Historians have identified these three broad factors - that of improvements in public health, medicinal advancements and increased nutrition through a rise in ‘living standards’. It is the debate between the three which fuels such a statement - each has been shown as valid to some extent, yet there are important criticisms of each that need to be assessed in order to identify the primary cause of improvements in the nation’s health. The decline of mortality in Britain in the period 1870-1939 was on a scale unprecedented and dramatic. Crude death rates were halved, infant mortality rates reduced by 80% and mortality due to infectious diseases was reduced by 90%. Clearly, therefore, the reasons for such an improvement lie within one of the three main arguments. However, as the statement suggests, it would perhaps be foolish to label merely one of these arguments as the most successful - instead we should seek to observe where they overlap and thus make a reasoned judgement concerning which was the most successful, whilst not discounting the influence of other arguments. For factors behind mortality debate have inspired a hotbed of debate, ranging from Mckeown’s thesis, promulgating nutrition as the single most important factor in the nation’s improved health to Szreter’s emphasis on the shift away from such a conclusion, arguing instead that improvements in public health facilitation and sanitation played a key role in reducing the spread of infectious disease. Medical advancements too must not be ignored - the National Health Service may not have been founded until 1948, but the importance of such advancements before this date has often been looked over.
To claim that the main cause of improvements in the nation’s health was due to rising living standards would be to agree, to a large extent, with the work of Mckeown. There is no doubt that in the second half of the 19th Century there occurred a sustained and significant rise in real wages. Mckeown argued that better nutrition, it was on food that the working class spent 60% of their income, meant an increased resistance to viral and bacterial infection. The thesis showed that medical science had remarkably little to do with the modern mortality decline. From observing the aggregate real wage index we may see that wage rises in this period were significantly high which meant more food could be purchased for the same proportionate outlay from the average family’s budget. Mckeown’s publications have sparked a long and protracted debate about the respective roles of improvements in sanitation and nutrition in the process of mortality decline. Harris underlines Mckeown’s key assumptions, arguing that nutrition needs to be regarded as a key factor in Britain’s mortality transition. However, there are key flaws in the Mckeown thesis, and it becomes possible to suggest we may be able to draw a line under the Mckeown interpretation and simply acknowledge that its greatest strength has proven to be its enduring ability to stimulate debate. He failed to take into account factors such as changes in the virulence of infectious organisms, improvements in personal and domestic hygiene, medical intervention and most importantly the beneficial effects of the sanitary ‘revolution’ from the second half of the 19th Century. This does not mean we can dismiss nutrition and rising living standards altogether ; it is true that humans require additional quantities of food in order to enable them to perform work and war off the effects of disease. Furthermore, there is a broad consensus on the part of the epidemiological community that nutritional deficiencies do play an important part in the development of a wide range of infectious diseases. Scrimshaw, Taylor and Gordon found that nutritional factors were important in situations where there was an equilibrium between the natural resistance of the host and the virulence of the infective agent. Lunn proposed, “it has become generally accepted that malnutrition predisposes an individual to infectious disease.” However, in 1982 a group of historians, scientists and economists concluded that nutritional status had little effect on the development of such diseases as plague, typhoid, tetanus, smallpox or malaria - it only exerted a ‘variable’ impact on the outcomes of diphtheria, syphilis and typhus. The relationship between nutrition and infection appears not to be continuous and nutrient deficiencies are only likely to affect disease outcomes if they are particularly severe.
Furthermore, Mckeown’s thesis was centred around the key assumption that “the decline of mortality between 1851-60 and 1891-1900 was attributable almost exclusively to a reduction in the frequency of death from infectious disease.” Therefore, we must ask to what extent was such a reduction due primarily to living standards and increased nutrition? Szreter drew on revealing epidemiological evidence to suggest that Mckeown exaggerated the extent of the contribution made, especially by pulmonary tuberculosis, to the overall decline in mortality, and that his led him to underestimate the significance of improvements in the incidence of mortality from water and food-borne disease. Woods’ exhaustive study concluded that even though the decline in the death rate from TB accounted for more than one third of the total decline in mortality in this period - it declined at much the same rate throughout the country. How can this be, if we are to believe Mckeown’s argument that only through an increase in living standards - as a result from a higher wage from industrial work in the major cities. We may conclude that this decline was unlikely to have been caused by changes in diet. Hardy claimed that, “recent research reinforces the conclusion that, for a significant proportion of Britain’s population, rising real incomes had little direct impact on improving nutritional standards”. Furthermore, TB appears to have been responsible for only about two seventh’s of the late 19th Century decline in mortality. We can attribute to typhoid a further seventh with scarlet fever, cholera, smallpox and ‘convulsions’ completing the list. Mckeown focuses primarily on TB, yet apart from this there were two other airborne diseases which declined significantly, smallpox and scarlet fever. Neither of these examples can be used to support a thesis centred around nutritional factors. It has been medically accepted that human intervention (inoculation, vaccination, quarantine) must be granted the major role in the case of smallpox, and scarlet fever appeared to burn itself out spontaneously. Furthermore, the examples of the composite airborne group, bronchitis, pneumonia and influenza, was further overlooked - by 1900 this category was clearly the most important killer, 16% of all mortality attributable to it - a greater proportion than TB represented in the mid-19th Century. Thus Mckeown’s crucial error lies in treating the airborne diseases as a single unitary group - that rising living standards can be considered responsible for the group as a whole is highly questionable. The fall in TB, after subtraction of the increases in the bronchitis group fatalities, would be only 6% of the total fall - a fifth of the 30% reduction before 1901.
‘Rising living standards’ appears somewhat opaque. We must recognise that airborne diseases spread most effectively when humans are in close unventilated proximity - such as the industrial centres of Britain. Therefore, as Britain became further industrialised and real wages did increase it also fostered these hazardous conditions. Mckeown’s judgement that increased wages automatically meant increased health appears far too simplistic, not acknowledging that such economic advance provided a paradox - that at the same time the average families real wages did increase, yet simultaneously exerting a negative influence on average life expectancy because of crowded and chaotic living conditions. The assumption that rapid economic growth should be correlated with improvements in health of a society is fatally incorrect. Szreter highlights the “four D’s” of disruption, deprivation, disease and death which can be attributed as negative consequences of economic growth. Economic growth, even with rising real wages, seems as likely to harm as to benefit a nation’s health. During the key period of industrialisation (arguably the three middle decades of the 19th Century) the pattern between the increase in real wages and health is contradicted by mortality trends. Wrigley and Schofield found there was no significant increase in the national average for life expectancy until the 1870’s. The period of most rapid and rising economic growth rates (1800-1870) ensued little if any health improvements for the nation as a whole. William Farr illuminated this further, finding revealing regional differences in life expectancy - the Surrey countryside, for example, giving 45 as above the national average. In this study, quite a contrasting picture emerged from the two largest provincial cities - the centres of the nations new-found prosperity and ‘rising living standards’ - the average life expectancy was 28 and 27 in Liverpool and Manchester respectively. The ever-increasing proportion of the population directly involved in urban and industrial expansion experience a marked deterioration in average life expectancy well into the third quarter of the 19th Century.
Szreter’s examination of the shift of focus to local public health level provides us with an opportunity to assert that the traditional view that rising living standards were the cause of the lower mortality rates has been littered with flaws. Public health involvement from around the 1870’s must be seen as crucial in aiding the lower rates of mortality experienced by the turn of the century. Three public health acts during the 1870’s formed the backbone for a programme of increasingly effective pursuit of the nation’s health. The 1871 Local Government Act provided a minister responsible for implementation of sanitation, the following year’s Public Health Act established a national network of local sanitary authorities each with a Medical Officer of Health - and a further Public Health Act in 1875 laid down most public health functions of these local authorities. The last third of the Century especially resulted in unprecedented growth for the public health movement. After 1875, local authorities used their new powers to regulate housing standards so that by 1900 the majority were connected to WC’s. Through looking at the finances of the period we can gauge just the extent of the positive involvement that public health authorities came to exert. In the period 1845-72 local government had borrowed only 11 million for sanitation, between 1880-97 the figure spent was closer to 62 million. The 1878 Public Health (Water) Act made purchase of private waterworks financially possible. There can be no doubt that the decline of mortality due to water-borne diseases is attributable to publicly enacted improvements in sanitation. The provision of a clean water supply was essential in the cases of typhoid and cholera and clearly showcases the effectiveness of large-scale public health measures. Crucially, mortality remained stationary until the 1870s - it was in the last two decades of the 19th Century that the rate of overall mortality decline noticeably accelerated. This coincided with major spending on sanitary infrastructure, by 1896-1900 expenditure was approaching £75,000 per town per annum, increasing to £91,000 by 1905. However, the system was not perfect, it was not until the interwar years that water-carriage systems of sewerage disposal displaced privy middens in the most deprived areas. Yet its success in eradicating infectious disease is unmatchable with Mckeown’s dubious charge that nutrition and rising living standards were the cause of mortality decline.
A revealing part of the mortality decline in this period arose from infant mortality rates (IMR), which remained stubbornly high into the 20th Century. Here we may use this as an example to illustrate the positive effects of public health information to mothers about which techniques and methods are best suited to keeping infants healthy. All too often, an increase in nutrition as a result of higher real wages caused babies to be fed artificially and with potentially fatal foods. The involvement of the Medical Officer of Health in many towns and provinces had an extremely positive effect upon lowering IMR - a clear reduction in IMR only appeared after these public health institutions were in place. The example of Norwich provides a picture of how changing infant feeding practices accompanied declining IMR. A decline in the use of potentially hazardous long-tube bottles from 72-6% and the provision of sterile dried safe cows milk to 46% rather than just 2% accompanied a growth in the percentage of mothers switching to national approved feeding methods. This paralleled a decline in Norwich’s IMR from 174 per 1,000 in 1905 to 86 in 1920. Changing feeding practices, therefore, as a result of an increased involvement from local public health authorities may well have contributed significantly to the decline in infant mortality which began at the outset of the 20th Century. Therefore it must be emphasised that public health involvement can indeed claim a mostly convincing role as the main cause of improvement in the nation’s health - yet we must be careful to note the advancements in curative and medicinal technology. Banting and Best’s discovery in 1922 of insulin for diabetics was adopted as standard practice by the Medical Research Council the following year. World War One led to the introduction of new and successful techniques for the treatment of wounds and fractures. The discovery of the bactericidal properties of prontosil rubrum in 1935 by Domagk was crucial - the first of the sulphonamides. Its introduction made a major contribution to the decline of puerperal fever, a major cause of maternal mortality. The Mckeown thesis therefore might be doing medical intervention a mis-justice in understating its importance, especially into the 20th Century. There were between 1870-1939 developments in medical treatment which may have reinforced the process of the control and eradication of both infectious and non-infectious diseases. Most major innovations came after 1900 - yet it can still claim some success in having a positive effect upon Britain’s lowering mortality.
In conclusion, therefore, there are clear limitations of a ‘standard of living’ thesis alone. In the absence of collective political decisions, at both local and national level, promoting objective, economic growth in itself had no inherently health enhancing properties, perhaps far from it. Evidence has been given to suggest the exact opposite, that the key period of industrialisation had a negative impact upon the health of those supposedly enjoying a higher standard of living. The period 1870-194 especially demonstrates the effectiveness of promoting and financing public health projects in a society possessing the necessary economic resources. Furthermore, the growth of the preventive and medicinal branch deserves much praise for the modern mortality decline, yet the key reduction in deadly infectious disease can be mostly attributed to public health projects. There can be little doubt that adequate nutrition and good intake of food are essential factors for a population to achieve high levels of health - rising living standards are not to be dismissed completely, yet other factors seem to suggest that the major cause of improvements in the nation’s health was not due to a rise in living standards.
Bibliography
H. Jones, Health and Society in Twentieth-Century Britain
V. Fildes, “Infant feeding practices and infant mortality 1900-1919”, Continuity and Change (1998)
F. Bell and R. Millward, “Public Health Expenditures 1870-1914”, Continuity and Change (1998)
S. Szreter, “Economic growth, disruption, deprivation, disease and death” Population and Development Review (Dec 1997)
S. Szreter, “The importance of social intervention in Britain’s mortality decline”, Social History of Medicine (1988)
S. Szreter, “Mortality and public health 1815-1914”, in A. Digby, C. Feinstein and D. Jenkins (eds.) New Direction iin Economic and Social History II (1992)
B. Harris, “Public health, nutrition and the decline of mortality : the Mckeown thesis revisited”, Social History of Medicine (2004)
B. Harris, The Origins of the British Welfare State
J. Winter, “The decline of mortality in Britain 1870-1950” in T. Barker and M. Drake, Population and Society 1850-1980
A. Hardy, Health and Medicine in Britain since 1860
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