Cities at War: Birmingham, Liverpool, and Manchester during the First World War

In 1914, in Birmingham, John Robertson reported a “great strain” from the outbreak of the Great War, which included the departure of sixteen medical officers and fifty sanitary inspectors for military service. Nevertheless, Robertson felt that the year was one of “steady progress” in public health, including expanding programs for infant welfare.1Robertson, Report of the Medical Officer of Health for the Year, 5–6. This was important because infant mortality remained a serious concern in Birmingham throughout the war years. In 1914, infant mortality in Birmingham remained at an average of 122 per 1,000 live births, which Robertson admitted was “still high” and well above the national average.2Robertson, Report of the Medical Officer of Health for the Year 1914, 14. Like his colleagues in the other two cities, Robertson believed that these infant deaths were “preventable and quite unnecessary,” because they frequently resulted from “ignorance” that could easily have been prevented by a “visit to the homes of the people where this high mortality occurs.”3Robertson, Report of the Medical Officer of Health for the Year 1914, 13.

As we have already well established, health visiting was essential to the efforts to reduce infant mortality, and it remained a staple of Birmingham’s public health efforts during the First World War. Despite other shortages caused by the war, health visitors continued their important work of providing in-home advice and educational materials to mothers. In fact, health visiting in Birmingham expanded during the war as the number of health visitors employed by the city increased. In 1914, the city of Birmingham employed thirty-one health visitors, who each conducted between five hundred and eight hundred visits per year. In 1915, the staff expanded to forty-three health visitors, although ten of these women were employed to attend solely to cases of tuberculosis.4Robertson, Report of the Medical Officer of Health for the Year 1915, 59–60. In 1916, Birmingham’s staff of health visitors rose again, to fifty-one. By 1918, the city of Birmingham employed a staff of seventy-eight professional health visitors.5Robertson, Report of the Medical Officer of Health for the Year 1918, 95. According to their Superintendent, Blanche Gardiner, these women continued to work “energetically” throughout war.6Robertson, Report of the Medical Officer of Health for the Year 1916, 61.

Whenever possible, health visitors referred mothers to Maternity and Infant Centres, which also expanded their services during the war. In 1914, there were four such Centres in Birmingham.7Robertson, Report of the Medical Officer of Health for the Year 1914, 18. By 1916 the number of municipally funded Maternity and Infant Centres in Birmingham had more than doubled, to nine. Figure 6.1 shows their geographic spread. Charitable organizations also continued to offer consultations and classes on the upbringing of young children and also provided meals for expectant and nursing mothers who were found to be insufficiently nourished themselves.8Robertson, Report of the Medical Officer of Health for the Year 1914, 17, 20 But health visiting remained paramount, as Robertson argued in 1914, because “the careless and ignorant mother may neglect much or all the advice given” or “stay away from classes of all kinds” and is thus “alone reached by the Health Visitor” who came to her instead.9Robertson, Report of the Medical Officer of Health for the Year 1914, 17.

The wartime growth in maternity and infant welfare services in Birmingham resulted in measurable success. From 1914 to 1918, the average infant mortality in Birmingham dropped from 122 to 99 per 1,000 live births. The year 1918 marked the first time in the city’s records that the infant mortality rate fell below 100, although it remained considerably higher in the poorest central districts of St. Paul’s (156) and St. Mary’s (148).10Robertson, Report of the Medical Officer of Health for the Year 1918, 60–61.

The School Medical Service was also minimally impacted by the outbreak of the war. Several members of the Birmingham School Medical Service (a School Medical Officer, a dental surgeon, two school nurses, and a clerk) volunteered for military service in 1914, though all were replaced to ensure their work continued.11Graham, Annual Report to the City of Birmingham Education Committee of the Temporary School Medical Officer for the Year Ended 31st December 1914, 5. Schools continued to provide spectacles and other forms of eye care, dental treatments, treatments for ringworm, and treatments for other minor ailments of the eyes, ears, and skin that were “frequently the forerunners of other and more serious defects.”12Graham, Annual Report to the City of Birmingham Education Committee of the Temporary School Medical Officer for the Year Ended 31st December 1914, 8, 14. Temporary School Medical Officer Lewis Graham believed that the work of the School Medical Service remained “adequate and effective,” despite the disruptions of the war.13Graham, Annual Report to the City of Birmingham Education Committee of the Temporary School Medical Officer for the Year Ended 31st December 1914, 6. By 1916, Graham embraced the patriotic spirit of the war in his annual report, in which he proclaimed that “no instrument exists in the City which does so much towards securing for the State a strong and healthy generation” as the School Medical Service.14Graham, Annual Report to the City of Birmingham Education Committee of the Temporary School Medical Officer for the Year Ended 31st December 1915, 1.

Public health efforts during the war were similar in Liverpool and Manchester. The Liverpool Public Health Department lost a considerable number of staff to military service in 1914 and had to recruit temporary staff to replace them. Female doctors took up much of the responsibility for public health work in schools, for example.15Hope, Report of the Health of the City of Liverpool during 1914, xiii. Public hospital beds normally reserved for children were reallocated for military use.16Hope, Report of the Health of the City of Liverpool during 1914, 60. Yet, despite these disruptions, infant mortality rates continued to decline. In Liverpool, infant mortality dropped from 139 per 1,000 live births in 1914 to 115 in 1917, rising slightly to 124 in 1918, before dropping to the lowest recorded infant mortality rate to date in 1919, at 110 per 1,000 live births.17Hope, Report of the Health of the City of Liverpool during 1914, xv; Hope, Report of the Health of the City of Liverpool during 1918, 40; Hope, Report of the Health of the City of Liverpool during 1919, 2. Medical Officer of Health E.W. Hope attributed this to the important work being done by the municipal Health Committee and voluntary agencies, which both continued to provide education on ante-natal hygiene and infant welfare throughout the duration of the war.

The expansion of the city’s female sanitary staff played a particularly important role, as their educational work served to “uplift” both the parents and children with whom they worked. In 1914, health visitors made 18,070 visits to births in the poorest parts of the city, during which they continued to offer advice on home hygiene and infant health, provided mothers with good-quality milk, and directed mothers to voluntary agencies for further consultations.18Hope, Report of the Health of the City of Liverpool during 1914, 59–60. Due to the disruptions of the war, the number of births visited declined to as low as 13,674 in 1918 (88 percent of births in Liverpool that year).19Hope, Report of the Health of the City of Liverpool during 1918, 42. However, female sanitary staff also continued to work in close partnership with the School Medical Officers conducting school medical examinations, and followed up with home visits for children who suffered from skin and eye afflictions, poor hygiene, or indicators of neglect, throughout the war years.20Hope, Report of the Health of the City of Liverpool during 1914, 64.

In Manchester, James Niven lamented the loss of some of his staff to the war effort in 1914. Yet, like his colleagues in Birmingham and Liverpool, Niven praised his remaining staff for taking on additional duties necessary to support the war effort. In 1914, Niven expressed cautious optimism about the prospect of a new Maternity and Infant Welfare scheme and praised the “considerable activity” of the health visitors.21Niven, Report of the Health of the City of Manchester, 1914, iii–iv, vi. Continuing their important pre-war work, Niven’s staff of health visitors also expanded during the war. The number of health visitors employed in Manchester doubled from eighteen in 1914 to thirty-six in 1916, by which time each health visitor conducted an average of 306 visits to new births per year and as many as nineteen welfare visits per day during their busiest summer months.22“Infantile Mortality Report for the Year Ending December 31st, 1916,” 6, 19, 21. As a result, the city proudly reported a reduction of infant mortality in Manchester over the last fifteen years, down from 198 per 1,000 births in 1901 to a record low of 111 per 1,000 births in 1916, resulted from “a long process of preparation and the mustering of many forces.”23“Infantile Mortality Report for the Year Ending December 31st, 1916,” 1.

Health visitors’ efforts to protect the health of the children in Manchester continued through the end of the war. In 1918, the city of Manchester employed a staff of forty-two health visitors, including thirty-seven who were certified nurses. These women conducted visits and revisits and continued monitoring of children at least until the age of three (though the goal was to extend health visits to the age of five) as much as possible. Health visitors referred mothers in need of further education or milk supplies to Child Welfare Centres and occasionally accompanied mothers to the Centre personally. Beginning in March 1918, health visitors also began to visit the homes of school children who had been treated at the Oldham Road Cleansing Station for scabies, conducting sanitary inspections of cases reported by the education authorities and thus tightening the connection between the sanitary and education authorities.24Niven, Report of the Health of the City of Manchester, 1918, 61–63. In part as a result of the hard work during the war, Niven proudly reported in 1919 that Manchester’s infant mortality rate had finally dropped below 100 per 1,000 live births for the first time, to a new low of 97.76 per 1,000 births.25Niven, Report of the Health of the City of Manchester, 1919, 6, 11.

What we should take from these brief wartime histories is generally a story of continuity. Despite staff shortages caused by the war, the Medical Officers of Health, and especially their health visitors, continued their important work to protect children’s health throughout the war years. The fact that all three cities not only sustained health visits to births during these years but also expanded their staff of health visitors highlights the importance public health officials placed on the vital role of health visiting in municipal public health. I find it notable that as the number of health visitors employed in each city rose, infant mortality rates declined. While it would be hyperbolic to suggest there is an isolated correlation, I suggest that health visitors clearly played an important role in the efforts to reduce infant mortality rates – both locally and nationwide. Additionally, and perhaps more importantly, we should also acknowledge that infant mortality rates reached record lows in each city by 1919, marking the end of First World War as an important inflection point in the campaign to curb infant mortality more broadly.