Entering a low ill-lit room full of murmuring voices, three rows of beds packed close together, he noticed a “foul smell, faecal and yet sweetish.��

In a nearby bed, a doctor and a student were performing a vaguely familiar medical procedure on someone, although it was not until later that George Orwell realised what it was. It was cupping, an “barbarous remedy�� dating from the 19th century and before. Without a word, and using the same uncleaned glasses, the two medics started treating him the same way:

“I had never been in the public ward of a hospital before, and it was my first experience of doctors who handle you without speaking to you, or, in a human sense, taking any notice of you ��

As I lay down again, humiliated, disgusted and frightened by the thing that had been done to me, I reflected that now at least they would leave me alone.��

But no, next was a mustard poultice, applied by “two slatternly nurses��. This was routine for all new patients, and also regarded as routine entertainment for the ward.

“These things are normally applied for a quarter of an hour and certainly they are funny enough if you don’t happen to be the person inside. During the second five minutes this belief evaporates, but the poultice is buckled at the back and you can’t get it off. This is the period the onlookers most enjoy.��

George Orwell did not sleep that night, and the next day he experienced daily life on the ward. The nurses woke the patients at 5 am, and took their temperature, but did not wash them. That was left to patients themselves, as was fetching bottles and “the grim bed-pan, nicknamed ‘la casserole’��.

Breakfast consisted of a thin vegetable soup with slimy hunks of bread floating about in it. Scraps of food and dirty dressings were discarded in the ward in a huge packing case infested with crickets. A tall, solemn, black-bearded doctor sped through, making his rounds, followed by a retinue of interns and students:

“sometimes followed by imploring cries. On the other hand if you had some disease with which the students wanted to familiarize themselves you got plenty of attention of a kind. I myself, with an exceptionally fine specimen of a bronchial rattle, sometimes had as many as a dozen students queuing up to listen to my chest ��

As a non-paying patient, in the uniform nightshirt, you were primarily ‘a specimen��, a thing I did not resent but could never quite get used to.��

The patients had no privacy. They lay exposed, suffering, urinating, and defecating in full public view.

“In most of the other beds within my angle of vision some squalid tragedy or some plain horror was being enacted��.

George Orwell gives details of some of those in the beds nearest to him. It makes for starkly grim reading. They died alone, their organs already marked for a bottle in the museum; their bodies designated for dissection. One such was known as “numéro 57��, who had cirrhosis of the liver. The doctor would sometimes wheel him into the middle of the ward on a sort of trolley, poke and examine him, whilst giving a medical lecture to yet another new group of students:

“As usual he neither spoke to his patient nor gave him a smile, a nod or any kind of recognition��.

The patient remained utterly uninterested. His liver had long since been marked down for a bottle in some pathological museum. He died some time during one night. Nobody knew or cared when.

“When the nurses came they received the news of his death indifferently and went about their work.��

The body was not removed until much, much later, and George Orwell had time to look and reflect on his fellow patient, and on the difference between this degradation and the violent deaths he had witnessed in India and Spain:

“[His] eyes were still open, his mouth also open, his small face contorted into an expression of agony �� it struck me that this disgusting piece of refuse, waiting to be carted away and dumped on a slab in the dissecting room, was an example of ‘natural�� death, one of the things you pray for �� that is how the lucky ones die, the ones who live to be old �� ‘Natural�� death, almost by definition, means something slow, smelly and painful …This poor old wretch who had just flickered out like a candle-end was not even important enough to have anyone watching by his deathbed. He was merely a number, then a ‘subject�� for the students�� scalpels. And the sordid publicity of dying in such a place!��

George Orwell comments that these appalling conditions had become a thing of the past, in England. “Just dying like animals, for instance, with nobody standing by, nobody interested�� reminded him of Victorian times. He says that the nurses had “a tinge of Mrs. Gamp about them��, alluding to the dissolute, sloppy and generally drunk “nurse�� of sorts, Mrs. Gamp, a famous character invented by Charles Dickens in his “Martin Chuzzlewit��. She was happy to “cure�� anyone for the price of a bottle of gin. Anyone recognising the reference would instantly then know how neglected the patients were.

As soon as George Orwell had got his clothes back and was strong enough to walk, he:

“fled from the Hôpital X, before my time was up and without waiting for a medical discharge. It was not the only hospital I have fled from, but its gloom and bareness, its sickly smell and, above all, something in its mental atmosphere stand out in my memory as exceptional.��

How the Poor Die is one of George Orwell’s longer essays, at just over 4500 words. In the second half he tells how this affected him, remembering tall tales in England about doctors cutting you open out of sheer curiosity or thinking it funny to start operating before you were properly “under��. Dreadful screams were said to issue from a little room in Hôpital X, and on one occasion George Orwell did see two students cause the death of a sixteen-year-old boy by a “mischievous experiment��. This made him wonder whether the stories were sometimes more than rumours.

“Well within living memory it used to be believed in London that in some of the big hospitals patients were killed off to get dissection subjects �� Hôpital X �� was a hospital in which not the methods, perhaps, but something of the atmosphere of the nineteenth century had managed to survive, and therein lay its peculiar interest��.

For the concluding part of the essay, George Orwell refers to the horrors of hospitals in the 19th century, and the literature of the period; as extreme as the scenes in Émile Zola’s “La Débâcle��, and the field hospitals in Leo Tolstoy’s “War and Peace��, or “that shocking description of an amputation in Herman Melville’s ‘White-Jacket’��. In “Hôpital X�� too, the patients were subject to barbaric horrors; virtual prisoners, they were held captive by their poverty. George Orwell describes Hôpital X as:

“an old-­fashioned, dungeon­like prison �� a place of filth and torture and death��.

Patients were denied humanity, but were moved quickly through the system. The hospital was about the “business of people dying like animals��; the doctors, with “the generic nickname ‘sawbones��, about as grim as they are comic��.

Since operations had to be conducted without anaesthetics, he says:

“it is difficult not to suspect the motives of people who would undertake such things. For these bloody horrors which the students so eagerly looked forward to (‘A magnificent sight if Slasher does it!��) were admittedly more or less useless: the patient who did not die of shock usually died of gangrene, a result which was taken for granted �� But anaesthetics were a turning-point, and disinfectants were another��.

The English public reading this essay when it was first published on the eve of the NHS, would have had experience in various types of hospital. For the large part, they would be from the working and lower ­middle classes, and the threat of what an experience in a bad hospital could be like, must have been at the forefront of their minds. Perhaps some had even had experiences similar to this themselves. They would be certain to champion the founding of an NHS, if this was a possible alternative. Memories of being unlikely to return once admitted to a hospital were routine in the 19th century (although it has to be said that some do still have this dread even today).

The essay is full of vivid and explicit images, and we feel the pathos of it all. We see many examples of traumatic experiences in “Hôpital X�� which left George Orwell hurt, frustrated, humiliated, angry and frightened. He must have been full of bitter resentment, yet he remains emotionally detached and critical; never self-indulgent. Occasionally George Orwell is ironic, or satirical, but this is for ease of reading, as the facts are so relentlessly grim. Mostly his descriptions are deliberately neutral, to avoid bias. Yet his explicit comparison with medical treatments and institutions of the 19th century show that this experience had nonetheless affected the 25 year old George Orwell mentally and psychologically.

George Orwell finishes his essay with a note of warning. He had been reminded of a poem by Alfred, Lord Tennyson, called “The Children’s Hospital��, which a old sick-nurse had read to him when he was tiny. It was full of horrors and suffering in an old-fashioned hospital, but it had been a vivid memory to her. He had forgotten the poem, but it came back to him word for word in Hôpital X.

It was a critical time for the original readers to read this essay. It is also a critical time right now, in a world pandemic. Health care systems in some countries are fragile at the best of times, and virtually nonexistent for the poor. With overwork, not enough drugs and equipment, and no end in sight, it would not take much for some formerly caring individuals, now under intolerable pressure, to lose heart, and slip into the callousness of Hôpital X.




The essay has been reprinted in various collections:

Now. �� GB, London. �� November 1946.
Reprinted:�� ‘Shooting an Elephant and Other Essays�� 1950.
‘The Orwell Reader, Fiction, Essays, and Reportage�� �� 1956.
‘Collected Essays��. �� 1961.
‘Decline of the English Murder and Other Essays��. �� 1965.
‘The Collected Essays, Journalism and Letters of George Orwell��. �� 1968.