The Health of the Nation: Lessons from the First World War
While municipal public health programs creatively continued their work throughout the war years, at the national level the Great War reinforced the same concerns about national health and fitness that had previously emerged in the aftermath of the Second Anglo-Boer War. George Newman once again provides us with a useful starting point. Reflecting in 1919 on the start of the war, Newman described how the “exigencies of the European War brought, voluntarily or compulsorily, the majority of the young men of the country to the recruiting station,” where they were “subjected to medical examinations of various kinds and degrees.”
1Newman, An Outline of the Practice of Preventive Medicine, 31. Similarly to what had occurred in 1899–1902, these medical examinations revealed a high degree of medical unfitness nationwide in 1914–18. This discovery would drive greater national attention to public health, including a concerted effort to continue to improve the lives and living conditions of English children. Before we think about the reforms that emerged in the wake of the First World War, though, let us first consider the data itself that gave cause for further public health reforms.
In August 1914, when the Great War broke out in Europe, the British maintained a highly trained, but small, professional military, as compared to the other Great Powers.
2Gilbert, The First World War, 37. They understood that the size of the British Expeditionary Force was not enough to fight a European war. So, the War Office appointed Field-Marshal Horatio Kitchener to oversee a massive recruitment campaign for volunteers for military service. Kitchener was well suited to the task. Within a day of taking up the position on August 6, 1914, he produced a call to arms, which encouraged men of ages nineteen to thirty to enlist for three years of service or for the course of the war effort.
3Simkins, Kitchener’s Army, 39. The recruitment campaign was a remarkable success. Between August 4 and 8, 1914, 8,193 men enlisted. The following week another 43,254 men volunteered.
4Simkins, Kitchener’s Army, 49, 54. In schools, boys were taught to do their duty, to meet the demands of any situation, and so they volunteered out of a sense of patriotism and duty to the nation.
5Mosse, The Image of Man, 108–10; Joll and Martel, The Origins of the First World War, 284–85.For our purposes, the quantity of recruits matters far less than the
quality of their capacity for military service. As Newman reflected in 1919, these
young men created an “index of the health of the people and the efficacy of their upbringing in infancy, childhood, and adolescence.”
6Newman, An Outline of the Practice of Preventive Medicine, 31. The youngest recruits, especially by the war’s end in 1918, were the children who were the first generation subject to regular, professional health visits in their infancy, and who received purposeful physical education during their primary schooling. They had grown up training in drill and military discipline as a part of their school physical education curriculum. So, their fitness for military service became an important test of the effectiveness of recent public health reforms.
Regrettably, quantitative data from the early years of the war is imprecise at best. Military medical examiners were equipped to examine 50,000 recruits
annually. In August 1914 alone, 168,249 men volunteered for military service and had to undergo medical examination.
7Silbey, “Bodies and Cultures Collide,” 66. Medical officers inspected up to two hundred potential recruits per day, although they were paid only for those whom they passed through the inspection – a problematic practice that continued until 1915 that encouraged doctors to overlook defects whenever possible.
8Winter, “Military Fitness and Civilian Health in Britain during the First World War,” 215. Beginning in December 1915, potential recruits were examined by a board of doctors rather than a single one, but the records are still limited.
9Galloway, “Medical Examination of Men for Military Service,” 666. Potential soldiers’ fitness was graded on a scale of A, B, or C: A meant they were fully fit and healthy for military service, B allowed them to serve in the field in a support capacity, and C-grade recruits could serve only at home.
10Winter, The Great War and the British People, 50. Still, the data remained ambiguous, and corruption was quite common.
Several months after the British enacted conscription in January 1916, the War Office established a new Medical Board to evaluate the physical condition of conscripts, beginning in August 1916. In November 1916, Sir James Galloway, a senior physician at Charing Cross Hospital, was brought home from military service in France to serve as the Inspector of Recruiting Medical Boards. Corruption remained a serious problem, so much so that by July 1917 a parliamentary committee was formed to reevaluate the entire process of medical inspections for military service. As a result of this parliamentary investigation, yet another system of inspections developed, which shifted the responsibility for medical examinations from the War Office to the newly formed Ministry of National Service, under the directorship of
Sir Auckland Geddes.
11Winter, The Great War and the British People, 50–53. Local medical examiners working for the Ministry of National Service Medical Board were paid a flat rate for their work, and potential soldiers were categorized into one of four grades of fitness:
Grade I – Those who attain the full normal standard of health and strength and are capable of enduring physical exertion suitable to their age. Such men must not suffer from progressive organic disease, nor have any serious disability or deformity. Minor defects which can be remedied or adequately compensated by artificial means will not be regarded as disqualifications.
Grade II – Those who for various causes, such as being subject to partial disabilities, do not reach the standard of Grade I. They must not suffer from progressive organic disease. They must have fair hearing and vision; be of moderate muscular development, and be able to undergo a considerable degree of physical exertion of a nature not involving severe strain.
Grade III – Those who present marked physical disabilities or such evidence of past disease that they are not considered fit to undergo the degree of physical exertion required for higher Grades. Examples of men suitable for this Grade are those with badly deformed toes, severe flat foot and some cases of hernia and of varicose veins . . . The third Grade will also include those who are fit only for clerical and other sedentary occupations, such as tailoring and bootmaking.
Grade IV – All those who are totally and permanently unfit for any form of Military Service.
12Ministry of National Service, Report on the Physical Examination of Men of Military Age, 2.The recruitment data that was collected during the last years of the First World War is much more comprehensive, accurate, and thus historically useful. Data collected by the Ministry of National Service was eventually compiled into a
Report on the Physical Examination of Men of Military Age by National Service Boards from November 1st, 1917–October 31st, 1918, written by a committee consisting of Sir James Galloway (chair), Professor Arthur Keith, Charles Ryall, T.H.C. Stevenson, Sir Walter M. Fletcher, Sir Duncan Rhind, Professor J.G. Adami, and Dr. H.W. Kaye. The
Report on the Physical Examination of Men of Military Age was a spiritual successor to the 1904
Report of the Inter-departmental Committee on Physical Deterioration. It professed to offer the largest “physical census” of British men of military age to date, an analysis of the “nature and distribution of physical disabilities,” as
well as some suggestions for “preventing what is preventable” and “ameliorating or palliating what is unavoidable.”
13Ministry of National Service, Report on the Physical Examination of Men of Military Age, 2. Aware that the data could be seen as biased in that it was a survey of a population “exhausted by three years of war” and thereby leaving only the “dregs” of society for military recruitment, the Report on the Physical Examination of Men of Military Age convincingly justifies the utility of its data on two grounds: first, it rejected the assumption that the patriotic first wave of volunteers were necessarily more “fit” or “unfit” than the rest of the population, and that the erratic medical assessments earlier in the war made it impossible to evaluate this. Second, men in “protected” domestic industries (e.g., agriculture or mining) were no longer protected from conscription by the end of the war. Thus, by the end of the war recruits came from a broader swath of society and provided a pool of recruits that better reflected the aggregate of the population than in the earlier years of the war (Ministry of National Service, Report on the Physical Examination of Men of Military Age, 5). I accept these justifications as satisfactory enough to find the data and the recommendations of the Report to be historically useful. Much like the 1904
Report of the Inter-departmental Committee on Physical Deterioration, the
Report on the Physical Examination of Men of Military Age highlighted (and quantified) national fitness as a matter of public health concern. To analyze the data, former president of the Royal Anthropological Institute Sir Arthur Keith calculated an “index of fitness,” a quantitative model for measuring a healthy population. Keith proposed that in a healthy population 89.3 percent of the population would fall into Grades I or II, and that “efficient fitness” existed in a population with an average of 70 percent or higher Grade I fitness.
14Ministry of National Service, Report on the Physical Examination of Men of Military Age, 7. For more on Arthur Keith and the war, see my article, Harris, “The ‘Tribal Spirit’ in Modern Britain,” 273–94. The data collected by the Ministry of National Service found that the British population of military age fell far below this mark. Among the 2,425,184 examinations of men aged eighteen to forty-two conducted during the last years of the war, only 36 percent were designated Grade I, 22.5 percent were placed in Grade II, 31.2 percent in Grade III, and 10.3 percent fell into Grade IV.
15Ministry of National Service, Report on the Physical Examination of Men of Military Age, 3. The degree to which these figures diverged from Keith’s standard is shown in Table 6.1.
Table 6.1. Grading of Fitness of Military British Recruits for the First World War, 1917–18. |
| Grade I | Grade II | Grade III | Grade IV |
Actual number of recruits in each grade | 871,769 | 546,276 | 756,859 | 250,280 |
Keith’s model | 1,697,595 | 485,040 | 181,902 | 60,647 |
Difference from “standard” | -825,826 | +65,236 | +574,957 | +189,633 |
Source: Ministry of National Service, Report on the Physical Examination of Men of Military Age, 12. |
Practically, for military medical examiners this meant that for:
every nine men of military age in Great Britain, on the average three were perfectly fit and healthy; two were upon a definitely infirm plane of health and strength, whether from some disability or some failure in development; three were incapable of undergoing more than a very moderate degree of physical exertion and could almost (in view of their age) be described with justice as physical wrecks; and the remaining man was a chronic invalid with a precarious hold upon life.
16Ministry of National Service, Report on the Physical Examination of Men of Military Age, 4.Somewhat morbidly, demographic historian Jay M. Winter argues that this low grading of fitness of many recruits, which both he and I partly attribute to the ecological dangers of urban life, “probably saved the lives of many industrial workers who simply could not reach the minimum physical standard for military service.”
17Winter, The Great War and the British People, 49.Of course, we must acknowledge an important caveat when making use of the data presented in the Report on the Physical Examination of Men of Military Age. As this data was collected late in the war, well into the mass mortality of trench warfare and after the devastating losses at the Battle of the Somme forced the British army to a shift its recruitment strategy from volunteerism to conscription, and because many of the nation’s “fittest” likely rushed to enlist in 1914, this data likely reflects a skewed and artificially heighted degree of national unfitness. This was a very different context from 1899, when the British Expeditionary Force relied solely on volunteers to fight in South Africa. However, the data presented in the Report on the Physical Examination of Men of Military Age would still influence public health policy in the aftermath of the Great War.
Among the 2,425,184 men examined, 261,137 (10.7 percent) were born since the year 1900 and were specifically the subject of the expanding systems of public health targeted at improving the healthy development of English children. Among these 261,137 young men, the
Report on the Physical Examination of Men of Military Age classified 169,834 (65 percent) in Grade I; 78,650 (30 percent) were reported in the combined Grades II and III; and 12,653 (4.9 percent) in Grade IV.
18Ministry of National Service, Report on the Physical Examination of Men of Military Age, 22. Although younger boys were slightly better off than the national average, they were still well below Keith’s standard, which Ernest Watt, the Medical Inspector for the Scottish Board of Health, provocatively argued “throws a lurid light upon the effects of our civilisation upon the adolescent population.”
19Watt, “Some Reasons for the Physical Unfitness of Our Manhood,” 263. Meanwhile, Newman attributed this high degree of “physical disability” to either “some form of organic or structural disease” that often occurred in childhood.
20Newman, An Outline of the Practice of Preventive Medicine, 31.Regional reports, including those from Liverpool and Manchester, included in
Report on the Physical Examination of Men of Military Age,
often attributed the rejection of the youth (those aged eighteen, nineteen, and twenty) to “poor physique.” “Poor physique,” the
Report suggested, often resulted from either a childhood case of tuberculosis or, in the case of Manchester, “gross ignorance of the simplest forms of domestic economy and cookery amongst the mothers.”
21Ministry of National Service, Report on the Physical Examination of Men of Military Age, 43. This often resulted in diseases like rickets, which results from a dietary deficiency during early childhood development – specifically a lack of vitamin D – and weakens bones, leading to their deformity during development. But, the
Report found, with “proper action” conditions like rickets were “entirely preventable,” which could do much to “improve the National Health and save national money.”
22Ministry of National Service, Report on the Physical Examination of Men of Military Age, 44.In the end, the
Report on the Physical Examination of Men of Military Age and its authors condemned “the half-hearted complacency with which in the past we have treated our most important national asset, the health of the nation.”
23Ministry of National Service, Report on the Physical Examination of Men of Military Age, 6. While it, like the 1904
Report of the Inter-departmental Committee, rejected the language of “degeneration” on a national scale,
the
Report on the Physical Examination of Men of Military Age concluded that
“there is, however, ample evidence to show the baneful effect of modern conditions of life upon the physique of youths and men of military age, which cannot fail to effect some degree of deterioration of the stock and militate against the health of succeeding generations.”
24Ministry of National Service, Report on the Physical Examination of Men of Military Age, 22. Thus the
Report on the Physical Examination of Men of Military Age reiterated the call to arms raised it in its predecessor
Report of the Inter-departmental Committee that further reforms were necessary to improve the health of the children of the nation. Many of the Grade III (or “C3” in the more commonly used parlance) adults who were barely fit for the most basic military service, grew up as “Class D” children: “those who, though able to stand school life, are constitutionally unable to stand the far greater strain of adult working life.”
25Manchester and Salford Council on Social Service, Report to the Standing Committee on Children, 14. Unlike the rankings of soldiers, in which grade I were the most fit and IV were the least fit, the degree of poor health ascended alphabetically. Class A children were the worst off, those who died in infancy, and class D were the most capable, but still unhealthy, grade of British children under this schema. The military rejects (grade IV recruits) were likely class B (those who survived infancy but “become physical wreckage”) or C (children with “constitutions unable to stand the strain of school life, where they in turn break down”).On the ground, and in the proverbial trenches of large English cities, the Medical Officers of Health and the School Medical Officers had been charting a path for public health reforms, with great success, before 1918. Unfortunately, as T.E. Knowles Stansfield, president of the Kent branch of the British Medical Association, lamented, it “required a great war” to bring the dangerous reality of national unfitness into “general knowledge.”
26Stansfield, “An Address on Some of the Causes of Our C3 Population,” 1020. Prime Minister David Lloyd George, in a speech in Manchester in September 1918, famously lamented that “I asked the Minister of National Service how many more men we could have put into the fighting ranks if the health of the country had been properly looked after. I was staggered by the reply. It was a considered reply, and it was ‘at least one million.’”
27“The War and After: Mr. Lloyd George’s Review,” 8. But with this “general knowledge” in hand, Parliament would at last take decisive action for the sake of the children in 1918.