CHAPTER
XXV
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
--506--
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
--507--
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
--508--
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
--509--
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.
--510--
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.
--511--
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
--512--
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
--513--
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
--514--
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
--515--
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
--516--
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.
--517--
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 was saying 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
--518--
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
--519--
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
--520--
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
indices continued 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 |
|
1936–8 average |
56 |
77 |
39 |
—1 |
|
1939 |
51 |
69 |
38 |
42 |
|
1940 |
57 |
78 |
37 |
42 |
|
1941 |
60 |
83 |
35 |
40 |
|
1942 |
51 |
69 |
33 |
38 |
|
1943 |
49 |
65 |
30 |
36 |
|
1944 |
45 |
65 |
28 |
32 |
|
1945 |
46 |
56 |
28 |
33 |
|
1946 |
43 |
54 |
27 |
32 |
| 1945 % of 1936–8 |
82 |
73 |
72 |
792 |
| 1946 % of 1941 |
72 |
65 |
77 |
80 |
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.
--521--
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
--522--
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.
--523--
Death rates per
1,000 population: England and Wales73
Civilians only
from 3rd September 1939
for men, and 1st June 1941 for women
All causes of death
excluding those due to operations of war
|
Men |
Women |
| Ages |
45–55 |
55–65 |
65–75 |
45–55 |
55–65 |
65–75 |
| 1938 |
10.2 |
23.1 |
53.7 |
6.97 |
15.5 |
38.8 |
| 1939 |
10.3 |
24.3 |
55.4 |
7.05 |
15.7 |
40.5 |
| 1940 |
11.7 |
27.4 |
60.5 |
7.49 |
17.1 |
44.3 |
| 1941 |
10.3 |
24.3 |
54.5 |
6.82 |
14.9 |
38.9 |
| 1942 |
9.41 |
22.2 |
51.1 |
6.28 |
13.8 |
35.3 |
| 1943 |
9.82 |
22.7 |
51.3 |
6.36 |
13.8 |
36.3 |
| 1944 |
9.33 |
22.4 |
50.3 |
5.96 |
13.1 |
34.3 |
| 1945 |
9.00 |
22.2 |
50.2 |
5.85 |
13.2 |
34.5 |
| 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.
--524--
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 1937–9.79This
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.
--525--
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.
--526--
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
--527--
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
--528--
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
--529--
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
--530--
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
--531--
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
--532--
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
--533--
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.
--534--
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.
--535--
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
--536--
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
--537--
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.
--538--
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