Chapter 25: Unfinished Business
(i) The Social Services: Decision and Development
The three themes of evacuation, hospital service, and help for the victims of air attack have largely dominated this book. The effects of the war on the ordinary, peacetime social services have not been described in detail, chiefly because the plan of the history allowed for studies of this kind to be brought together in a second volume.1 In the opening part of this last chapter of the first volume, however, some of the more important developments in the field of social policy are briefly noticed; these, set against the background of Government policy to protect and sustain the civilian population from air bombardment, serve as an introduction to a tentative analysis of the total effects of the war on the people’s health.
It would, in any relative sense, be true to say that by the end of the Second World War the Government had, through the agency of newly established or existing services, assumed and developed a measure of direct concern for the health and well-being of the population which, by contrast with the role of Government in the nineteen-thirties, was little short of remarkable. No longer did concern rest on the belief that, in respect to many social needs, it was proper to intervene only to assist the poor and those who were unable to pay for services of one kind and another. Instead, it was increasingly regarded as a proper function or even obligation of Government to war off distress and strain not only among the poor but almost all classes of society. And, because the area of responsibility had so perceptibly widened, it was no longer thought sufficient to provide through various branches of social assistance a standard of service hitherto considered appropriate for those in receipt of poor law relief—a standard inflexible in administration and attuned to a philosophy which regarded individual distress as a mark of social incapacity.
That all were engaged in war whereas only some were afflicted with poverty and disease had much to do with the less constraining, less discriminating scope and quality of the wartime social services. Damage to homes and injuries to persons were not less likely among
the rich than the poor and so, after the worst of the original defects in policy had been corrected—such as the belief that only the poor would need help when their homes were smashed—the assistance provided by the Government to counter the hazards of war carried little social discrimination, and was offered to all groups in the community. The pooling of national resources and the sharing of risks were not always practicable nor always applied; but they were the guiding principles.
Acceptance of these principles moved forward the goals of welfare. New obligations were shouldered, higher standards were set. The benefits were considerable. The community relinquished, for instance, a ten-year old practice of not providing cheap school meals unless children were first proved to be both ‘necessitous’ and ‘under-nourished’.2 Better pensions were given to old people as a right and not as a concession. Certain groups—expectant and nursing mothers and young children—were singled out to receive extra allowances and special aids, not because they were rich or poor or politically vocal, but because common-sense, supported by science and pushed along by common humanity, said it was a good thing to do.
These and other developments in the scope and character of the welfare services did not happen in any planned or ordered sequence; nor were they always a matter of deliberate intent. Some were pressed forward because of the needs of the war machine for more men and more work. Some took place almost by accident. Some were the results of recognition of needs hitherto hidden by ignorance of social conditions. Some came about because war ‘exposed weaknesses ruthlessly and brutally … which called for revolutionary changes in the economic and social life of the country’.3
Reports in 1939 about the condition of evacuated mothers and children aroused the conscience of the nation in the opening phase of the war; much sooner, indeed, than might have been expected from the country’s experience in previous war of changes of the conception of the nation’s responsibilities towards the poor and distressed. It was in 1815–after Waterloo—that Lord Brougham’s committee met to consider ‘the Education of the Lower Orders’. It was after victory in the Boer War that inquests on the physical condition of the people were opened.4 It was not until the later years of the First World War that plans for reconstruction began to take shape.5 But the evacuation
of mothers and children and the bombing of homes during 1939–40 stimulated inquiry and proposals for reform long before victory was even thought possible.6 This was an important experience, for it meant that for five years of war the pressures for a high standard of welfare and a deeper comprehension of social justice steadily gained in strength. And during the period, despite all the handicaps of limited resources in men and materials, a big expansion took place in the responsibilities accepted by the State for those in need.
The reality of military disaster and the threat of invasion in the summer of 1940 urged on these tendencies in social policy. The mood of the people changed and, in sympathetic response, values changed as well. If dangers were to be shared, then resources should also be shared. Dunkirk, and all that the name evokes, was an important event in the wartime history of the social services. It summoned forth a not of self-criticism, of national introspection, and it set in motion ideas and talk of principles and plans. The Times, in a remarkable leader a few weeks after the evacuation of the British Expeditionary Force from the Continent, gave expression to these views. ‘If we speak of democracy, we do not mean a democracy which maintains the right to vote but forgets the right to work and the right to live. If we speak of freedom, we do not mean a rugged individualism which excludes social organisation and economic planning. If we speak of equality, we do not mean a political equality nullified by social and economic privilege. If we speak of economic reconstruction, we thin less of maximum production (though this too will be required) than of equitable distribution.’7
This was a declaration of faith. In a few months it was to be repeatedly affirmed with the bombing of London and Coventry and many other cities. The long, dispiriting years of hard work that followed these dramatic events on the home front served only to reinforce the war-warmed impulse of people for a more generous society.
These broad generalisations, subject, as they will be, to revision by historians better placed to study this phase of the war, are relevant to the story of welfare. For it was during this period, extending from June 1940 until bombing temporarily ceased in the following year, that certain decisions were taken and certain policies were shaped which not only looked forward to ‘social reconstruction’ after the war, but were destined also during the war itself to play a vital role in sustaining the health and working capacity of the people. To the examples of these policies that have been given in earlier chapters8 others will now be added; together, they support the proposition that
this dangerous period of the war was most fruitful for social policy and action.
The provision of meals at school had been interpreted by most education authorities, until a decisive change in Government policy in July 1940, as a relief measure for malnourished children.9 Dinners of a poor quality were frequently supplied, often by private caterers; a charity outlook combined with the caterers’ need to make a profit were reflected in the poverty of the meals and a lack of decency in serving them. ‘Many of the dietaries are out of date, having been introduced ten and in some cases twenty years ago.’10 These conditions in many parts of the country did not make the school meals service attractive to self-respecting parents.
In July 1940 positive steps were taken, with Treasury backing, to broaden the scope of the service and improve its quality.11 The number of school meals supplied doubled in twelve months and the provision of school milk rose by about fifty percent. These advances more than recovered the ground lost by the disruption of the social services during the first year of war. In September 1941 policy took another big step forward. Three minsters presented to the War Cabinet a joint paper recommending that a greatly increased rate of grant-in-aid should be given to local authorities.12 As part of the national food policy it was proposed to expand the provision of school meals and milk as quickly as possible. Evidence of unsatisfactory health indices during the first two years of war—for instance, higher infant death rates and rising tuberculosis rates—had a hand in these proposals. ‘There is a danger’, it was said, ‘of deficiencies occurring in the quality and quantity of children’s diets … There is no question of capacity to pay: we may find the children of well-to-do parents and the children of the poor suffering alike from an inability to get the food they need’. The War Cabinet agreed to these proposals, and the campaign, originally launched in July 1940, was pressed forward with renewed vigour to increase the number of children taking meals at school and to provide milk for every child at every school in the country.
Within three years the situation had been completely transformed, both in quantity and quality of service, despite all the very real difficulties caused by the need to provide new dining rooms, school
canteens, kitchens and equipment, the rationing of food supplies, inadequate transport facilities in rural areas and shortages of staff.13 In February 1945, 1,650,000 dinners were taken on every school day in England and Wales, about fourteen percent being free and the rest costing the parents 4d. to 5d. a meal.14 In July 1940 the corresponding figure had been 130,000.15 In round figures, one child in three was fed at school in 1945 in place of one child in thirty in 1940. The speed at which these changes were accomplished may be judged by a contrast with the years 1935–9; a period during which efforts were also being made to expand the school meals service under the spur of nutritional science and reports of under-nourishment in industrial areas. In 1935, 143,000 dinners were provided daily in England and Wales; four years later the number stood on the brink of 160,000.16
Between 1940 and 1945 a big advance was also made in the number of children receiving milk at school, although the aim of universal provision was not achieved by the end of the war. In July 1940 the proportion benefiting in primary and secondary schools in England and Wales was around fifty percent; by February 1945 it had risen to seventy-three percent.17 The increased quantity of milk being drunk in 1945 was greater than the difference between these figures suggests, for the proportion of children taking two-thirds of a pint each day rose from nineteen percent in February 1941 to forty-six percent in February 1946.18 The milk-in-schools scheme (with its benefit of a reduced price) was also extended to pupils attending private and other non grant-aided schools; thus, children at all types of school in the country were entitled to participate in the scheme.
These developments in the provision of meals and milk at school expressed something very close to a revolution in the attitude of parents, teachers and children to a scheme which, only a few years earlier, had not been regarded with much respect or sympathy. In place of a relief measure, tainted with the poor law, it became a social service, fused into school life, and making its own contribution to the physical nurture of the children and to their social education.
The national milk scheme, conceived and developed by the Ministry of Health and destined to play an important part in sustaining the health of mothers and young children during the war, was also adopted by the Government in the summer of 1940 without dispute or financial argument. Before Dunkirk, the Ministry of Health had been worried by the failure of its scheme of August 1939 for supplying cheap milk to mothers through the maternity and child welfare authorities.19 What it wanted to do could not, seemingly, be done without a big Exchequer subsidy, and no one believed that this would be forthcoming. But on 7th June 1940 the Food Policy Committee of the War Cabinet approved in principle a scheme for supplying cheap or free milk to mothers and children and have the Ministers of Food and Health authority to work out the details without further reference to the Cabinet.
Introduced in July 1940, the national milk scheme provided for every child under five and for all expectant and nursing mothers in Britain a pint of milk daily at 2d. instead of the price of 4½d. a pint ruling in most districts at the time.20 If the family income was below 40s. a week (plus an allowance of 6s. a week for each non-earning dependent) the milk was supplied free. The scheme was administered not by the local government bodies who had handled the abortive measure of 1939, but by the Ministry of Food and the local food offices. The whole cost was borne by the Exchequer.
For over a decade many authorities, vigorously led by Sir John Orr, had demonstrated the need for getting more milk into mothers and children. Consumption pre head of the whole population of the United Kingdom was little higher in the nineteen-thirties than it had been before the First World War.21 Among the better-off income groups, however, the quantity drunk each day was about three times in excess of that consumed by the poor.22 It was, in the main, a problem of purchasing power. This problem was solved for mothers with young children by decision of the Government five days after the evacuation of the British Expeditionary Force from Dunkirk.
The scheme was an immediate success. Within three months the response had falsified the estimates of the experts in the Ministries of Food and Health, who appear either to have underestimated the effect of insufficient purchasing power on the consumption of such an essential food as milk, or to have misjudged the extent to which the higher income groups would share in a welfare service of this character.23 Of the 3,500,000 or so mothers and children in Britain entitled to participate, seventy percent were doing so in September 1940, and of this proportion nearly thirty percent received their milk free of cost. This figure of thirty percent, representing families living in a state of poverty, fell in a remarkable way during the war. It fell to two percent by 1945. Thus, even though the test of resources made no allowance for increases in the cost of living, the decline in the number of free beneficiaries was a rough measure of the economic effects of the war in diminishing the amount of poverty among families containing expectant or nursing mothers and young children.24
There are problems affecting the production and supply of milk—including its quality25—that cannot be considered here;26 but it is important to observe at this point that the national milk and the milk-in-schools schemes led to a more equitable sharing out of what was available, and to increased consumption among those groups in the
community who most needed milk.27 As between families of the same size with the same number of children of comparable ages, weekly consumption figures collected by the Ministry of Food during 1941–3 still showed a steady increase—in common with other important foods—from the lowest to the highest income groups. The differences, however, were much less striking than before the war.28
The special scheme took their place within the general rationing arrangements of milk.29 Priority of supply was guaranteed to expectant and nursing mothers and children, and also to invalids and sick people suffering from certain diseases. The intervention of the State led to about eighteen percent of total milk supplies being made available for the priority groups of expectant and nursing mothers and children up to school leaving age.30 (The figures for the other priority group of sick people were affected by some anomalies in distribution.) This quantity of milk was not only provided for these groups of mothers and children but positive economic measures were taken to ensure that it actually reached them.31
Closely associated with the national milk scheme, in intention and administration, was the vitamin welfare scheme. This was introduced in December 1941 because of misgivings about a possible shortage of vitamins in the diet of young children resulting from the lack of fruit, particularly oranges, and the shortage of butter and eggs. The
principal began by providing free of charge blackcurrant syrup or purée and cod liver oil for children up to two years of age. A few months later, the blackcurrant products were gradually replaced by orange juice, and the issue was made subject to a small payment. Further extensions of the scheme led to all expectant mothers and children aged under five who received cheap or free milk being automatically entitled to cheap or free supplies of orange juice and cod liver oil. For expectant mothers, who could not always take cod liver oil, vitamin A and D tablets were provided as an alternative. In January 1944 the proportions entitled to these supplements who actually collected them were: orange juice fifty-seven percent, cod liver oil thirty percent, vitamin A and D and tablets forty-five percent.32
What was remarkable about these wartime developments in the provision of school meals, milk and special foods for certain groups in the community was the unanimity underlying policy and the speed at which decisions were acted on. No longer was it argued (as it often was before the war) that the condition of the people did not warrant such measures or that nothing should be done until unmistakable evidence of a deterioration in the public health had shown itself for some time.33 No longer were fruit juices for children dismissed as ‘exotic’,34 or state aid in such matters as school dinners regarded as an invasion of parents’ rights. It was the universal character of these welfare policies which ensured their acceptance and success. They were free of social discrimination and the indignities of the poor law.
The same impulse to remove or lessen inequalities was apparent elsewhere: in the higher pensions paid to old people and their removal from the machinery of the poor law;35 in the abolition of the
household means test from social service payments;36 in the transformation after 1941 in the quality of the Assistance Board’s work and in the relationship between its officers and its clients (symbolised by the employment of ‘friendly visitors’ to call on old age pensioners);37 and in the nation-wide character of the scheme for immunising children against diphtheria under which nearly 7,000,000 children in Britain were treated during 1940–5.38 In all these instruments of welfare there was a conspicuous absence of direct or implied discrimination. Where it was present, as in the ill-fated Ministry of Health scheme for giving special monetary allowances only to tubercular people likely to benefit from treatment, it aroused resentment.39
By and large, the experience of those who had used the social services after 1940 was different from that of the people who had sought social assistance during the nineteen-thirties The spirit in which many of these services were ordered and administered from about 1941 onwards underwent a subtle but noticeable change. To an increasing
degree, human needs were considered and dealt with in a humane way. This was a sharp contrast with the mass treatment of individual distress during the years of heavy and prolonged unemployment.
Between these two periods of time with their different conceptions of the meaning of social duty there was the year of revaluation; the year when needs were made manifest and complacencies shaken. Evacuation, ‘the most important subject in the social history of the war because it revealed to the whole people the black spots in its social life’,40 was the first big entry in the balance sheet which war, beginning its great audit, made inevitable. Then came, in the summer of 1940, the ‘remarkable discovery of secret need’41 among some 750,000 old people. A new act,42 setting up a scheme whereby old age pensioners and widows could apply for supplementary allowances if their resources were insufficient, led to over 1,000,000 pensioners receiving extra grants at an annual cost to the nation of £26,00,000 in 1941 rising to £60,000,000 in 145.43 Before the Act took effect in August 1940, it had been estimated that only 275,000 pensioners were receiving supplementary allowances from the poor law at an annual cost to the rates of £5,000,000.44
Another surprising experience during the same year was the unexpected success of the national milk scheme; the first warning that demand for milk, long lagging behind production, would outstrip supplies and compel the Government to establish a system of rationing. From yet another field of the public health there came, too, evidence which called for—and obtained—a new examination of old facts. The standard of fitness of the nation’s young men was found, in 1940, to fall short of what many believed had been achieved during the nineteen-thirties. It had been claimed that the results of the medical examination of men aged twenty and twenty-one under the Military Training Act, 1939, showed a remarkably high standard of fitness. ‘Only 2·3 percent of those examined are definitely unfit for military service’, said the Minister of Health; ‘these are striking results’.45 ‘Others besides the military authorities will be pleasantly surprised’, echoed The Times in a leader headed ‘An A1 People?’.46
But within a year these views were to be upset. The Comptroller and Auditor General was one of several authorities to put their doubts in writing: ‘It appears to me’ (he wrote in 1941) ‘that during the early months of the war many men, who were accepted following a cursory preliminary medical examination, were later found on a more thorough examination to be unfit for military service.47
But if the physical health of the people was not all that it had been thought to be, this year of great events, of setbacks and self-criticism, did not close without at least one reassuring message. Trial by bombing was endured without panic or hysteria; the people, responding to vigorous leadership, showed deep reserves of mental stability.
In many ways it was fortunate for the nation that this revision of ideas and rearrangement of values came so early in the war. They allowed and quickly encouraged great extensions and additions to the social services; they helped many of these services to escape from the traditions of the poor law, and they made them more acceptable to more people. The fact that the area of collective responsibility moved out so soon in a wider circle, drawing in more people and broadening the obligations to protect those in need, was to serve the national well during the following five years of strain and deprivation. Some of the benefits contributed to a good record of national health during these years. It now remains to consider this record.
(ii) Wartime Health: Complexities and Contradictions
An explanation that will satisfy everyone will probably never be given of the causes of the deterioration in certain health indices in 1940 and again in 1941, nor of the reasons why this downward trend was suddenly reversed in 1942, and why improvement continued to the end of the war and beyond. The conjunction of these trends and the new policies of welfare embarked on during the twelve months or so following Dunkirk suggests an easy and simple answer. But cause and effect are seldom demonstrated as fluently as this; the correlation is by no means perfect, the facts fir in some places but not in others; there is always a history of the health of nations as there is of the health of individuals.
During the first year of war there were many expressions of surprise and relief by medical authorities and members of the Government and the health of the nation had been maintained at a high standard. So long did this feeling of relief prevail that, even as late as September 1941, the Minister of Food wassaying that the nation had ‘never been in better health for years’.48 Yet, in retrospect, it seems probable that these authorities were still more astonished when, after five years of war, of food shortage, of bombing and other tribulations, many of the important health indices showed improvement, and in some respects astonishing improvement, over the figures for 1938 and 1939.
This relief, so naturally and spontaneously expressed in the first twelve months of war, was, to a limited extent at least, a reaction from previously held fears. It had been thought that if war was to come, with its new and violent threats to civilian health and life, there might well be more disease in various shapes and forms, and general deterioration in natural stamina.49 But there were no explosions of disease; no dramatic upsets in standards of health. In some measure, of course, the feelings of relief were psychological descendants of the view of the nineteen-thirties that there was not much wrong with the nation’s health. According to that view, there was relatively little to gain but a great deal to lose. After a year and more of war, nothing seemed lost.
But, as the winter of 1940 passed, with its strains of bombing and shelter life, and as fresh restrictions were imposed on food supplies,50 a more cautious note began to colour official views about the health of the people. Signs were accumulating that a deterioration might be setting in; tuberculosis deaths were increasing in number faster than had been the case during 1914–16—particularly at ages under twenty51—infant mortality and deaths among young children had risen in 1940 and again in 1941, and reports were reaching the Health Departments of more anaemia among certain groups of women and children.52
These pieces of evidence, though not firmly conclusive and in some respects equivocal,53 suggested that there might be danger ahead. With the prospect of a long war, the probability of heavier bombing to come, and a growing conviction that the shortage of food, clothing and houseroom was no temporary matter, the authorities began to look round for means to study and watch the trend of civilian health. At the same time, symptoms of public uneasiness found expression in demands for a national nutrition council to stimulate and aid research.54 It was during this period that the wartime search for signs of undernourishment began in earnest.
The trouble was that most of the existing methods of diagnosing the state of the public health relied on instruments which time and progress had blunted. The rate at which people died, a valuable index in the hands of Chadwick and Farr when outbursts of cholera and other dramatic forms of disease were likely at any time, had lost some of its value to a society with a higher standard of life, a cleaner environment, and which at least knew how to prevent people from dying if it did not know how to keep them health. The advances in medical and allied sciences since the nineteenth century, developments in the use of sulphonamide drugs, and the growth of the social services, had all contributed to a decline in the usefulness of the death rate as a ready index of trends in the nation’s health.
But, as yet, little had been put in its place.55 No comprehensive figures were available before the war concerning the amount of sickness in the community;56 information on absence from work because of ill-health was fragmentary and unreliable; the statistics of notifications of certain diseases, e.g. tuberculosis, were unsatisfactory;57 and
the results of the medical inspection of the nutritional state of schoolchildren had proved to be ambiguous and untrustworthy.58 The lack of sensitive instruments for recording disturbances in the public health handicapped the authorities when they tried to estimate the effects of food shortages and other wartime changes in the standard of living. It meant that there was no reliable pre-war base-line from which moderate degrees of change could be measured.59
There was only one way to overcome this lack of public health data; to set on foot ad hoc inquiries and surveys to search out and watch for danger signals. At various times during 1941–2 and later in the war many investigations of different kinds were made by the Medical Research Council, the Health Departments, the Ministry of Food, other bodies inside and outside the Government and individual research workers. Among the more important of these were the Medical Research Council’s investigation into anaemia (know as the haemoglobin survey),60 the report of the Council’s committee on tuberculosis in wartime,61 and the Ministry of Health’s monthly survey of sickness in a small but representative sample of the population aged over sixteen.62
Many of the new investigations had not progressed very far before it began to appear that the signs of deterioration, which had shown themselves during 1940–1, were fading away. The increases in the death rate among infants and young children, and from diseases of poverty like pulmonary tuberculosis, were arrested in 1942. They then began to turn downwards.63 Some important fact, or more
probably a combination of factors, became sufficiently powerful during the third year of the war to exert a favourable influence on these rates of mortality. The improvement in certain of these vital indicescontinued to the end of the war and beyond.
The total mass of material bearing on the public health during the war is so immense, and so complex in character, that this discussion can only treat broadly and superficially two or three features of general interest. Among all the changes in health indices between 1941 and 1946, perhaps the most striking were the reductions in the rates of death for infants, young children and mothers in childbirth. The movement of two of these rates is show in the following table, and it may be seen, by reference to the annual reports of the Registrars-General, that changes of corresponding magnitude occurred among young children—especially those aged from one to five—and that much greater reductions were recorded in the rate of maternal mortality.
Infant Mortality and Statistics
|Number of infant deaths under one year per 1,000 related live births||Number of stillbirths per 1,000 total live and stillbirths|
|England and Wales||Scotland||England and Wales||Scotland|
|1945 % of 1936–8||82||73||72||79†|
|1946 % of 1941||72||65||77||80|
* Not registered before 1939.
† Percent of 1939.
The improvements shown in this table would have been considered by any student of national welfare as a remarkable achievement in peacetime; they were more remarkable for a period of war, and doubly so when set in a wider frame of history. In the hundred years or so since national records of infant mortality were first kept for England and Wales, the decline of twenty-eight percent in the rate between 1941–6 was only once equalled for any similar or shorter period of time.64 In Scotland, the decline of thirty-five percent in the rate between 1941–6 was easily the greatest percentage reduction since records were first kept in 1855.
Such figures as these, although they are only death rates and in no sense an index of health, must surely mean something important. IT is inconceivable that the saving of child life at this rate could have been accompanied by a deterioration in the general state of health and well-being of the average child. The results of a variety of clinical and biochemical studies, of height and weight changes and other investigations among children of all ages, did not show that any deterioration took place between 1942 and 1945.65
The improvements in the vital statistics of infantry during 1942–5 were probably shared by all social classes. Surprisingly, the stillbirth rate for Scotland suggested, however, that it was the better-off in come groups—and not the poor—who registered the greatest reductions during the war, although there was much less scope for further gains by these groups as their pre-war rates were easily the lowest.66 While, therefore, all social groups in Scotland showed better figures, the gap between the best and the worst widened by 1945 in comparison with the difference in 1939.67 To those who believed that the Government’s food and economic policies were bound to lead to less in equality in the distribution of death these Scottish figures were unexpected and difficult to interpret.68 There may be some explanation of a medical or biological nature which has not yet been identified, or the answer may have to be sought in the actual working of the food rationing system or in a differential consumption by expectant mothers of the relatively expensive and scarce non-rationed foods. But the vague speculations of this kind cannot obscure the fact that knowledge in this field cannot obscure the fact that knowledge in this field of the interaction of social and biological forces is still very limited.
There was still, it is true, undernourishment, bad feeding and stunted growth, particularly among large families,69 and in areas like Merthyr Tydfil, Liverpool and Glasgow which had suffered acutely during the years of unemployment. The consumption of certain rationed and unrationed foods, especially of meat and meat products, fish, vegetables and fruit, was, during the war, still largely governed
by purchasing power and again, therefore, in many instances, by the number of children in the family.70 The war did not abolish poverty; rationing by price continued to exist side-by-side with rationing by coupons. But nothing emerged from all the available evidence to suggest that these social and economic ills were more common than before the war. In many respects they were much less common and much less serious. That there were some groups in the community who were significantly better off in their diets while others were worse off cannot be doubted; what is not known, however, is the respective size of these groups, their composition at different periods of the war, and the extent to which their diets rose or fell in nutritional value by peacetime standards.71
Among young people and adults, wartime vital statistics are even less informative and more difficult to analyse than those for children. Death rates and measures of sickness and absence from work were confused by many special factors, notably the selective recruitment of several million men and women in the Armed Forces, the changing age and sex composition of the civilian population and the effects of air raids. If the death rates for older men and women are studied, however, it is apparent that substantial gains were achieved after 1941.
In comparing the figures for 1945 with those for 1938, there is nothing in the table on the next page to suggest that any deterioration in health standards took place among middle-aged and elderly men and women. On the contrary, when these reductions in death rates are set against the background of wartime strains and stresses, and when further comparisons are made with the trend of the death rates during the nineteen-thirties (especially for men72), the gains appear in a more impressive light.
Death rates per 1,000 population: England and Wales73
Civilians only from 3 rd September 1939 for men, and 1 st June 1941 for women
All causes of death excluding those due to operations of war
|1945 % of 1938||88||96||96||84||85||89|
Most of the rates for different causes of death which make up the total mortality declined in varying degrees during the war. There was, however, one big exception—that of tuberculosis—to the general favourable experience. War and tuberculosis have so often conspired to kill that an increase in the power and spread of the disease after 1939 might have been expected. A serious rise did, in fact, take place in 1940 and again in 1941, both in the number of civilian deaths and the number of people notified as suffering from tuberculosis.74 The drastic ejection of many patients from sanatoria on the outbreak of war, and their return home in an infective state, probably contributed to these increases.75 The attack, however, took somewhat different forms and affected somewhat different groups of the population from that which had developed during the early years of the First World War. More children died, for instance, from tuberculosis of the glands, bones and joints, and perhaps because of the discharge of infective patients from sanatoria more deaths were recorded among children from tuberculosis of the nervous system. There was, too, a rise in the number of deaths from respiratory tuberculosis among young women and older men.76 But after 1941 there was, in general, and except in Scotland, a surprising reversal of these upward trends in mortality.
By the end of the war practically all the tuberculosis death rates for England and Wales had either returned to the level at which they stood in 1938 or had registered small improvements.77 Most of the gains were achieved by women over fifteen years of age. Scotland, however, fared badly. The number of deaths from all forms of the disease was, despite some reduction after 1941, about eleven percent higher in 1945 than in 1938.78 What was particularly bad about these Scottish figures was the adverse trend in mortality among young people and, in rather less degree, schoolchildren. During the two post-war years 1946–7 the combined death rate from the respiratory and meningeal forms of the disease was one-third higher at ages five to fifteen and fifteen to twenty-five than during 1937–9.79 This rate meant for the latter group of young people that mortality at the end of the war was thirty percent higher than it had been seventeen years earlier—in the depression years of 1931–3. For schoolchildren, it was about ten percent higher in 1946–7 than in 1931–3.
In both countries the number of people newly notified each year as suffering from respiratory tuberculosis80 rose more or less continuously throughout the war, and was higher at the end than in 1938.81 Again, Scotland’s experience was much more unfavourable with a rise of over fifty percent in notifications in 1945 as compared with 1938. Better and quicker diagnosis was no doubt one reason for these increase,82 for the figures of notifications are a guide to the degree of ascertainment rather than to the incidence of the disease. But that a real increase in the number of civilians in Britain suffering from tuberculosis did take place during the war is beyond question. Because of the time that elapses between the onset of the disease and death, many additional deaths will thus be recorded in peacetime—deaths primarily due to war conditions.
While Scotland lost much ground in the wartime battle against tuberculosis, England and Wales just about held their own. But to maintain this position meant that the downward trend of the disease before the war flattened itself out during the war—for at least six years. In other words, many more people in England and Wales, and proportionately more in Scotland, contracted the disease and died from it as a results of the war.83
The national bills of mortality, recording the particulars of nearly 3,250,000 people who died between the beginning and the end of the war, can profitably be studied in many different ways. In the present chapter only three subjects have been selected from this mass of data for brief examination: infant mortality and stillbirths, deaths rates among men and women aged forty-five to seventy-five and tuberculosis. They were arbitrarily chosen because they seemed to present important features in this discussion of war conditions and the public health, because in some respects they show divergent trends, and because they point to the futility of generalising about the whole population irrespective of the age and the experience of life of different groups of people both before and during the war.
Despite the limitations in the use of death rates as an index of tendencies in public health, the conclusions to be drawn from the rates for infants and children are not at variance with the results of the clinical and other studies undertaken in the later years of the war. No evidence was found, for instance, of more undernourishment, more rickets or more anaemia.84 On the contrary, signs of betterment were detected; one being the improved condition of children’s teeth,85 although the amount of dental treatment given to children under the school medical service was much reduced during the war.86 Little can be said here about the effects of the war on young men and women because the question of their health is mixed up with the experience of service in the Armed Forces; the subject is, therefore, left to the medical historians.
As regards the older men and women who were not recruited into the Forces and who made up the bulk of the civilian population it is not easy to sum up the effects of the war on their health. The trend of the death rate at different ages among men and women considered separately, the different behaviour of the rates for different causes of death, and the varying causes of death, and the varying records for different parts of the country, suggest that the effects were not uniformly borne; some groups and some areas saw more of the adversities of war then others. Conversely, some groups benefited more than others from the social and economic changes wrought by the war. While it is necessary to emphasises these reservations, and to remember that averages can hide greater or less internal variation though still presenting much the same sort of face to the world, it is nevertheless clear that, considered as a whole, the trend of the death rate for middle-aged and elderly men and women was far more favourable than might have been expected in 1939. When, however, the rates of sickness are examined the evidence is less favourable. There was, for example, unlike the downward trend during the First World War,87 a substantial rise in the number of claims for sickness benefit by insured workers under the national health insurance scheme. This was due to an increase in illnesses of short duration and not to any change in the amount of prolonged illness.88 Many reports from war factories about attendance at work during 1941–4 spoke in similar terms. It is arguable that this increase in the number of short-term illnesses could have been brought about by the great changes which occurred in the composition of the working population, leading to the employment of a much larger proportion of women and unfit and elderly men. Dr. Stocks has shown that women, irrespective of whether they are ‘gainfully employed’ or not, have more minor illnesses and fewer serious illnesses than men.89
When the statistics of workers who drew sickness benefit are looked at closely, it appears that there was a substantial increase among each of three groups considered separately—men, spinsters and widows, and married women.90 These increases, which began during 1941–2, reached very high levels in 1943–5—the years when nearly every paid of hands in the country was called into service of some kind. With
the end of the war and a rapid demobilisation of the Armed Forces the rates of sickness turned downwards in 1946. They continued to decline in 1947.
This big increase in short-term sickness during the war could, therefore, be explained, at least in part, by changes in the age composition of the insured population, and by the employment of a larger proportion of workers in an inferior state of health and carrying heavier domestic responsibilities. Other factors, which cannot easily be discounted, include the effect of re-employment and long hours of work on people who previously had been unemployed or under-employed, and the consequences of transferring workers away from their homes. Moreover, some increase must be attributed to all the social, psychological and industrial stresses of war, the immediate and after effects of air raids, the evacuation of members of families, the worry and anxiety caused by the absence of menfolk on service and often in danger, the difficulties of getting hospital treatment, greater overcrowding due to the housing shortage and many other factors.
According to some authorities, diminished resistance to infection as a result of changes in the character of the diet may have played a part in causing more minor illnesses among certain sections of the population. Slight, rather than substantial, deficiencies in the value of the food consumed by some adults at certain times during the war may have contributed, in combination with other difficulties of life, to a more widespread feeling of tiredness and vague ill-health. More people may have suffered, for a variety of reasons, from digestive upsets,91 peptic ulcers, rheumatic pains, colds, constipation and headaches—some of the principal maladies which lead to an immense amount of absence from work and disturbance in the home. But all this is conjectural. Even if adequate records of the quantities and causes of sickness were available for the war years no figures of pre-war experience exist for purposes of comparison.
What is know, however, is that in certain parts of the country the number of medical prescriptions given to insured workers increased during the war, particularly for vitamin preparations, nerve sedatives and tonics.92 Moreover, an astonishingly large proportion of the
adult population—perhaps a larger proportion than before the war—dosed themselves with patent medicines, laxatives, aspirins, cold preventives and vitamin preparations.93 One remarkable feature of the economic history of the war was the stability of the patent medicine industry; after four years of war, and despite the shortage of paper, the industry was still spending as much on £2,250,000 a year on press advertising alone. While the industries concerned with household equipment, cigarettes, travel, magazines, newspapers, books and other educational items reduced their press advertising expenditure by nearly ninety percent between 1938 and 1943, that of the patent medicine industry fell by only twenty-eight percent although there was no evidence of a fall in demand for its products.94
Whatever the reasons for this state of affairs may be, it does seem to follow from evidence of this kind that the individual worker did not, in himself, feel better in health as the war went on. It cannot, however, be concluded that a majority of the insured population, or even a large proportion, felt decidedly worse. There may have been as much—or more—self-medication before the war. Unfortunately, however, comparisons cannot be made with the nineteen-thirties, for very little is know about the standard of health of the working population, and especially about those who were unemployed at the time but who joined the ranks of the employed population during the war and added a new, and perhaps excessive, quota of claims for sickness benefit, medicine and medical treatment.
When the whole monotonous array of strains and stresses that have forced themselves haphazardly into this book are assembled in some sort of order, and when account is also take of wartime working conditions—long hours and night shifts,95 the employment of young, inexperienced and elderly people and those excluded from the Armed Forces, loss of sleep as a result of air raids, and the hardships of queueing for and travelling by crowded buses and trams—it may be
thought a remarkable fact that there was not much more sickness and many more absences from work among all adult groups. If doctors could not help, and if aspirins, sedatives, cigarettes and laxatives helped people to stay on the job then they—and the patent medicine industry—were good things in the short-run. And if, in 1945, it meant that health troubles had been stored up for the future, at least there was some satisfaction in knowing that the war was over.
It is clear that the costs of war in terms of impaired bodily and mental health were not distributed evenly over the whole of the population; nor had all the bills been rendered by the end of the war. It is also clear that there was no steady progression upwards or downwards during the war in standards of life and standards of health among the civilian population. The events that stand out sharply in this brief survey of the public health are three in number. There was the deterioration during 1939–41 and then the arresting change in health trend in 19423. There were the astonishing improvements after 1941 in the health and expectation of life of infant and young children. There was the absence of any sure signs that the health of the workers and the housewives had been undermined despite the burdens they carried for over six years. The war did not lead to any serious recession in the public health or to any dramatic increase in disease. This, in the circumstances, may be regarded as a remarkable and unexpected experience.
It was remarkable, too, when set against the fact that the war deprived the civilian population of a large part of its pre-war medical resources. The difficulties and delays encountered by sick people in getting access to hospital care have already been stated. Similar difficulties, caused by shortages of medical, dental, nursing and other staffs hampered the school medical services, the maternity and child welfare clinics and other branches of public health work. By 1843, for example, the number of doctors in all the public health services in Britain had fallen by over twenty percent from the 1939 strength. The number of dental officers in the school medical service fell to a greater extent.96 In all these services, and in all the hospitals, clinics and sanatoria, the medical staffs who were left to carry on were generally either very young or elderly or unfit for military service. More important still, the ranks of the general practitioners in Britain were depleted by the end of the war by over one-third, and of those who remained ten percent were over seventy years of age. Even as early as January 1943, three general practitioners were trying to do the work formerly done by four.97
The standard of medical service available for the civilian population was, in the judgement of the Lord Privy Seal in June 1943, ‘dangerously low’. This was the conclusion of a special inquiry carried out for the War Cabinet, the first thorough and searching examination of the great demands of the Armed Forces for more doctors.98 At that time, for instance, there were five times more doctors per 10,000 population for the Army stationed in Britain99 than were available for civilian needs.
Although it was considered by some authorities that certain notable health records were among the ‘medical triumphs of the war’100 it is, nevertheless, difficult to believe that they were attributable to more and better care. The use of the sulphonamide drugs, penicillin, blood transfusion and other scientific advances undoubtedly offset to some extent the subtraction of medical manpower and hospital resources from the civilian sector, but their achievements in saving life cannot explain, for instance, more than a small part of the fall in infant and child mortality.
Why, then, was the health of the people and, in particular, the health of babies and young children so well maintained during the war? Why did it start to deteriorate, then stop, then recover? Hardly anyone, medical or lay, expected the British nation to emerge from the rigours of six years of war, bombing, food shortage and incomparably worse housing conditions with some of its vital statistics more favourable than they had ever been in its history. But this was not the first time when many of the privations and calamities attendant upon war had been held at bay. They had been held at bay during the two decades of struggle against Revolutionary and Napoleonic France. ‘England’, a distinguished statisticians has written, ‘was healthier at the end than the beginning of the eighteenth century and indeed continued throughout the Sturm and Drang of the struggle for existence against Bonaparte to be healthier than it was ever to be again until a time within the memory of some now living’.101
Full employment, doubtless, had much to do with the good record of the British people’s health during the Bonapartist wars. In the Second World War full employment was not achieved for some time;102 but from 1941 onwards the number of people whose diet was gravely circumscribed by the amount of money in their pockets must have been small. Up to 1941, the rise in the cost of living had been faster than the rate of wage rates—if not earnings;103 but in the middle of the year the Government decided to take firm control of the cost of living.104 Moreover, in 1941 the first benefits were felt of the social policies—chief among them the national milk scheme—which were so bravely born in the summer of 1940. The year 1941 was, thus, a year of many turning-points.
Regular employment for all who were capable of work and, in consequence, regular weekly sums of housekeeping money for food, clothes, rent and other necessities, not for a limited span of months but for a period of years, represented, alongside a stable price level, the first defence against a fall in health standards. A state of full employment and stable prices needed, however, to be accompanied by a fair distribution of what was scarce; by measures to influence the quality of what was distributed—bread being the supreme example—and by schemes to meet the special needs of special groups—of expectant mothers and young children, the families of Service men, the war injured, old people and others.
The successes and the failures of the Government in all these fields of the war economy will be told in the history of food policy and other volumes of this series. In considering their combined effect on the nation’s health comparisons should, of course, be made with the state of employment and the value of money before the war, the consumption of food at that time by different groups in the community, the quality of the food that was consumed, and with many other factors that directly and indirectly contribute to the standard of living.
After a broad assessment of the relative influence of all these pre-war and wartime factors, and after applying certain tests drawn from public health statistics, it may be concluded here that the results of Government action to safeguard the nation’s health were fare more effective than anyone expected or thought feasible in 1939. While it remains true that the dramatic change in the curve of vital statistics in 1942 was attributable to many complex forces joining hands at a
particular moment in the nation’s history, nevertheless, the decisions taken and the policies shaped by the Government earlier in the war may be counted among the predominantly favourable forces.
A period of time had, of course, to elapse before the effects of these policies were sufficiently powerful to make an impression on the course of vital statistics. An improvement, for instance, in the character of the diet of the poorest third of the population was not likely to be reflected at once in clear-cut signs of better health. But by 1942 the social schemes that had been developed in earlier years were spreading their benefits, and the rationing of food was beginning to rest on sounder nutritional principles. These favourable processes were reinforced in 1942 by a general increase in the consumption of milk,105 by an improvement in supplies of meant, cheese, fresh fruit and vegetables,106 by a growth in the provision of meals in canteens, schools and British restaurants,107 by increases in financial aid to members of the Armed Forces and their families,108 and by the fact that heavy air raids ceased. Finally, there was the important fact that the nutritive quality of bread was greatly improved by the Government’s decision, taken in March 1942 because of the shipping situation, to raise the extraction rate of flour from about seventy percent to eighty-five percent, thus leaving in the flour some fifteen percent more of the wheat berry rich in essential nutrients.
All these measures and events, supported by a steady expansion in the application of scientific knowledge of nutrition to the task of providing a good diet in circumstances of shortage, helped to sustain the health and working capacity of a people who were fully employed, and who carried more money in their pockets than they had been accustomed for a very long while.
This powerful combination of influences—full employment, food subsidies, ‘fair shares’, price control and the welfare foods schemes—which drew their inspiration and bestowed their benefits as a result of Government action, and which weighted the scales of national health in favour of less serious disease and fewer deaths, were strongly aided by other forces less directly in the gift of contemporary Government. The nation was remarkably fortunate, for instance, in escaping any disastrous epidemics. It may, perhaps, be said that on the whole the weather during six winters of war was helpful; certainly there was no
long and rigorous spell of cold comparable to that which the country experienced in 1947 when its fuel supplies ran short.109
Many authorities had expected that the evacuation of city children to rural areas in 1939 would lead to an increased speed of the infectious diseases of childhood; yet, to the surprise of the medical profession, there was less disease than usual.110 Many more feared that the overcrowding of shelters, tube stations and rest centres in the winter of 1940, and the constant migration of people to and from bombed areas, would cause outbreaks of respiratory disease; yet, again, nothing exceptional happened. ‘The year 1941 will long be remembered by those who foolishly imagined that we knew all about the causes of influenza epidemics’, wrote one authority in reviewing the history of the disease.111 ‘Our gloomy prophecy proved unjustified; no spreading epidemic developed, and we were spared a disaster.’ Throughout the war, in fact, and in spite of great overcrowding in houses and even greater movements of population, outbreaks of influenza were milder than in the pre-war years.112 Apart from a sharp increase in cerebro-spinal meningitis in the early period of the war, the country was indeed favoured by the absence of serious epidemics of any kind during the years when it was commonly thought that the people’s resistance to disease was lower than usual.
While those who labour to understand the inconsistencies of infective disease continue to be puzzled by the mutual reaction of host and microbe, and by the sudden re-appearance of disease often in waves of mortality and by its equally sudden disappearance, there are few who question the achievements of the authorities in protecting the country from a serious outbreak of typhoid during the war. Despite the bombing of water mains and sewers and the many consequential opportunities for dangerous pollution to occur, not a single case of typhoid attributable to the water supply was recorded in London throughout the war, and no outbreaks of water-borne disease occurred anywhere in the country as a result of enemy action.113 The benefit of clean water from a public service provides yet one more reason why the nation’s vital statistics were better than anyone had expected.
Many reasons have now been entered in this catalogue of social defences to account for the state of the people’s health during the Second World War. Some defences were vital to the well-being of all groups; some were worth more to particular groups and less to others; some played a subordinate role at certain times and places and a more effective role at others. Among all the physical elements which can and do dispose in favour of good health some, to adapt the words of René Sand, were purchased by decision of the Government. ‘We can’, he said, ‘buy human life. Each country, within certain limits, decides its own death rate’.114
Such decisions in favour of a lower death rate were taken, not only during the Second World War, but before it began. The health of one generation is reflected—again, within certain limits—in the health of a succeeding generation. Changes in the average environment to which children born in successive periods of time are exposed in their early years tend to impress themselves on subsequent rates of dying throughout life.115 Changes in the death rate from a particular disease may express not what is happening to the disease at the moment but what happened, perhaps a decade earlier, when the pathological process was beginning.116 To understand to the full, therefore, why the health of expectant mothers and young children improved, why the condition of children’s teeth was better, and why certain mortality and stillbirth rates declined, it is necessary to consider the quality of the diet and the general circumstances of life, not only at the time when the child was born, but when the mother herself was born and grew up.
It was not an accident that with each succeeding year of the Second World War there was an increasing number of mothers bearing children who had themselves been born and bred in more favourable circumstances than previous generations of mothers. The legacy of infantile rickets, for example, reflecting the social conditions of one age and leading, twenty to thirty years later, to pelvic contraction with its sequelae of deaths and injuries to mothers in childbirth, had been diminishing with the disappearance of rickets in its grosser forms. In short, it is probably true to say that mothers who were bearing children during the nineteen-forties were, on the average, better physical stock than the mothers of the nineteen-twenties and the nineteen-thirties.
Broadly, two reasons may be advanced in support of this proposition. One is represented by the gradual—if uneven—improvement in the conditions of life for the mass of the people since the turn of the twentieth century, brought about by a rise in the average level of real wages, better food, better housing and the first effects—mental as well as physical—of developing State education and welfare policies. The full fruits of such policies rarely show themselves at once and ever dramatically; a long time may elapse before the nation can assess by scientific method the benefits of universal education, school meals and milk services and social insurance. If Britain continued to gather, during the Second World War, more of the benefits of past endeavour for social justice, the rewards could not have come at a more propitious time.
The second reason may be sought in the decline of the birth rate, and principally in the decline among the families of industrial workers since the census of 1911. Between this census and the outbreak of war in 1939 the national rate had fallen by roughly forty percent; most of it being due to the smaller families born to the mass of the workers earning less than £5 a week. This great section of the population, dominating as it does the general level of national birth and death rates, achieved a substantial rise in its standard of life by reducing the size of its families by, perhaps, one-half in less than half a century. Children born into these families thus had a better start in life, and were better able to draw benefit from the expanding social and education services. It was not until the late nineteen-thirties and especially the nineteen-forties that these children, springing from smaller families, enjoying more parental time and care, and more attention from the State, began themselves, in their turn, to found families. History would have been utterly confounded if, as mothers, they had not performed better in childbirth and if their babies had not been healthier babies.
The effects of these biological changes on the structure, size and economic circumstances of families had been showing themselves for some years in lower death rates and a longer expectation of life at birth.117 This process continued during the war. Although the birth rate, which fell at the beginning of the war, recovered after 1941 and rose substantially, the number of families containing four or more dependent children fell steadily during the whole of the war.118
Moreover, because of the recognised association between large families and poverty, it is relevant to this discussion to record the further fact that the trend was just as marked—if not more so—among the families of industrial workers.
As the risk of death among infants increases with increasing size of family,119 a continuing decline in ‘high-order; births would, almost automatically, bring about some reduction in the infant death rate during the war. Another important rate—the stillbirth rate—which also fell decisively during the war is similarly affected by changes in family size and by changes in maternal age. The wartime records show a larger proportion of second and third births, a smaller proportion of fifth and subsequent births, and a lower average age among all mothers who bore children. All these changes favoured a lower stillbirth rate for the country.120 It is not possible, however, to state how influential these so-called biological factors were in contributing to the decline that occurred in both the infant death rate and the stillbirth rate.
Such reductions in the number of large families, in conjunction with the pronounced trend towards earlier childbearing, may well have had other consequences beneficial to the nation’s vital statistics. Because, for instance, there were fewer older mothers bearing fifth or subsequent children the maternal mortality rate may perhaps have profited. They may, too, have been less sickness and ill-health following upon childbearing as a result of these changes in the age and order of reproduction. And because there were fewer large-sized families there were, correspondingly, fewer children living in those circumstances of hardship historically associated with big families.
So far, then, as the statistics for mothers and children are concerned, the impressive reductions in death rates which were registered during the war cannot be wholly ascribed to the effects of full employment and all that the Government achieved in the field of nutrition and health. Some part of the improvement must, it seems, be credited to the past, and some part to the collective decisions of parents both before and during the war to limit the size of their families. The contribution made to the maintenance of health standards by these and all the other inter-related forces discussed in this
chapter cannot, of course, be precisely determined. Nevertheless, the deterioration in health indices observed during 1940–1 and the arresting change in trend thereafter, which cannot be fully explained by these favourable social and biological factors, point to the supreme importance of full employment and an adequate diet. This, perhaps, is the predominant strand of truth in a bundle of many strands, many-sided, interdependent, all more or less true. The achievements of the Government’s food and social polices in bringing about an improvement in the diet of poor families may well have been reinforced and backed by the action of other forces, but without these policies there is no evidence that the deterioration would have been arrested.
But just as the advances of one generation may only show their full effects through the lives of succeeding generations so, too, may have retreats. Some of the scars of the First World War may not yet have been wiped away. It has been suggested, for instance, by Dr. Stocks that the unfavourable trend during the nineteen-thirties of the death rate among middle-aged men, and particularly that part of it attributable to heart disease, may have been due to the strains and hardships to which they were exposed as younger men during 1914–18.121 The same authority has pointed out also that the arrest in the fall of tuberculosis mortality among young adults after 1926 could possibly be traced to the effects on children of the food shortages of 1916–18, resulting in a lowered resistance to active tuberculosis of the lungs as these children reached the sensitive period of young adult life.122
These may not be the best illustrations to use, but they suffice to show that the character of the legacy that modern war can bequeath to the future. Perhaps all the advances that were made on the social front in 1940 and in subsequent years were sufficient to protect the people from carrying into the future the scares of the Second World War. Perhaps only the children were adequately protected—and here it should be recalled that the nation had 2,000,000 fewer to nourish than during the First World War. Perhaps more lasting harm was wrought to the minds and to the hearts of men, women and children than to their bodies. The disturbances to family life, the separation of mothers and fathers from their children, of husbands from their wives, of pupils from their schools, of people from their recreation, of society from the pursuits of peace—perhaps all these indignities of war have left wounds which will take time to heal and infinite patience to understand.