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Post by Stanley » 21 Apr 2012, 08:04


Charles Webster

With more than a sideways glance at Engels, Harry Pollitt proclaimed: 'The stark reality is that in 1933, for the mass of the population, Britain is a hungry Britain, badly fed, clothed and housed'. Evidence for this dramatic contention was strong enough to support a volume explicitly modelled on Engels' Condition of the Working Class in England, and assembling data to refute the widely publicised tenet that the march of capitalism had entailed ever increasing benefits to the living standards of the working classes as a whole. (1) The Secretary General of the Communist Party of Great Britain unleashed a fierce debate among contemporaries, and even now the issue remains unresolved and contentious. Were the thirties characterised by severe social deprivation, or was this idea a myth assiduously cultivated by a mischievous minority for the sake of political advantage?

The modern historian has become progressively more impatient with
the array of brilliant impressionistic sources which have given such strong conviction to the notion of the Hungry Thirties. Recent reviews of this problem have increasingly questioned the general relevance of observations of the Orwell type and they have cast serious doubt on the constructions of Pollitt and his confederates. While it is accepted that poverty, poor housing and ill-health constituted meaningful problems during the depression, we are warned that colourful detail relating to residual pockets of depression should not detract from recognition of a secular trend towards improvement in the social and economic condition of the population as a whole. Despite minor failures, the thirties are regarded as marking an irreversible shift towards the standards of the modern welfare state. This view has been developing for some time among economic analysts, and in the absence of countervailing statistical data, it is rapidly taking on the character of orthodoxy in textbooks of economic and social history. (2) There is now a risk that impediments standing in the path of health and social improvement in the interwar period will scarcely deserve mention. (3)

It is beyond the scope of the present essay to review the broader issue, but a useful preliminary exercise might be undertaken by reconsidering the evidence relating to standards of health during the thirties. The voluminous statistics pertaining to health have been regarded as offering some of the firmest ground for optimistic interpretations of trends in standards of living and social conditions during the interwar period. Evidence about health figures prominently in assessments of this period. Aldcroft usefully encapsulates conclusions which directly contradicted Pollitt, and now command general support:

‘Not only was there a significant increase in real incomes and real wages but, partly as a result of this improvement and together with the extension of community services, the nation generally was better fed and clothed and was housed in better conditions than those prevailing before the war. The statistics again point to an improvement in the national health and physical well-being of the population. Death rates declined, children were on average fatter and healthier than their parents had been, and the worst forms of malnutritional diseases, such as rickets and scurvy, had all but disappeared by the second world war.’ (4)

Improvements indicated by various averages among the indices of health are thought to demonstrate convincingly the improvement of all of the population apart from a decreasing residue conventionally described as the 'submerged fraction'. Crucial support for this position is derived from the most recent technical survey of trends in infant and maternal mortality, which concludes that ‘such deprivation as undoubtedly existed did not affect adversely the life expectation of the infant and maternal population'. (5)

In further discussion of this problem it is important to shift the emphasis of discussion away from the relatively minor issue of the impact of temporary economic fluctuations, to the more important question of the level of biological disadvantage experienced by major sections of the population up to the eve of the second world war. Before deciding on this issue it is essential to consider whether the imposing array of official health statistics can be taken at face value. This preliminary has tended to be overlooked owing to the mistaken assumption that scientific evidence enjoys privileged status as an impartial insight into objective reality.

Biological statistics seem to offer a firm bedrock upon which to base any objective and demystified assessment of health and living standards. By 1920 health was being monitored by an elaborate mechanism involving the well established apparatus of the Registrar General, the Board of Education, the local Medical Officers of Health, and the important newly formed bodies, the
Medical Research Council, the Ministry of Health and the Board of Health for Scotland. Besides the regular annual reports of these agencies, the Medical Research Council by 1940 had issued some two hundred reports in its Special Reports Series. In addition periodicals, such as the Journal of the Royal Statistical Society, provided an important outlet for official health statistics. Quickly established as the most up-to-date, accessible, and comprehensive of official health statistics were the Annual Reports of the Chief Medical Officer to the Ministry of Health, and parallel reports written in his capacity as Chief Medical Officer to the Board of Education. These reports reflect, and are reflected by innumerable local and specialist reports sponsored by the Ministry of Health, or by local authority health committees.

In this arena, it is essential to recognize that one man, Sir George Newman, was the outstandingly dominant witness. Newman was a public health official with unparalleled experience, well established as Chief Medical officer to the Board of Education, Chief Medical Officer since the formation of the Ministry of Health in 1919, an expert on infant mortality, and a voluminous writer on preventive medicine. Newman was succeeded by his well-known assistant, Sir Arthur MacNalty, who was in turn replaced just after the outbreak of war. The optimistic tone of the Annual Reports throughout the interwar years is founded on the irrefutable logic of mortality and morbidity statistics. In virtually every year it was possible to report advance on all fronts with respect to mortality. With respect to the longer-term trends it was legitimate to speak of 'extraordinary decline' in mortality rates; the traditional enemies of health seemed to have been amply contained; the population was freed from much of the burden of preventable illness; and minor reversals in one direction could be excused by hopeful trends in a related area. Special importance was attached to the decline in infant mortality. For sound scientific reasons the stillbirth rate, together with the infant mortality rate, were accepted by epidemiologists from Newsholme to Crew as 'the most sensitive index we possess of social welfare and of sanitary administration'. Indeed it was argued that the league table of infant mortality rates was the best indicator of 'the stage of social evolution reached by any given population ... it is a measure of the people's progress'. (6)

Infant mortality had remained at about 150 until the turn of the century; thereafter it declined sharply. In his report for 1932 Newman proudly proclaimed that for the first time no English or Welsh County or County Borough had recorded an infant mortality rate of above 100. When in the following years the improvement was checked, the Chief Medical Officers warned that no further ‘spectacular improvement' could be expected; the rate was adduced to have reached its 'irreducible minimum'. (7) This caveat was repeated in similar terms in most of the pre-war reports. With the increasing elimination of infectious diseases as a cause of premature death, public health worker's sensed that they were approaching the boundaries of their operation. Any further progress would be limited by biological factors. Experience of rates of infant mortality even above 100 had already convinced some investigators that further reduction would be limited by racial characteristics of the poorer classes. Stunted stature of the Scottish working classes was attributed to their inferior growth impulses, or to racial character. Indeed there were those who doubted the wisdom of pressing forward with medical innovation for fear of propagating the unfit, unless compensating measures such as compulsory sterilisation were introduced. (8)

Notwithstanding their solid features, founded on the prestigious Victorian tradition of public health reporting, the Annual Reports of the interwar years bear the unmistakeable imprint of complacency. These reports were essentially reports of progress and nothing was allowed to detract from this image. There was no absence of minor criticism or of appeals for greater effort, but never were deficiencies in the record systematically explored. Any problem exposed was expected to be solved by continuing expansion of the services already in existence. Anything not admitting solution in these terms was swept aside as atypical or insignificant. There was more than a hint of impatience with any reputable investigator producing findings contrary to the line promoted by the Ministry of Health. There was particular resistance to the growing body of opinion which ascribed medical problems to underlying social and economic causes beyond individual control. Where social factors were admitted it was believed that the situation could be redeemed by the correction of personal habits, or by education. Residual problems of ill health facing Britain in the thirties were to a large degree ascribed to ignorance or moral perversity. Thus the Reports risked becoming a means whereby a body of unquestionably accurate mortality data was manipulated by the medical bureaucracy to defend the status quo. Any serious check in the improvement of health at this time of political and economic crisis was difficult to admit without throwing doubt on the efficiency of the state and municipal medical services as they had developed under Newman and his colleagues, or without implying criticism of the social and economic policies of the coalition governments. On the other hand, even modest continuing improvements in health during the depression constituted much needed publicity for services developed under the auspices of the Ministry of Health and much-needed buttressing for the unemployment and social welfare policies of the government. Politicians and the press seized upon the Annual Reports in an attempt to dispel widely circulated rumours concerning an increasing tide of ill-health and malnutrition among the families of low-paid workers and the unemployed. Typically, in November 1937, armed with the recently published Annual Reports for 1936, Chamberlain boasted that the recent history of the dramatic curtailment of infant mortality constituted a 'very wonderful' story. (9) The infant mortality rate for 1936 had in fact increased to 59, compared with 57 for the previous year!

Notwithstanding admission of minor checks, the continuing and almost unexpected fall in infant mortality provided the most solid evidence for the image of improving health assiduously cultivated by Newman and his political masters. Modern authorities such as Winter have confirmed that by 1939, on the basis of national averages, infant and maternal survival rates were higher than ever before. (10) Nevertheless, closer attention to the handling of the data relating to infant mortality suggests a more diverse and less flattering picture than is sketched in the official reports. In 1921 the infant mortality rate in England and Wales stood at 83; in 1931 it was 66; in 1941, 60; and in 1946, 43. In this story of advance, the thirties emerge as a drag in the downward trend in infant mortality. The most rapid rate of decline was reached with 28% between 1918 and 1923, and this rate was again equalled between 1941 and 1946. (11) During the thirties this momentum was reduced by more than 50%, enough for England and Wales to fall decisively behind other western nations with respect to most of the components of infant mortality. Even after the major revival during the second world war England and Wales were left eighth in the international league table of infant mortality.

Impossible to dismiss lightly was the persistently high level of maternal mortality, which in 1933 and 1934 reached a peak surpassing levels at the turn of the century. The rate of maternal mortality rose by 22% between 1923 and 1933. This problem was embarrassing to governments pledged to promote motherhood and bad publicity for a Ministry proud of its concern for the Maternal and Child Welfare field. It was particularly unfortunate to have an added disincentive to motherhood at a time of mounting anxieties concerning the threat of under population. Partly out of political necessity, and partly due to pressure from such unofficial pressure groups as the Maternal Mortality Committee, the Ministry initiated detailed investigations into this problem. (12) All parties recognized that the existing midwifery services were inadequate; calls were made to backward authorities to improve their efficiency in order to remove this major blemish from the reports; Newman singled out for special rebuke 36 areas which for the last ten years had reported a maternal mortality rate of above five. (12) This problem was seen primarily in terms of administration and the training of medical personnel, rather than as reflecting intrinsically greater health problems in the 36 areas, all of which were experiencing severe economic problems during this period.
Economic and social factors were never accorded more than passing mention in the detailed investigations into maternal mortality in 'problem areas' sponsored by the Ministry of Health between 1924 and 1937. These surveys, conducted under the capable management of Janet Campbell, constituted the most sustained research effort of the Ministry of Health. Despite their merits however, these reports gave little consideration to the general state of health of the mother as a factor in maternal mortality. Even in the last report dealing with Wales, where it was admitted that anaemia and debility resulting from 'inadequate diet and wrong feeding may be factors' and were prevalent, it was contended that 'their influence cannot at the moment be accurately assessed'. (14) A somewhat acid editorial in The Medical Officer reviewing this report, was dismayed by the bald single-sentence conclusion devoted to the relationship between maternal health and nutrition: ‘We are left convinced that in this sentence will be found the explanation of the exceptional maternal mortality in Wales and that its reduction is more likely to be achieved by a herd of cows than by a herd of specialists'. (15)

The 'problem areas' of maternal mortality, some of them witnessing as many as ten maternal deaths per thousand live births, compared with levels of less than two per thousand under favourable conditions, threw into sharp relief the great diversity of health standards concealed beneath national averages.

Recognition of the existence of problem areas represented a reluctant concession to the notion that certain regions, occupational groups and social classes were not enjoying the full benefits of national improvements in health. Persistent failure to pay proper attention to this problem of diversity, while sheltering behind averages, proved to be one of the most serious factors undermining the credibility of the Ministry of Health's handling of health statistics during the interwar period. National averages constituted the staple of the Annual Reports. More specific data were usually included for colour, often to reinforce the didactic message of the Chief Medical Officer, or to draw attention to the force of local idiosyncrasy, but rarely for more than incidental purposes.

However, eventually, outside circumstances forced the Chief Medical Officer to pay more serious attention to the problem of standards of health in distressed areas. The government was faced with mounting accusations that the unemployed and low paid were sinking into conditions of extreme poverty. Such varied works as Fenner Brockway's Hungry England (1932) and Allen Hutt's Condition of the Working Class in Britain (1933), or the agitation of such organisations as The Women's Health Inquiry Committee or the National Unemployed Workers' Movement required decisive rebuttal. The Ministry of Health was particularly relevant to any counter-offensive in view of the effective exploitation of official health statistics by authors like Hutt or the Maternal Mortality Committee. One of the most impressive features of The Condition of the Working Class was the demonstration of astounding variations in the standards of health between the poorer and more prosperous areas. Hutt was of course merely applying the weapon forged by Engels; but Medical Officers of Health unwittingly supplied the ammunition. Although these lines of attack were predictable, the Ministry of Health had, by ignoring adverse signs on all sides, failed to take effective pre-emptive action.

In response to the mounting tide of external pressure the Ministry of Health and Board of Education reports became mobilized for an apologetic purpose. The Ministry of Health Report for 1932 was reorganized; a new section 'Unemployment and Public Health' was placed at the beginning; ‘Conclusions' were added to the report, conspicuously reinforcing the message of the chapter on unemployment. A chapter or section on unemployment occupied a place in the reports in subsequent years, and the section on nutrition, introduced somewhat reluctantly in 1931, came to occupy a major place in the Ministry of Health reports of MacNalty. 'Undernourishment and School Feeding' occupied the eleventh chapter in the Board of Education reports until 1933, when 'Nutrition and School Feeding' was elevated to the first chapter, where it was to remain subsequently.

After a period of relative silence on the issue, the Ministry of Health Report for 1932 initiated a full-dress survey of local evidence to decide whether there was any truth in rumours concerning increase of ill-health among the families of the unemployed. Two major statistical comparisons were undertaken; first an investigation of the mortality rates in eight Counties and sixteen County Boroughs in areas of depression; secondly, comparison between two groups of County Boroughs with high or low incidence of unemployment. The conclusions were unambiguous; health was poorer in depressed areas according to the selected criteria, but not greatly worse than the average. In some respects these depressed areas were enjoying the general rise in health standards - indeed the percentage improvement was greater than for the country as a whole; 'bad' towns were faring better than 'good' towns in the chosen samples. Admittedly adverse trends occurred locally, but they were likely to be due to 'chance' factors, sometimes exacerbated by ignorance within the population, rather than to any underlying economic cause. Medical Officers of Health and local experts experiencing such crises were warned not to hazard rash speculations concerning social and economic causation. (16) When in 1933 a similar exercise revealed a rise in the infant mortality rate in half of the fourteen County Boroughs (in St. Helen's taking the rate from 89 to 116), consolation was drawn from the fact that the local mortality statistics were an improvement on national averages for the period before 1921. (17)

The above conclusions were backed by copious extracts from the Annual Reports of some thirty mainly supportive Medical Officers of Health from depressed areas. Some important witnesses, such as Dr. J. J. Butterworth of Lancashire, Dr. K. Fraser of Cumberland and Dr. W.M. Frazer of Liverpool, expressed consistently optimistic conclusions. In Lancashire there appeared to be no direct evidence that the depression had seriously affected the health of the community. There were not even expressions of undue concern about high rates of infant mortality, twice, or even three times as high as in more prosperous areas. In his report for 1932 the Medical officer of Health for St. Helen's expressed general satisfaction with an infant mortality rate which had fluctuated between 89 and 102 over the last decade. (18)

Particular importance was attached both in the Ministry of Health and Board of Education reports to the incidence of malnutrition, regarded by both sides in the health debate as providing crucial confirmatory evidence for their position. The national statistics based on periodic examination of schoolchildren provided data on malnutrition, impressive in scale, and seemingly decisive in its implications. Malnutrition, it was admitted, had been a serious problem before the first world war, dietary deficiency affecting 15-20% of the school population, but with the advent of Maternity and Child Welfare and school meals services after the war, the position improved, the level falling sharply to below 5% in 1925. While in the period 1925-32 'malnutrition requiring treatment' affected only 1% of the school population. By 1932 the problem was virtually eliminated. (19) This conclusion was supported by a major inquiry into health problems experienced in the National Health Insurance regions. Only fifteen out of 66 regions in 1933 reported any adverse trends during the depression. Both in 1932 and 1933 there was no more than local evidence of 'excess of sickness, ill-health or physical incapacity attributed to unemployment'. The reporters were impressed by the 'surprisingly good nutrition of the people even in the most depressed areas'. (20)

The above findings were confirmed by reports of the Medical Officers of Health for 1932 and 1933. In the London County Council area below average nutrition stood at about 5%, of which only 1% were definitely ill-nourished. Upon closer clinical inspection residual poor nutrition emerged as 'an idiosyncrasy of certain children', rather than as a problem with clear economic roots. Confidence was expressed by such major authorities as the LCC and
Liverpool that such problems could be adequately contained by utilising the available social welfare services. In Cumberland it was concluded that there was 'really very little malnutrition due to actual lack of food - there are a number of poorly nourished looking children, but in nearly all of them it is a case of poor general physique, rather than malnutrition'. At Wakefield the defective nutrition rate slumped from 9.4% in 1928 to 1.5% in 1932. In the North Riding between 1925 and 1933 marked malnutrition never rose above 0.08%. At Neath no 'real malnutrition' was evident; the children had never seemed so healthy and happy; while Wednesbury children in 'nutrition and development, mental alertness and happy spirit' stood comparison with children anywhere else. In Sheffield the 'nutrition of the children is not only as good as it was, but even shows some improvement'. Such sentiments could be multiplied. In general, malnutrition and associated problems seemed to be sliding into insignificance, except in isolated pockets, where the problem appeared to be related to poor nutritional habits or temporary fluctuations in disease. (21)

Inquiries conducted by public health officials into the relationship between unemployment and health at a national and local level in 1932 and 1933 totally to substantiate the claims of the pessimists. Minor problems, particularly relating to the health of women, continued to be experienced, but on the whole the fabric of welfare agencies had proved more than adequate to compensate for the adverse effects of unemployment. The exercise conducted by the Ministry of Health provided an occasion to discredit speculations equating social conditions in twentieth-century Britain with those reported by Engels a hundred years earlier. It was also hoped to restrain more responsible investigators who were inclining to exaggeration on the basis of their unrepresentative local experience. Unqualified and unfounded remarks made by critics had been offset against 'indisputable statistics' presented by the Ministry after an examination of the problem conducted with 'extreme gravity, avoiding the abstract, historically and scientifically, and not in a careless or arbitrary manner'. ‘Though specially sought for, of evidence of widespread malnutrition there is none'; there was 'no available evidence of any general increase in physical impairment, in sickness or in mortality, as the result of the economic depression or unemployment'. (22) Indeed the depressed areas were to a great extent sharing in the improvement of health of the nation as a whole. Not only was the nation not experiencing any crisis of health or subsistence, but the 'exceptionally good health of the English people continues to be maintained'. (23) Similar sentiments were echoed at the local level. Fraser of Cumberland found 'no visible evidence of deterioration in the health of our children in any part of the county ... In fact the contrary is the case, and recent reports, both of a national and local nature, appear to show that the physique and nutrition of school children is certainly no worse today, and, in fact, is probably better than it was, shall we say, ten or twenty years ago'.(24) In light of the categorical tone and unanimity displayed in the official reports it is scarcely surprising that Ministers and other dignitaries during the thirties proved difficult to convince that Britain was facing any serious health problems. In Parliament, the Minister of Health, Sir E. Hilton Young, merely parroted Newman: 'there is no available medical evidence of any general increase in physical impairment, sickness, or mortality as a result of the economic depression or unemployment'. (25) Consistent with this line the
Minister was unresponsive to calls from leading experts that levels of malnutrition urgently required investigating. The Bishop of St. Edmunds firmly denied that a substantial section of the population was underfed: 'the number who are underfed is really extremely small, and for the most part it is their own fault because their money is unwisely spent'. (26)

Owing to the determined stand taken by Newman and his colleagues at the height of the depression, the central question of the condition of Britain seemed to be settled, at least as far as official circles were concerned. Positive findings of enquiries conducted from various angles, by confirming high standards of health, granted tacit approval to the main lines of government social welfare policy. After a shaky start, gradual but distinct improvements in one area or another of national health statistics during the rest of the decade confirmed Newman's view that the 'national health defence' had proved sufficient to fortify the national body against minor impediments occasioned by the depression.

The above analysis carried conviction; and in essential respects it has been accepted by economic historians. But it is not entirely convincing. Very few of the elements in the Ministry of Health analysis retained immunity from criticism. There was little satisfaction that health statistics expressed in terms of national averages were providing a meaningful insight into the complexity of the situation, or that local officials were necessarily conveying an accurate impression of conditions of health in their areas. The Ministry appeared to be lethargic in undertaking research initiatives, obstructive to any outside body

wanting to conduct research in sensitive fields, and its own research was often limited in its goals, and unacceptable by the epidemiological standards of the day. Even more important, there were serious doubts whether the Ministry of Health was committed to objective investigation of those problems of health which might have led to politically embarrassing findings. Perhaps more than they originally intended, Newman and his colleagues were driven to defend an unrealistic position, bound and ultimately compromised by their inflexible attitudes.

Efforts by the Ministry of Health to silence criticism and promote confidence proved to be counterproductive. The official reports merely strengthened public and expert feeling that the nation faced a serious health problem. The Condition of the Working Class proved to be the precursor of a substantial groundswell of effective and widely circulated monographs developing themes touched upon by Hutt. (27) A particular target for criticism was the national averages which determined the tone of comment in the Annual Reports. Major Greenwood, Britain's leading epidemiologist and member of the Socialist Medical Association, wrote of such averages as an 'arithmetical veil' which 'conceals diversities which may be of the highest importance ... We need to pass beyond these comparatively unhelpful averages to the immediate data of human experience’. (28) The official reports conveyed little impression of the great diversity of the regional pattern of morbidity and mortality underlying the national averages. When the national rate for infant mortality stood at 65, it was thought to represent an ‘astonishing saving of life', a level at which problems would be caused by the preservation of the unfit. (29) The degree to which this assessment was unrealistic is indicated by the ease with which this rate was reduced from 60 to 43 in the course of the second world war.

The infant mortality rate for England and Wales for 1931-5 was 62, and for 1936-40 it was 56. By contrast, the comparative rates for Scotland, almost never alluded to by Ministry officials in London, were 81 and 74. Scotland was thus some ten years behind England and Wales in its control of infant mortality. This comparison gives an incomplete impression of the extent and nature of regional variation. Even within small areas there were sharp differences from district to district. Hence in Oldham in 1931, seven of the twelve wards recorded an infant mortality rate of more than 140, while four of these wards experienced a rate above 170. Burnley and Stockport reported moderately bad infant mortality rates of 86 and 79 respectively, but each contained wards having a rate above 100. In Manchester these rates ranged from the best ward with 44, to the worst with 143. In North 4 Region of the Registrar General, comprising Lancashire and Cheshire, the levels of infant mortality ranged from 31.3 for social class I, to 78.9 and 93.3 for social classes IV and V (see fig.1 in appendices.) (30)

The full extent of regional, occupational and class differences with respect to infant mortality could be calculated from data assembled by the Registrar General's department. This information was rarely utilized by the Ministry of Health, and the public was not provided with an up-to-date analysis of mortality by the Registrar General. The breakdown for 1930-32 was not published until the eve of the war, while until about 1950 independent commentators had no access to relevant statistics beyond 1932. Absence of information on important demographic questions was a cause of concern. The significance of this issue was demonstrated by Richard Titmuss who exploited the limited available sources to show the full extent of class inequalities in health. His primary method was to estimate the wastage of life in the lower social groups by calculating the percentage excess in mortality rates of the lower classes when compared with class I. This work confirmed the findings of previous local studies which had suggested that any decline in overall mortality rates was not matched by any narrowing of the gulf between the social classes. Indeed with respect to certain factors the divergence in standards between the classes had actually increased in the thirties when compared with 1911 or 1921. It was also clear that the class differential increased rapidly after the first month of life. In 1930-2 for England and Wales the stillbirth rate for class V was 30% in excess of class I; the neonatal excess was 49%; the post-neonatal excess 305%, while for the 6-12 month age group this excess was 439%.

Contemporaries had no means of determining whether the differentials between the classes persisted after 1932. Winter suggests that Titmuss was mistaken in assuming that the demographic gap was widening, arguing that this trend was substantially reversed by 1939. However, the statistics do not all point in the same direction, and even in cases where narrowing of the gap occurred, the percentage improvement was slight. In 1939 the stillbirth excess was 85%, the neonatal excess 59%, the post-neonatal excess 280%, and the 6-12 month excess 352% (see fig.2 in the appendices) In 1939 the equivalent neonatal excess for Scotland was 55%, while the post-neonatal excess was 488% (see fig. 3 in the appendices) (31) These ratios proved to be enduring, but were not a cause of urgent concern until the mid-50s when it was realised that, despite improvements in the health services, there had been 'no narrowing of the difference between the various social classes’ in the area of infant mortality. (32)

By reorganising mortality and morbidity data along normal actuarial lines with respect to standard economic and regional divisions, it proved possible to demonstrate the full extent of differentials in health between different sections of the population. A distinct biological disadvantage persisting into the thirties could be shown to affect the lower social classes, particular occupational groups, large families, or areas of low wages and unemployment. It was difficult to ascribe such substantial differences to anything other than economic and social factors, unless it was believed that there were racial distinctions between the social classes. (33)

All sides accepted that there was a close parallel between levels of infant mortality and the general standard of health of the community, this correlation being perhaps closest with respect to the post-neonatal mortality rate. Here Titmuss exposed the largest class differential, and this was reflected by a similar class differential in the incidence of diseases of childhood. Although the social class differentials were smaller for maternal mortality, stillbirth, and neonatal mortality rates, and the connection with social factors more difficult to elucidate with certainty, there was increasing support from professional and official sources for the views of Titmuss respecting the origin of these differences. An influential wartime report on this issue concluded: ‘It can be stated that social and economic factors play a very important part in the causation of stillbirths and neonatal mortality, and a less important part in the causation of maternal mortality and morbidity. As regards stillbirths and neonatal mortality, an important factor appears to be malnutrition'. (34)

By the end of the second world war the full extent of the pre-war experience of biological wastage, having much of its roots in unavoidable social and economic causes, was becoming fully recognized. The various categories of mortality provide an important yardstick. But mortality is merely one factor in the epidemiological situation. Even more important in any assessment of biological disadvantage is the consideration of class differentials with respect to morbidity. It is essential to discover the degree to which the 'survivors' were handicapped by the unavoidable circumstances of their lives. The move from assertion to proof in this area is obstructed by profound technical and methodological difficulties. Compared with the elaborate mechanism for gathering mortality data, only the most primitive arrangements existed for recording morbidity in the pre-war period. It was not until wartime scares about the low level of health of the civilian population that steps were taken
to remedy this fundamental defect in the official statistical machinery. (35) There is thus no firm data either to support or check the recurrent assertions made in the Annual Reports that the population as a whole was not merely living longer but was enjoying a high standard of health.

The Ministry of Health remained content to work with the largely redundant framework of notifiable diseases. No attempt was made systematically to exploit the data relating to health made available under National Health Insurance, although the Health Insurance regions were called upon for subjective reports when the Ministry's line was in need of defence. As indicated below, the few methods used by the Ministry to assess health standards were open to serious objection.

Some straightforward calculations made by independent investigators suggested the existence of class differentials with respect to respiratory diseases, tuberculosis and cancer, of the kind found for infant mortality. Fatalities in these cases were presumed to reflect similar or greater differentials in non-fatal conditions, but the data was inadequate to support further investigation on such questions. (36) There were also clear signs that for major age groups and lower social groups, the long decline of the still important tuberculous diseases had been arrested, and indeed by the outbreak of war a substantial increase had begun. (37) Equally significant, despite much publicised improvements in the maternity services, maternal deaths from toxaemia, haemorrhage, and other accidents of childbirth had failed to subside during the thirties. (38) Firm data was also available relating to maternal morbidity, suggesting that strong class and regional differentials evident in maternal mortality were matched by a high incidence of maternal morbidity among working-class women. Neither strong class variations nor the high incidence of maternal disablement was taken into account when MacNalty pronounced that 'motherhood in this country has reached a comparatively high level of safety'. (39)

Maternal disablement occasioned relatively little interest, yet it was a factor of acute concern to gynaecologists. Maternal disablement had been mentioned as a serious problem at one of the first meetings of the Consultative Council on
Medical and Allied Services in 1919. It was claimed that as many as half of the women attending outpatient departments were suffering from conditions attributable to this cause. (40) Subsequent detailed reports emanating from Liverpool, Glasgow and Edinburgh confirmed that more than 30% of women attending gynaecological departments were suffering from some form of maternal disablement. (41) A major share of these problems was firmly attributed to the poor state of general health of the women involved, or to physical deformities resulting from nutritional defects in early life. More searching investigations suggested that the high incidence of anaemia and toxaemia among mothers in depressed areas, as well as the high incidence of death and disease among their infants, could be related to poor standards of health and especially deficient nutrition. (42)

The above findings were potentially alarming. Among other things they suggested that the vast expansion of maternity and child welfare clinics was not resulting in a proportionate advantage to the health of mothers. The Ministry of Health had regarded these clinics as its major line of defence, and its statistics suggested that 41% of mothers were attending antenatal clinics in 1933, and this figure had risen to 76% by 1944. More critical investigation showed that women were deriving little benefit from these clinics, and even the statistics of attendance were greatly inflated owing to double reporting and inclusion of pregnancies begun at any time over twenty months, in the statistics for a year. (43) Looking back on this situation, Professor James Young underlined the lack of sense in public policy of developing a 'huge system of clinics' without having regard 'for protecting the mother and child against the damaging influence of deficient family resources'. (44) Women's representatives pressed for the more serious investigation of maternal morbidity. Newman's response is deeply revealing: he believed that it was inadvisable to incur the costs of an official inquiry which 'could have but one ending, namely, the demonstration of a great mass of sickness and impairment attributable to childbirth, which would create a demand for organized treatment by the state'. In Newman's opinion such problems of health lay outside the capacities of the organized facilities offered by 'modern civilized nations’. (45)

Various lines of evidence pointed to the relevance of impoverished nutrition as one of the major contributive factors to ill health and poor physique among the lower social groups. Once again this interpretation conflicted with the opinion of the Ministry of Health and Board of Education. As indicated above, their local surveys strongly believed that malnutrition was no longer a serious problem by the thirties. This problem was not amenable to clear-cut actuarial analysis of the kind undertaken with reference to other classes of morbidity and mortality records. The clinical detection of malnutrition and related conditions offered ample room for subjective error. This point was readily conceded in the context of the school dental services, an area of the health services regarded with helpless dismay by the Board of Education officials. The annual school inspections revealed that two-thirds of the children required dental treatment. Newman conceded that even this was an underestimate. The hard-pressed school dentists, 'faced with the problem of dealing with a much larger number of children than they can possibly treat, ... do not record the actual number of those requiring treatment, but only the number referred for treatment’. He cited one area where only 20% of the children were noted as requiring treatment, and appealed for more diligent recording of the dental statistics. (46) But there was no standardisation of school dental inspections. It was admitted that the normal practice involved only naked eye inspection taking a few seconds, and without an attempt at maintaining dental charts. (47) Less casual methods applying the probe and mirror undertaken in London and Stockton-on-Tees revealed that only 5% of the children possessed entirely sound teeth, while a severe degree of caries was recorded for 83.6% of the London children. (48) Professor Mellanby and his wife strongly argued that dietary deficiency of mothers and young children was responsible for the poor state of the teeth of school entrants. Their work also suggested a strong correlation between rickets and dental defects. Ultimately calcium and vitamin dietary deficiency was found irrelevant to the state of teeth, but relevant to rickets. (49)

The Board of Education Reports suggested that rickets, like malnutrition, was a virtually extinct problem. By 1933 the incidence of rickets had fallen to little more than 0.1%, compared with some 20% at the turn of the century. In Manchester the level of rickets had fallen from 0.62% to 0.33% between 1929 and 1933. (50) By contrast, a more critical investigation of rickets diagnosed according to five standard signs was undertaken in Durham from 1921 onwards and later in other areas. The Durham investigation found definite traces of rickets in no fewer than 83% of the children; a more sophisticated survey undertaken in London suggested 87.5%, while more than 40% showed three or more signs of early rickets. (51)

Findings such as those given above suggest that there was a considerable degree of under-reporting of conditions not instantly recognisable on the basis of a cursory examination. This must raise the issue of the accuracy of estimates concerning malnutrition, a defect which was traditionally reported on the basis of a subjective 'clinical' assessment by the school doctor at the regular medical inspections. In view of the difficulty of evolving objective tests for malnutrition, and especially because of the known unreliability of height/weight estimates, the Ministry placed its faith on the judgement and trained eye of its experienced school medical staff. Medical Officers were advised to follow the approach of Hutchinson, who gauged malnutrition by the 'state of the skin, the lustre of the hair, the appearance of the eyes, the colour of the mucous membranes, and the alertness and attitude of the child'. (52)

Essentially this form of 'clinical' procedure was employed in one of the few direct investigations undertaken by the Ministry of Health into the physical condition of workers in an area of unemployment. One critic regarded the optimistic findings of this enquiry as superficial and scientifically worthless, the report being castigated as 'a farce' carried to 'ridiculous extremes'. Even the more elaborate investigations conducted by the Ministry into the health of schoolchildren gave little satisfaction to the epidemiologist who warned that the findings 'should be regarded absolutely with considerable suspicion', 'at the most' permitting 'a few extremely tentative conclusions. (53) It was argued by one of the most experienced authorities that malnutrition was reported only 'where evidence of malnutrition is so marked as to arrest attention in the course of medical inspection'. In prosperous areas a condition might be diagnosed as malnutrition which in poorer districts would pass unnoticed. (54) School medical officers also varied greatly in their interest in this problem, with the result that greatly different rates were reported for adjacent areas of similar socio-economic character. The paediatrician J.C. Spence noted that rates for comparable areas of Northumberland varied from 0.5% to 7.5%; and the rate for Bootle was twelve times that for Liverpool. These inconsistencies were explored at length in a memorandum produced by the Committee Against Malnutrition. (55) An additional reason for this chaotic situation was the difficulty in operating the four-point ‘Dunfermline Scale' which had been in use since 1908. A widely reported experiment conducted by Dr. W.F.W. Betenson, the County Medical Officer for Breconshire, demonstrated complete lack of uniformity in the assessment of levels of malnutrition by three male and three female medical officers. The male observers noted only three cases of pronounced malnutrition, while the female observers recorded seventeen among the hundred children examined. One of the women recorded 47 cases of subnormal nutrition, while one of the men found only 13. (56)

Sensing disquiet concerning official guidelines respecting malnutrition, a cosmetic change was introduced in 1934, in which the long-established division into 'Good', 'Normal', 'Subnormal', and 'Bad', was replaced by supposedly more practicable categories 'Excellent', 'Normal’, 'Slightly Subnormal', and 'Bad'. No guidelines were provided concerning the precise application of this 'improved' categorization. Application of this new method did little to unify standards. But this formula, by including ‘slightly' subnormal nutrition, gave some encouragement to medical officers in depressed areas to pay more attention to their malnutrition problem. Suddenly, areas which hitherto acknowledged no nutritional problem, began to report malnutrition rates of between 10% and 20%. Fraser in Cumberland, having previously found very little evidence of malnutrition in his area, or of any adverse effects of economic distress on standards of health, in his 1934 report began to recognise the widespread incidence of malnutrition, which was now firmly ascribed to economic distress. But the Chief Medical Officer continued to place the most optimistic construction on these results, singling out for special mention local reports asserting that notwithstanding certain deleterious tendencies there had overall been 'no physical deterioration', or 'no appreciable deterioration' in their areas. On the whole the higher rates were regarded as an indication of more demanding standards and higher expectations among the medical officers. (57)

It was difficult to stave off fears that the elaborate body of statistical data demonstrating the steady improvement in the nutritional state of schoolchildren rested on totally unsound foundations. A large-scale confidential inquiry into this question, sponsored by the Board of Education and the Ministry of Health between 1933 and 1934, confirmed Betenson's

opinion that the results of routine assessments of nutritional standards were untrustworthy, and that the official reports had provided no indication of the scale of the problem. Optimistic pronouncements of departmental officials about the nutritional state of the nation were groundless. No doubt concerned that public confidence in the entire edifice of official health statistics would be undermined by these findings, the departments suppressed this report. The old clinical method of nutritional assessment remained in use, and it was defended as giving 'some concept of the state of nutrition of schoolchildren in the country as a whole'. (58) The full force of criticisms contained in the report was eventually revealed to a specialist audience, but only after a decent interval from the retirement of Sir George Newman, when steps were belatedly being taken to adopt alternative and more reliable assessments of nutritional standards. The author of this report was in no doubt that his findings were 'important and deeply disturbing'. Adoption of unreliable machinery of investigation, and its retention in the face of countermanding evidence had misled the public, and had given the impression of effective action without the reality. (59)

The assessment of standards of human nutrition is a subject upon which there is still widespread debate. In the interwar period nutrition represented one of the most rapidly advancing fields of scientific research. However by 1930 the basic foundations for modern knowledge had been established. The main outlines of quantitative nutritional needs were worked out, and the importance of vitamins and mineral salts was fully appreciated. During the thirties the vitamin B complex was sorted out and minor adjustments in nutritional standards negotiated. Britain played a leading part in nutritional research and much of this prestige research was government-backed, but the Ministry of Health was resistant to applying this knowledge to establish the nutritional standard of the British people, and reticent to face the implications of findings in this area. Until 1935 the Ministry of Health stood aloof from committees of various other government departments conducting research into human nutrition. Particularly damaging were the poor relations between the Ministry and the Medical Research Council. Belatedly and without enthusiasm the Ministry created a Nutrition Advisory Committee in 1931, but this collapsed in 1934, after making a negligible contribution. Under MacNalty this committee was revived, and it adopted a more unified and positive stance, more in line with current expert thinking. But even this committee exercised virtually no influence, and its one major research initiative was abandoned. The coordination of research on nutrition was chaotic, even at the outbreak of war.

Traditionally malnutrition had been gauged by deviation from a given standard for stature, weight, or physical performance. In the absence of a single universally accepted standard, investigators fell back on numerous local standards. Whatever the limitations of this method, certain conclusions emerged from the anthropometric data. The averages for stature and weight were gradually climbing for children of all ages in all areas, but the differential between children from poorer and more prosperous homes was undiminished. Some striking comparisons were made between public schoolboys and their counterparts in elementary schools, but racial grounds could be invoked to excuse the small stature of working-class stock. Of more significance were comparative studies conducted on children coming from various income groups in the same town, or between similar classes in different towns. In his pioneer comparative study J.C. Spence demonstrated major differences in physique and health between 'city' and 'professional' children in Newcastle. On the basis of physical and clinical tests at least 36% of the children from the poorer district were declared unhealthy and malnourished. Even in a prosperous town like Cambridge, children from poorer areas proved to be appreciably inferior in height, weight, strength and haemoglobin level, to their counterparts from a better-off district. Similar differences, coinciding with income differentials, were found among three groups of manual workers in Glasgow, and among a mixed sample of manual workers in Aberdeen. Scottish working class children emerged as 1 ½ inches shorter, 4 pounds lighter, and as having 4% less haemoglobin and a strength of grip 1 ½ kilo. lower, than a parallel group in Cambridge. Various investigations produced consistent results. It seemed incontrovertible to scientists undertaking such comparative exercises that the revealed differential in general health and physique between the social classes was preventable by the improvement of living standards. (60)

Owing to increased knowledge of the biochemistry of nutrition, it became-possible to devise precise quantitative tests to replace the older and unsatisfactory clinical and anthropometric estimates of malnutrition. As indicated above, clinical and x-ray examination methods exposed the much greater incidence of rickets than was reported in routine school medical inspections. Hence calcium and vitamin D deficiency could be detected by such methods. Standardised tests for other vitamin deficiencies were evolved in the thirties, but none had been applied on more than a limited scale in Britain by the outbreak of war. Haemoglobin levels were readily ascertainable, and this test was important in view of the widespread evidence for the relevance of hypochromic anaemia to maternal and neonatal mortality and morbidity. Although no completely accepted standards with regard to the limits for haemoglobin levels for women or children were evolved even by 1945, the findings of an impressive series of major investigations were consistent and sufficiently clear-cut to be generally accepted. (61) Mackay and Davidson, taking working-class samples in London and Aberdeen respectively, established a high incidence of nutritional anaemia among pregnant women and their infants, as well as among women and children more generally. Anaemic babies proved more susceptible to the diseases of infancy. (62) McCance and his co-workers discovered that a precise relationship existed between haemoglobin deficiency, iron and protein levels in diet, and family income. (63)

The above research on sample groups suggesting widespread nutritional deficiency, especially among women and children, tended to be confirmed when, in the same or separate investigations, dietary supplementation was found to reduce maternal or infant morbidity, or increase the rate of growth and improve the health of children. These experiments were initiated in a

classic study by Dr. Corry Mann, who reported the beneficial effects of adding a pint of milk each day to the diet of children in a poor law institution. An even more dramatic result was obtained in the Welsh mining areas when dietary supplementation among pregnant women was thought to contribute to the reduction of the maternal mortality rate from 11.3 in 1934 to 3.9 in 1935. Davidson concluded that such conditions as anaemia attributable to nutritional deficiency was responsible for the poorer classes becoming inured to ill health, 'living subnormal lives for years, and having nearly forgotten the joy of good health'. (64)

Clinical and experimental methods of the kind described above were useful in demonstrating that inferior nutrition was instrumental in undermining the health and physique of working class women and children, so supporting the tenaciously-held view of McCarrison that 'faulty food, and the faulty nutrition resulting from it, is a principal cause of ill-health'. (65) But sample studies provided only an incomplete indication of the scale of the problem. It seemed that the nutritional state of the nation could be determined quite straightforwardly from the economic angle, by working out a diet sufficient for the maintenance of health and calculating the cost of such a diet, which might then be set against income available for food and the actual family budgets of the various social classes. This was worthy of the political arithmetic of William Petty, to offer an irrefutable method of calculating the extent of malnutrition from premises determinable with great precision. Much effort was devoted to this exercise, and the results have become threadbare with repetition. (66)

The original report forming the basis for this method, undertaken under the sponsorship of the Market Supply Committee and supervised by E.M.H. Lloyd, caused alarm in official circles. It was discussed by the Nutrition Committee of the Ministry of Health, but not published officially. The published account appeared in an obscure journal, where Lloyd concentrated on the analysis of family budgets without explicitly raising the question of nutritional adequacy. Only in discussion was the possibility raised that lower-class diets were likely to be inadequate or unbalanced. The further the social scale was descended, the greater the deficiency in milk, eggs, fruit and fresh vegetables, recognised as the 'protective and growth promoting foodstuffs'. Lloyd concluded: 'To that extent the diet of the lowest groups is not only unbalanced but insufficient'. (67) Sir John Orr was present at this discussion; and it was his use of the same research material which established the full relevance of this approach to the study of malnutrition.

When first applied the method of Lloyd and Orr seemed to provide definitive support for the pessimistic conclusion concerning the condition of Britain in the thirties. But on closer analysis this approach is found incapable of fulfilling the expectation of its originators, its wide-reaching statistical generalisations being as open to objection as those stating opposite conclusion emanating from the Ministry of Health under Newman. Among the problems besetting the economic analysis of malnutrition are the following: were the dietaries to be based on a ‘minimum' suitable for survival, or an 'optimum' for a reasonable level of well-being? Rival dietary standards were in use, the main ones deriving from the BMA, the Advisory Council of the Ministry of Health, the US Bureau of Home Economics, the League of Nations Technical Commission and the International Labour Office. These standards were subject to constant minor revision. Nutritionists were not entirely agreed about calorie or protein requirements, their pronouncements on ‘protective' foods were even more unsettled; milk, after being neglected, became elevated to the pinnacle of dietary excellence helped no doubt by medical propaganda issuing from the Milk Marketing Board. After deciding 'man values', what proportions of this standard should be applied to women, pregnant women, children or the elderly; how should it be adapted to various occupational groups? Calculation of the cost of the standard diet was itself fraught with difficulties. Prices varied seasonally and between areas, and levels gradually increased with inflation. Was the price index of the Ministry of Labour an adequate basis for assessment of the real increase in costs of the constituents of the chosen diet? It was not easy to determine the proportion of income available for food. Official figures tended to underestimate the extent of financial obligations of families with respect to items other than food. When the proportion available for food was determined, was the distribution within the family to be calculated according to a scale of the kind used for diets, or on an even 'per caput' basis? Was the exercise to be simplified by assuming maximum efficiency of expenditure, or prolonged by undertaking a sample study of actual food purchases and family food habits? Complete accuracy on these latter points was by no means easy to achieve. Presentation and analysis of the data posed its own problems owing to diversities in family size and the heterogeneity of major class divisions. Orr in particular was criticised for not having selected his budgetary sample with enough care. The sample was also far too small for the purpose to which it was applied.

By adopting stringent requirements for optimum diet, paying full attention to the need for vitamins and trace elements, it was quite possible to demonstrate that malnutrition was so extensive that it entirely embraced social groups III to V, and even reached into class II. Investigators were very uncertain about the implications of their findings. In his Chadwick lecture for 1934, Orr speculated that there were ten million malnourished, whereas after fuller investigation he concluded that only 50% of the population was securing a completely adequate diet. A later survey conducted by Orr on the eve of the war suggested that the situation was improving, only 33% of the population being malnourished. Crawford, somewhat embarrassed that use of the by then officially accepted League of Nations standard diet [which] generated twenty million or even thirty million malnourished, relegated this calculation to an appendix, inserting in his text calculations based on the discredited BMA 'minimum'. Even this minimum value suggested that there were eight million unable to secure an adequate diet. (68)

Regardless of their wider implications, the dietary and budgetary surveys of 1200 families undertaken by Orr, and of 5000 families by Crawford, constitute an invaluable source of evidence. Orr embarked on a larger survey backed by the Carnegie Foundation. When this and the numerous small-scale budgetary surveys are also taken into account these studies achieved substantial coverage of the distressed areas of Britain. Unfortunately, owing to the slow rate at which this type of research gathered momentum, most of the data relates to the period of economic upturning immediately before and during the second world war. (69)

It is beyond the scope of the present essay to analyse the budgetary surveys in detail. It is sufficient to emphasise that a great degree of consistency in the findings is apparent. Where intensive studies were conducted in conjunction with epidemiological work, differences in health and physique were found to correlate closely with the level of income available for food. The surveys provided solid support for the view that major sections of the working classes, even after the worst phase of the depression, were left with an income insufficient to support an adequate diet, however expert the housewife might have been in her housekeeping or knowledge of dietetics. (70) The conclusions of budgetary surveys were thus consistent with the parallel nutritional surveys, which by consensus pointed to some degree of malnutrition among 50% of the nation's children. Try as they would it was difficult for the women and children of impoverished families to improve on their staple diet of white bread, margarine, condensed milk, tea, potatoes, and a little corned beef. (71)

Hannington pointed to the lack of realism in official thinking on diet, observing that the allowance per meal on the BMA scale, three pence farthing for an adult male, and two pence three farthings for an adult female was totally inadequate to support the diet which the experts advocated for the poor. The cost of milk alone, regarded by Newman as essential for the health of a pregnant mother, would absorb 4s.1d. out of the 4s.11d. female dietary allowance. (72) The fresh milk content of children's diet would have absorbed a similar portion of their dietary allowance. Gradually the force of this inconsistency became recognised in official circles. It was not possible for the Ministry of Health to promote ever higher nutritional standards without accepting that application of these standards would reveal an ever-increasing level of malnutrition, given a situation where real incomes were not rising to any significant extent.

To a greater degree than his predecessor, Sir Arthur MacNalty faced up to this dilemma, conceding that the introduction of new scientific criteria would indicate a less favourable nutritional state of the population, but ‘improvement is, and will be there, but owing to the increased attention to nutrition, and the gradual rise in standards, the returns will not show it'. (73) While not hastening to spread alarm about low nutritional standards, MacNalty promoted scientific appraisal of the problem. He reactivated and expanded the scope of the Advisory Committee on Nutrition. This immediately brought his department into closer acquaintance with informed thinking on nutrition, preparing the way for acceptance of the relatively enlightened nutritional standards evolved by the League of Nations Commission on Nutrition. The Board of Education Annual Reports for 1937 and 1938 included adequate statistical detail about local variations in nutritional standards, rather than relying as in previous years on selective impressions gathered from chosen Medical Officers of Health. It was acknowledged that 'special' areas habitually recording high levels of malnutrition were experiencing little remission of this defect.

Breaking a long period of inertia, in 1937, the Ministry of Health, prompted by its Nutrition Advisory Committee, initiated surveys designed to establish the precise scale and nature of the problem of malnutrition and ill-health in selected areas. The results of these surveys were never made public, so depriving the Ministry of any direct contribution to the substantial body of research published during the thirties on local and individual standards of diet and nutrition. (74) Nevertheless on the nutritional issue at least, there emerged a new spirit of realism within the Ministry, which was at least in part a response to a formidable body of outside criticism, not merely confined to
left-wing groups, but by 1935 capturing the support of such famous scientists as Sir Frederick Gowland Hopkins and Sir Robert McCarrison. Pressure on the Ministry was mobilized by a host of such bodies as the Committee against Malnutrition, the Maternal Mortality Committee, the Children's Minimum Council, the People's League of Health and the National Birthday Trust. The scale of this pressure, and the degree to which it claimed the support of expert opinion, are indicative of the seriousness of the health problem.

In drawing attention to problems involved in the interpretation of official reports concerning health, it is not suggested that non-official sources possess special objective virtues, and are thereby immune from criticism. Official
health reports need to be handled with special care because they give every impression of being scientific, dispassionate, objective and comprehensive. They claim higher standards of authority than non-official sources. Indeed the compilers of official health statistics in the interwar period were armed with incalculably better resources than other investigators, and were thereby well-placed to establish their case. Many of our problems of interpretation derive from the treatment of official health reports as privileged sources, rather than subjecting these materials to the critical scrutiny accorded to other classes of historical document.

As demonstrated above the official reports from the 1930s filter the problems of health in accordance with the priorities of that particular generation of senior public health officials, and reflect the political pressures to which these officials were subjected. Newman, as the first Chief Medical Officer, was in a particularly difficult position, attempting to establish the reputation of a new department at a time of mounting economic and political crisis. Every major political and administrative influence operated to coerce the Ministry of Health into adopting the most optimistic interpretation of the available evidence, and there was little incentive for the Ministry to take initiatives which might not reinforce this impression. Once an impression had been built up of the nation’s sound and improving health record, it was difficult to undertake any radical reappraisal without prejudicing the reputation of the public health administration.

Official health reports must be interpreted in the light of these limitations. In the case of mortality, one of the major defects of the official sources is their relatively slight attention to the diversity underlying the national averages. Such averages dominate current historical reviews of health during the interwar period. Averages are not only assumed to provide the best representation of reality; the average has also taken on an independent character, being assumed to represent the normal national condition. Thus departures from the average condition are thought of as exceptions to the normal condition. It has yet to be proved with respect to the interwar period that average infant or maternal mortality, average incidence of tuberculosis or malnutrition &c. provide the most satisfactory summary description of the health of the British population. It should not be overlooked that the average is an abstraction, the value of which depends on the pattern of dispersion of the class of phenomena under analysis. Any trend in an average is of little explanatory significance unless it is described with reference to underlying shifts in dispersion. The condition of Britain is not different from the condition of its separate parts. Consequently, there is little justification for concentrating on continuing improvements in the infant and maternal mortality rates without also attaching proper weight to equally prominent demographical features such as regional and social inequalities of health which find their expression in the phenomena of infant and maternal mortality. Such persisting inequalities are quite as valid as a representation of reality, and as important historically as the decline in average rates of mortality. Life chances within the lower social groups fell drastically short of the optimum attainable at the time in Britain and increasingly achieved by equivalent social classes in other English-speaking countries and Scandinavia. [See fig. 4 in the appendices] Among its other disadvantages the average is not particularly relevant to the estimation of the extent of avoidable biological wastage, for which the most realistic yardstick is provided by best standards achieved on a significant scale at the time. On this basis, even the relatively crude comparisons by region, occupation or social class, demonstrate major differences between the best-off and the rest. With reference to virtually any of the sensitive indicators of mortality these comparisons suggest that the 'submerged fraction' includes dominant parts of the populations of Scotland, Wales, Northern Ireland, and the north of England; it would also embrace major sections of the population of many other English cities. Substantial departures from the average in areas of such major extent can scarcely be dismissed as exceptions of minor consequence. By contrast with substantial improvements elsewhere, for areas dominated by traditional industries the thirties had not witnessed any significant improvement in the mortality rates, and the degree to which the situation was amenable to improvement is underlined by the rapidity with which the mortality rates fell during the second world war. Just as expert opinion explains this improvement by a rise in economic standards, so it is clear that economic disadvantage must carry the weight of the explanation for the adverse situation during the interwar period. It was little consolation to the populations of northern industrial areas when in the mid-thirties a major public health effort held down their stillbirth and infant mortality rates, in one town to 61 and 78.8 respectively, and in mining districts to 40.1 and 82.9 respectively, when it was also known that rates for both stillbirth and infant mortality of the middle classes in the same area stood at 29.5. To reach the standards of the healthier countries, Scotland would have needed to have reduced its post-neonatal mortality by 75%. (75)

Official reports were inclined to explain high levels of infant and maternal mortality in terms of uneven provision or lack of coordination of the existing services, the limitations of science, or the fecklessness of mothers. Increasingly this view was displaced as research confirmed the statistical exercises of Titmuss and demonstrated that this problem was the result of the defective physique, health and nutritional status of mothers, which was in turn rooted in 'unemployment, poverty, bad housing, malnutrition, ignorance, high fertility together with insufficient help in the home, and lack of preparation for marriage'. (76) The relevance of the latter factors is strongly supported by evidence of the rising biological disadvantage of lower-class infants during each successive month in the first year of life. This change in perspective is of the utmost importance since it firmly connects mortality differentials with economic disadvantage, rather than regarding circumstances unrelated to inevitable impairments of the health of mothers and infants as the major limiting factors.

Once it is accepted that economic factors lay at the root of high levels of maternal and infant mortality, it must also be recognized that mortality was merely the most striking indicator of a largely submerged mass of ill-health. Morbidity must be granted its full weight in any assessment of the scale of biological disadvantage experienced by the working classes during the interwar period. It was not until the 1930s that a significant range of critical scientific techniques was available to test the sharp disparities of outlook on standards of health between the official reports and impressionistic witnesses.
This dispute also revolved around the question of averages. The Ministry believed that its large-scale data implied a steady improvement in average standards of health, and that contrary observations constituted unrepresentative exceptions irrelevant to the general picture. Consistent with this line, recent commentators have urged caution in the use of the testimony of witnesses dependent on local sources. Not only writers like Hannington and Orwell, but also technical experts such as M'Gonigle and Orr are suspected of journalistic exaggeration, partisanship, or lack of critical discrimination. (77) However, epidemiological studies securing long-term acceptance, produced by specialists coming from a variety of backgrounds, were deeply critical of the official viewpoint, on both methodological grounds and with respect to substantive issues. There was a rapid trend towards intensive small-scale studies, the conclusions of which coincided closely with more impressionistic estimates. Consequently the deeply pessimistic conclusions concerning the health of major sections of the population contained in journalistic surveys are mirrored in the measured conclusions of the best technical sources.

At the present stage it is difficult to compile a precise catalogue of the scale of morbidity having its roots in economic disadvantage. This factor was clearly important in the 50,000 maternal disablements each year estimated by Blair, or in various degrees of malnutrition which most authorities agreed affected 50% of children. Clearly the problems of morbidity related to economic causes existed on such a major scale that it is unrealistic for them to be regarded as the prerogative of residual and diminishing pockets of unemployment. Indeed certain of the social changes of the thirties, such as the development of high-rent council housing and changes in nutritional habits dictated by mass market conditions contributed towards the worsening of the health situation. Malnutrition reached well beyond unemployment, into larger working-class families, and it affected the entire families of low-wage earners. The scale of biological disadvantage reached a particularly large segment of working class women. It is not denied that substantial sections of the community were enjoying improved conditions of life during the interwar period, these changes being responsible for the improving averages. (42) Such groups enjoyed economic advantages and were genuinely more healthy. But these benefits were distributed unevenly between the social classes with the result that major sections of the population were deprived of the full
benefits of increased health and longevity made possible by medical advance and higher incomes. These groups were subjected to standards of life involving a high degree of discomfort, minor deformity and persistent non-fatal illness. They were perhaps not as hungry as their forebears, but, according to increasingly recognized minimal standards they were by no means healthy. It may well be found that the case for the Hungry Thirties is not merely a 'myth', or romantic gesture towards the past, ripe for an exercise of demystification by hard-headed economic historians, but a well-founded historical thesis tenable on the basis of a balanced appraisal of the entire range of available sources.

[This essay is the revised form of a paper given at the Modern Medicine Seminar in Oxford, November 1979, and circulated for the Annual Conference of the Society for the Social History of Medicine, July 1980. The author is grateful for comments on this paper made by D. Englander, Brenda Fox, Margaret Pelling, A. and N.W. Pirie, Janet Vaughan, J.M. Winter, L..J. Witts, J. Yudkin, and participants in the above meetings.]


1. Harry Pollitt, Introduction to Allen Hutt, The Condition of the Working Class in England (London, 1933), p.xii.

2. C.L. Mowatt writes of the 'myth, sedulously propagated later, of the "hungry thirties". The reality was rather different', Britain Between the Wars, 1918-1940, 2nd edn (London, 1968), p.432. See also, J. Burnett, Plenty and Want (London, 1966), pp.255. D.H. Aldcroft, The Interwar Economy: Britain, 1919-1939 (London, 1970),Chap.10; J. Stevenson and C. Cook, The Slump (London, 1974); J. Stevenson, Social Conditions in Britain Between the Wars
(Harmondsworth, 1977).

3. B. Harrison, 'Women's Health and the Women's Movement in Britain' in, C. Webster (ed )) Biology, Medicine and Society, 1840-1940. Cambridge, 1981), pp.15-71; B. Watkin, The National Health Service: The First Phase 1948-1974 (London, 1978), chapter 1.

4. Aldcroft, op.cit., p.375.

5. J.M. Winter, 'Infant Mortality, Maternal Mortality, and Public Health in Britain in the 1930s', The Journal of European Economic History, 1979, 8: 439-62; p.440.

6. Sir Arthur Newsholme, Infant and Child Mortality: Supplement to 39th Annual Report of the Local Government Board, 1909/10. (Cmd. 5263), p.74. F.A.E. Crew, Measurements of the Public Health. (Edinburgh, 1948), pp.204, 217-18.

7. Annual Report of the Chief Medical Officer of the Ministry of Health for 1932 (HMSO, 1933), p.223; Report for 1933, p.9; Report for 1934, p.15 - hereafter MH Report. CMO Board of Education Annual Reports are given hereafter as BE Report.

8. C. Rolleston, 'Factors affecting Infant Mortality in Rural Areas', The Medical Officer, 1918, 20: 201-2. D.N. Paton and L. Findlay, Poverty, Nutrition and Growth, Medical Research Council, Special Report, No.101, 1926. E. Lewis-Faning, A Study of Mortality Rates in Urban Communities of England and Wales, with special Reference to Depressed Areas, Ministry of Health, Public Health Report, No.86, 1938. J.A. Scott, 'The Dysgenic Effect of the Social Services', Public Health, 1934, 47: 380-5. Sir Robert Hutchinson, 'Paediatrics, Past, Present and Prospective', Lancet, 1940, ii: 799-803. Hutchinson (President of the Royal College of Physicians) wondered 'whether the stinting production and careful saving of infant lives today is really, biologically speaking, as wholesome as the mass production and lavish
scrapping of the last century'. Lord Dawson of Penn, leader of the medical peers, expressed similar ideas in the House of Lords, 10 November 1936, House of Lords Debates, vol.103, 1936/7, cols. 54-62.

9. The Times, 13 November 1937.

10. Winter, 'Infant Mortality', pp.440,462.

11. R.M. Titmuss, Problems in Social Policy (London, 1950), pp. 551-2. M. Flinn et al., Scottish Population History from the 17th Century to the 1930s (Cambridge, 1977), pp.416-20.

12. J. Lewis, The Politics of Motherhood: Child and Maternal Welfare in England 1900~1939 (London, 1980), pp.26-9.

13. MH Report 1933, pp.262-3.

14. Ministry of Health, Report on Maternal Mortality in Wales, 1937. (Cmd. 5423), pp.93-4, 115.

15. The Medical Officer, 1937, 57: 215.

16. The Annual Reports for a particular year were late in the following year, and were accordingly influenced by events in that year. MH Report 1932, pp.16-43; pp.223--1,

17. MH Report 1933, pp.206-8.

18. MH Report 1932 pp.23~31; 1933, pp.209-11.

19. MH Report 1932, pp.21-2; 1933, p.208. BE Report 1933, pp.17-27.

20. MH Report 1932, pp.32-8; 1933, pp.215-20; p.219.

21. MH Report 1932, pp.23-31; 1933, pp.209-11.

22. MH Report 1932, pp.39-40, see also pp.16,34; 1933, pp.219-21.

23. MH Report 1932, p.223; 1933, pp.220-1.

24. BE Report 1934, pp.15-16.

25. Sir E. Hilton Young, House of Commons Debates, 7 July, 1933, vol.280, 1932/3, cols.657-8. See also cols.656, 657.

26. Lord Boyd Orr, As I Recall (London, 1966), p.(?) Bishop of St. Edmundsbury quoted in Daily Herald, 24 January 1938, and in J. Kuczynski, Hunger and Work. Statistical Studies, (London, 1938), p. ix. See also note 69 below. The Archbishop of Canterbury and the Bishop of Winchester adopted a more sympathetic attitude to the health problems of the lower classes, and were in turn criticised by Lord Dawson, see note 8 above.

27. The more important publications following up Hutt's contribution, and explicitly critical of the official reports, include: C.E. McNally, Public Ill Health (London, 1935) - by the Secretary of the Committee Against Malnutrition, a book ‘conceived in anger - anger at the way in which Sir George Newman's Report for 1933 was being used' (pp.28-9); G.C.M. M'Gonigle and J. Kirby, Poverty and Public Health (London, 1936); G.D.H. Cole and M.I. Cole, The Condition of Britain (London, 1937) - slight; W. Hannington, The Problem of the Distressed Areas (London, 1937); R.M. Titmuss, Poverty and Population. A Factual Study of Contemporary Social Waste (London, 1937); J. Kuczynski, Hunger and Work: Statistical Studies (London, 1938); idem, The Condition of the Workers in Great Britain, Germany and the Soviet Union 1932-1938 (London, 1939). M. Spring Rice, Working-Class Wives. Their Health and Conditions (London, 1939).

28. M. Greenwood, B.M.J., 1939, i:862.

29. MH Report 1932, pp.10-11.

30. Hutt, Condition of the British Working Class, pp. 85-6. R.M. Titmuss, Birth, Poverty and Wealth, A Study of infant Mortality (London, 1943), p.52..

31. Titmuss, Birth, Poverty and Wealth, p.45, pp.57-8 (corrected). Crew, Measurements of the Public Health, p.214. Joint Committee of the Royal College of Obstetricians and Gynaecologists and the British Paediatric Association. Neonatal Mortality and Morbidity, Ministry of Health Report on Public Health and Medical Subjects, No.94 (HMSO, 1949). Registrar General, Decennial Supplement for England and Wales. 1931. Part IIB. Occupational Mortality (1953), Table Q1, p.86. Winter, 'Infant Mortality', p.451. For an official 'reply' to the pessimists, see P. Stocks, 'The Effects of Occupation and of its accompanying Environment on Mortality', Jnl. Roy. Statistical Soc., 1938, 101: 669-98.

32. J.N. Morris and J.A. Heady, 'Social and Biological Factors in Infant Mortality: V. Mortality in Relation to the Father's Occupation, 1911-1950', Lancet, 1955, i: 554-9; W.P.D. Logan, 'Social Class Variations in Mortality', British Jnl. Prev. and Soc. Med., 1954, 8: 128-38. These conclusions are not materially affected by unsatisfactory features of the Registrar-General's classification, or reference to the social class of the father; see W.M. Susser, 'Social Medicine in Britain : Studies of Social Class' in A.T. Welford et al., Society, Problems and Methods of Study (London, 1962), pp.127-51.

33. Titmuss, Birth, Poverty and Wealth, pp.90-94.

34. Royal College of Obstetricians and Gynaecologists, Report on a National Maternity Service (London, 1944), p.16. See also, Department of Health for Scotland, Infant Mortality in Scotland, Report of Sub-Committee of the Scientific Advisory Committee (HMSO, Edinburgh,1943). Joint Committee of the Royal College of Obstetricians and Gynaecologists and the British Paediatric Association, Neonatal Mortality and Morbidity (HMSO, 1949), p.25. Joint Committee of the Royal College of Obstetricians and Gynaecologists and the Population Investigation Committee, Maternity in Great Britain (London, 1948).

35. P. Stocks, 'Morbidity Statistics', Public Health, 1947, 60: 137-40.

36. R.M. Titmuss, Poverty and Population, pp.157-82.

37. F.C. Bradbury, Causal Factors in Tuberculosis, National Association for the Prevention of Tuberculosis (London, 1933); P.D’A. Hart and G.P. Wright, Tuberculosis and Social Conditions in England, Nat. Assoc. Prev. Tub. (London,1939); Report of the Committee on Tuberculosis in Wartime, Medical Research Council, Special Report Series, No.246 (1942).

38. Maternity in Great Britain (n.34 above), p.35.

39. MH Report 1936, p. 57.

40. PRO. MH 79/49, Minutes of Consultative Council, 24 October 1919. V Bonney. ‘The Continued High Maternal Mortality of Childbearing'. Proceedings of the Royal Society of Medicine. 1918/1919, 12: 75-107.

41. J. Young, 'The Woman Damaged by Childbearing', B.M.J. / 1928, I, 891-5. Ministry of Health, Final Report of the Departmental Committee on Maternal Mortality and Morbidity (HMSO, 1932); W. Blair Bell, 'Maternal Disablement', Lancet, 1931, i: 1971---, 1279-86.

42. Evidence summarised in Neonatal Mortality and Morbidity (1949),

43. Maternity in Great Britain (n.34 above), pp.23, 35, 46.
44. J. Young, 'Mother and Child', The Medical Officer,1945, 74: 119-20, 127-8; p.120.

45. PRO, MH 55/262, Memo from Newman to Sir Arthur Robinson,
26 October 1932. Quoted in J. Lewis, The Politics of Motherhood (n.12 above), p.49. This study contains an excellent review of the question of maternal health.

46. BE Report 1933, p.120

47. BE Report 1932, pp.56~7.

48. M’Gonigle and Kirby, Poverty and Public Health, pp.59-62. Medical Research Council, Special Reports, Nos. 140, 153, 191.

49. I am grateful to Brenda Fox for clarifying this latter important point, not widely known among laymen. The Medical Research Council invested greatly in this unfruitful line of research, see A. Landsborough Thomson, Half a Century of Medical Research, 2 vols (HMSO,1973),ii, 87-90.

50. BE Report 1933, p.22.

51. G.C.M. M'Gonigle, 'Rickets and Tonsils and Adenoids’, The Medical Officer, 1925, 34: 5-8, 21. J.W. McIntosh, ‘Incidence of Rickets in Durham and Norfolk', Jnl. State Medicine, 1935, 43: 187-198. M’Gonigle and Kirby, Poverty and Public Health, pp.63-74.

52. R. Hutchinson, Proc. Roy. Soc. Med.,1933, 725. BE Report 1934, pp.26-9.

53. Report of an Inquiry into the Effects of Existing Economic Circumstances on the Health of the Community in the County Borough of Sunderland and of Certain Districts of County Durham.(Cmd.4837) 1934/35, PP IX, p627. [Essentially consists of a letter from Dr G F Walker in The Times 11th December 193?. J.R. Marrack, Food and Planning. (London, 1942),p.88. Bradford Hill in MH Report 1931, pp.247-56.

54. W.R. Dunstan, 'Underfeeding - Does it Exist?', The Medical Officer, 1934, 52: 15-16.

55. J.C. Spence, Lancet, 1935, i: 268. Committee Against Malnutrition, On the Present Classification of Schoolchildren According to the Condition of their Nutrition (1936).

56. Betenson's Report for 1935, summarised by W.R. Dunstan in 'The General Assessment of Nutrition', The Medical Officer, 1937, 57: 55.

57. MH Report 1933, pp..208-11. BE Report 1934, pp.26-7; 1935,


58. BE Report 1935, p.19.
59. R. Huws Jones, 'Physical Indices and Clinical Assessments of the Nutrition of School Children', Jnl. Roy. Statistical Soc., 1938, 101: 1-34; pp.24, 33.

60. J.C. Spence, 'Investigation into the Health and Nutrition of Children of Newcastle-upon-Tyne between the Ages of 1 and 5 Years' in J.A. Charles, MOH Annual Report for 1933, Newcastle upon Tyne 1934; J. Yudkin 'The Nutritional Status of Cambridge School-Children', B.M.J., 1944, ii: 201; idem, 'The Nutritional Status of Children and Mothers of Industrial Towns', The Medical Officer, 1944, 72: 93-4, 101-2.

61. H.M.M. Mackay, et al., 'Discussion on Nutritional Anaemia', Proc. Roy. Soc. Med., 1942, 36: 69-85; see especially graph summarising previous researches, p.72.

62. H.M.M. Mackay, L. Goodfellow, and A.B. Hill, Nutritional Anaemia in Infancy: The Influence of Iron Deficiency on Infant Health, MRC Special Report Series No.157 (HMSO, 1931); H.M.M. Mackay, 'Factors causing variation in haemoglobin level with age during the first year of life', Arch. Diseases of Childhood 1933, 8: 251-64; idem, 'Dietetic Deficiencies and Susceptibility to Infection', Lancet, 1934, ii: 1462--6; idem, 'The Haemoglobin
Level among London Mothers', Lancet, 1935, i.. 1431-3. L.S.P. Davidson et al., 'Nutritional Iron-Deficiency Anaemia', B.M.J., 1935, ii: 195~8. See also H.W. Fullerton, 'Iron Deficiency Anaemia of Late Infancy', Arch. Diseases of Childhood, 1937, 12: 91-110. W.J.S. Reid and J.M. MacIntosh, 'The Influence of Anaemia in Pregnancy', Lancet, 1937, i: 43-5. L. McIlroy, L Wills, et al., 'Discussion on Diet in Pregnancy', Proc. Roy. Soc. Med., 1934/5, 28: 1385-1406. M. Spring Rice, Working Class Wives, p.57.

63. R.A. McCance et al., 'A Study of English Diets by the Individual Method, III: Pregnant Women at Different Economic Levels', Jnl. Of Hygiene, 1938, 38 :596.

64. H.C.C. Mann, Diet for Boys During the School Age, MRC Special Report Series, No.105. (HMSO, 1926); Mackay, 1934, 1935 (n.62 above). People's League of Health, 'Nutrition of Expectant and Nursing Mothers', Lancet, 1942, ii: 10-12; Lady Rhys Williams, 'Malnutrition as a Cause of Maternal Mortality', Public Health, 1936, 50: 11-19; M.T. Balfour, 'Supplementary Feeding in Pregnancy', Lancet, 1944, i: 208-11; L.S.P. Davidson et, al., 'Nutrition in Relation to Anaemia', B.M.J., 1933, i: 685-90.

65. This view was given wide publicity through The Cantor Lectures delivered by Sir Robert McCarrison at the Royal Society of Arts in 1936, Nutrition and Health (London, 1936; 2nd edn, 1944).

66. J.C. Drummond and A. Wilbraham, The Englishman’s Food revised edn (London, 1959), pp.428-48; J. Burnett, Plenty and Want, A Social History of Diet in England from 1815 to the Present Day revised edn (London, 1979), pp.307-19. See also sources cited in note 2 above.

67. E.M.H. Lloyd, 'Food Supplies and Consumption at Different Income Levels', Jnl. of Proceedings of the Agricultural Economics Society, 1936, 4: 89-110. A paper originally delivered at a Conference of the Society in December 1935.

68. See especially J.B. Orr, The National Food Supply and its Influence on Public Health (London, 1934); idem, Food, Health and Income (London, 1936); and idem, 'National Food Requirements', in J.C. Drummond et al., The Nation's Larder (London, 1940), pp. 46-64; Orr and D. Lubbock, Feeding the People in War Time (London, 1940). Sir William Crawford and H. Broadley, The People's Food (London, 1938); R.F. George, 'A New Calculation of the
Poverty Line', Jnl. Roy. Statistical Soc., 1937, 100: '74-95. M’Gonigle and Kirby, Poverty and Public Health, p.263, speculated that the results of sample surveys made it 'not improbable that nearly one half of the population' was to some degree malnourished., For similar conclusions, see S. Rowntree, Poverty and Progress, (n.69 below), p.459.

69. Orr's sample was weighted towards the industrial north. For Orr's later study, see Rowett Research Institute, Family, diet and Health in Pre-War Britain (Carnegie Trust, Dunfermline, 1955). Crawford’s sample was more. generally representative of urban areas. Other studies investigated St. Andrews, Cardiff, Reading (Cathcart and Murray, MRC Special Reports, Nos. 151, 165, 218); Peterhead, Aberdeen (Davidson et al., 1933, see n.64 above); Newcastle-upon- Tyne (Health Dept., Dietary Survey of Working Class Families, 1937); Stockton-on-Tees (G. C. M. M'Gonigle, Proc. Roy. Soc. Med.,
1933, 26: 677; M’Gonigle and Kirby, Poverty and Public Health; Cuckfield and Burgess Hill (W.B. Scott, The Medical Officer, 1937, 57 .259-61); Scottish Industrial Towns (Yudkin, 'The Nutritional Status of Children and Mothers', see n.60 above); Birmingham, (M.S. Soutar et al., Nutrition and Size of Family, London, 1942); Sussex (F. Brockington, 'The Influence of the Growing Family upon the Diet in Urban and Rural Districts', Jnl. of Hygiene, 1938, 38: 40-61.) There were many less specifically medical local surveys of poverty conducted during this period, particularly well-known being S. Rowntree's work on York, Poverty and Progress (London, 1941). Against the above experience, a small number of authorities protested that malnutrition was not a serious problem. See Hutchinson (n.8 above), and C. Rolleston, The Medical Officer, 1941, 65: 203; 1941, 66: 40. Rolleston stated that in his experience of examining the children of Rutland since 1908 he had concluded that 'poverty is not the cause of malnutrition'. Hutchinson (p.802) was 'sceptical about claims concerning widespread malnutrition or even under-nourishment, except in pockets in the more distressed areas'.

70. A.H.J. Baines, D.F. Hollingsworth and I. Leitch, 'Diets of' Working-Class Families with Children before and after the Second World War', Nutrition Abstracts and Reviews, 1963, 33: 653-68. M’Gonigle and Kirby, Poverty and Public Health, p.189; W. Hannington, Problem of the Distressed Areas, pp.62-3. J. Yudkin, 'The Nutritional Status', pp.101-2; M. Spring Rice,
Working Class Women, p.156. Among those proving the good dietary sense of housewives were: W. Hannington, The Problem of the Distressed Areas, pp.61-2; M'Gonigle and Kirby, Poverty and Public Health, pp.193, 274. M'Gonigle, letter to The Times, 26 March 1936; MOH Newcastle, Dietary Survey (n.69 above); M. Spring Rice, Working Class Wives, chap. 7. A more pessimistic opinion concerning working-class housewives is expressed by E.P. Cathcart and A.H.T. Murray, MRC Special Report, No.218 (1936); many MOH reports e.g. Dr. E. Jones, Cardiganshire, 1932; Dr. L.W. Pole, Llanelli, 1933; or A.M.N. Pringle, MOH for Ipswich, The Medical Officer, 1937, 57: 65-6; and more sympathetically by George Orwell, The Road to Wigan Pier (1937) quoted from 1962 edn, pp.85-6.

71. Orwell, pp.85-6; Hannington, p.57; Spring Rice, chap. 7.

72. Hannington, pp.58-9. Newman in his Ministry of Health Report for 1933 (pp.260-1) outlined the necessary constituents of the diet for a pregnant woman as 'ample milk (two pints a day), cheese, butter, eggs, fish, liver, fruit and fresh vegetables.

73. BE Report 1938,p.12; italics as in the original.

74. MH Report 1936, pp.133-4; 1937, pp.127-31; 1938, pp.94-5.

75. M'Gonigle and Kirby, pp. 114/15; C.M. Burns, Infant and Maternal Mortality in Relation to Size of Family and Rapidity of Breeding (Newcastle-upon-Tyne, 1942), p.139.

76. Neonatal Mortality and Morbidity (n.34 above), p.22. See also D. Baird, 'The Influence of Social and Economic Factors on Stillbirths and Neonatal Deaths', Jnl. Obst. & Gynaec. Brit. Empire, 1945, 52: 217-34, 339-66.

77. See for instance: Stevenson and Cook, The Slump, pp.44-5, 53, 75,79. Winter, 'Infant Mortality, Maternal Mortality', pp.339-40, 460-2.

Figure 1. Infant Mortality Rates by Regions for Social Classes 1 and V, England and Wales 1930-2. From: S. Leff, Social Medicine (London, 1953), p.91.

Figure 2. Infant Deaths and Stillbirths by Social Class, England and Wales 1939. From Leff, p.92.

Figure 3. Stillbirth and Post-neonatal Mortality by Social Class for Scotland 1939, 1945. From Crew, Measurements of the Public Health, p.215.

Figure 4. Selected Comparative Mortality Rates of Whites compared with Coloureds and Blacks, 1931-1949. Adapted from Leff, p.83.

SCG/23 June 2005
14926 words.
Stanley Challenger Graham
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Post by Stanley » 11 Nov 2014, 06:47

Bumped to reinforce Tiz's post in Lies, damned lies.
Stanley Challenger Graham
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Post by Stanley » 13 Nov 2014, 07:01

Nice to see that bumping this has attracted new views....
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Post by Stanley » 09 Jan 2017, 04:42

Bumped again. Well worth a read......
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