Conclusion

During the First World War, Fabian Society members Beatrice and Sidney Webb hoped that the wartime expansion of the British state would create a more egalitarian society, in which the state would at last be able to offer more interventions into the lives of the poor. At least with regards to children’s health, this was true. In 1919 Parliament passed the Ministry of Health Act, which consolidated the Local Government Board and the National Insurance Commission and brought the medical and public health functions of national government together into a single body – a newly formed Ministry of Health. The Ministry emerged from a series of political concessions and a growing distrust within the Liberal Party in the capability of the Local Government Board to enact meaningful social reforms.1Bellamy, Administering Central–Local Relations, 252. The Society of Medical Officers of Health generally supported the Ministry of Health Bill while it was under consideration in Parliament in 1918, but expressed concern about delegation of oversight over the medical inspection and treatment of school children to the Board of Education. The Society insisted that the “Minister of Health must from the outset assume control of all the health functions of existing central departments” and that the Ministry must “protect, maintain, and improve the health of the Nation . . . regardless of age, sex, or occupation.”2“Ministries of Health Bill, 1918: Memorandum by Society of Medical Officers of Health,” 51. To leave school-age children outside this work was seen as a mistake.

According to historian Christine Bellamy, the new Ministry was given a mandate to develop “a coherent welfare system, based on the local authorities” and “a national health service.”3Bellamy, Administering Central–Local Relations, 255–56. The establishment of this Ministry, which became the administrator of the National Health Service (NHS) after the Second World War, at last clearly defined a centralized role for the British state in public health. The formation of the Ministry of Health was a commitment to provide for the basic welfare of Britons and their health. Christopher Addison, a former medical school professor at the University of Sheffield and Charing Cross Hospital in London, and Lloyd George’s ally in establishing a National Insurance scheme in 1911, was appointed the first Minister of Health.4Fox, Health Policies, Health Politics, 22, 28. Under Addison’s direction, the newly formed Ministry restructured the administration of public health, dividing it between medical officers and bureaucratic administrators, and, in doing so, greatly expanded the trained medical staff within the government, as compared to their relatively small representation within the bureaucratic Local Government Board.

Still, the passage of the Maternity and Child Welfare Act in 1918 and the establishment of the Ministry of Health the following year greatly expanded local public health campaigns by nationalizing the administration of public health focused on children’s wellbeing. The Ministry of Health had created a distinct department specifically to oversee maternal and infant welfare programs. Additionally, in 1919 the Ministry of Health established a two-year training program for health visitors without previous experience and a one-year course for trained nurses, women with experience in health visiting, or those with a university degree to improve the quality of their important work. This training became compulsory after 1928.7F.A. Sharpe, “Training the Health Visitor,” 390; Reid, “Health Visitors and Child Health,” 119. While the Ministry of Health did not directly oversee the School Medical Service, it worked closely with the Board of Education to provide medical care and physical education as part of the school curriculum.8Welshman, “Child Health, National Fitness, and Physical Education in Britain, 1900–1940,” 66–67.

George Newman was appointed as the Chief Medical Officer to the new Ministry of Health, where he emphatically professed that preventative medicine could make “life better, larger, more capable and useful.”9Newman, The Place of Public Opinion in Preventative Medicine, 5. Newman continued to believe that a physically healthy and fit population was a “principal asset of the nation” and that the “the first line of defence [against unfitness] is a healthy, well-nourished and resistant human body,” and so he maintained that it was an “essential” task of the newly formed Ministry of Health to continue to educate Britons about the “principles and practice of hygiene.”10Newman, An Outline of the Practice of Preventive Medicine, 9–10; Zweiniger-Bargielowoska, Managing the Body, 156. Under Newman’s leadership, the newly formed Ministry of Health made the promotion of “national efficiency” a core policy objective.

Newman also maintained his position as Chief Medical Officer of the Board of Education. Thus, while the School Medical Service remained under the auspices of the Board of Education rather than the new Ministry of Health, the close coordination between the two systems of public health remained separate but complementary until 1922, when the power to oversee medical inspections and treatments of schoolchildren was finally transferred to the Ministry of Health.11“School Medical Service and the Ministry of Health,” 99. The rationale was simple: although school officials had made great strides in promoting children’s health, “the fact remains that they are appointed for the administration of education and not for the promotion of health.”12“School Medical Service and the Ministry of Health,” 100. Contemporaries believed that this often resulted in inefficiencies and redundant committees, especially with regards to the supervision of infectious diseases. Furthermore, having two parallel organizations administering similar systems of public health resulted in excess costs stemming from the frequent “duplication of domiciliary and school visitations” by some combination of the Medical Officer of Health, the School Medical Officer, the health visitor, the school nurse, and the School Attendance Officer.13“School Medical Service and the Ministry of Health,” 100.

The birth of the Ministry of Health marks our final important inflection point in the history of children’s health, for at last the British state had established a strong national interest in protecting the health of the children, exemplified by the passage of the 1918 Infant and Maternal Welfare Act, which the new Ministry managed. However, new challenges soon emerged as financial rollbacks during the interwar years once again rocked the boat. Bellamy argues that after Addison was replaced as the Minister of Health in April 1921, the Ministry of Health became increasingly “bureaucratic” and politically vulnerable to competing national interests and legalistic debates within Whitehall, rather than remaining wedded to its original goal to promote the health of the public. This became even more problematic after Newman resigned his position as Chief Medical Officer in 1935.14Bellamy, Administering Central–Local Relations, 258. In addition, after the Conservatives reclaimed a majority in Parliament in 1922 they sought to restore the “normalcy of 1914” by cutting excess government spending.15Zweiniger-Bargielowoska, Managing the Body, 156; Rodney Lowe, “The Erosion of State Intervention in Britain,” 270. A Committee on National Expenditure chaired by Sir Eric Geddes, who had served as First Lord of the Admiralty during the Great War and Minister of Transportation in Lloyd George’s administration, sought to find ways to reduce “wasteful spending.” One of the Committee’s recommendations was to decrease state funding for social programs under the so-called “Geddes Axe.”16McDonald, “The Geddes Committee and the Formation of Public Expenditure Policy,” 643–74. This included expenditures both on public health and by the Board of Education.

In turn, the financial burden of administering the maternal and child welfare services mandated by the 1918 Maternity and Child Welfare Act was partially returned to municipal and local authorities.17The degree of variance has been studied qualitatively in Levene, Powell, and Stewart, “Patterns of Municipal Health Expenditure in Interwar England and Wales,” 635–69 and quantitatively in Levene, Powell, and Stewart, “Investment Choices,” 434–58. However, the Ministry of Health was still able to direct public health functions using the promise of national block grants to local authorities as both the carrot and the stick.18Levene, Powell, and Stewart, “Patterns of Municipal Health Expenditure in Interwar England and Wales,” 642–45. Still, contemporaries feared that “the use of the permissive powers is actively discouraged . . . for financial reasons.”19Manchester and Salford Council on Social Service, Report to the Standing Committee on Children, 4. This was particularly alarming to the members of the Manchester Council on Social Services, who feared that without greater national investment it was doubtful that the “object of all Health Work . . . to reduce the C3 position in the nation” would be successful.20Manchester and Salford Council on Social Service, Report to the Standing Committee on Children, 15. This decentralization continued until after the Second World War, when the Labour Party won a majority in Parliament in 1945 and “introduced a comprehensive system of social welfare . . . from cradle-to-grave” that included health care, unemployment insurance, and a range of other welfare programs such as the provisioning of foodstuffs that historian Nadja Durbach contends reconfigured “the relationship between citizen and the state.”21Durbach, Many Mouths, 10. The establishment of the NHS in 1948 returned the primary responsibility for the administration of public health to the central state once again and codified this new responsibility to promote welfare for its citizens.

Of course, greater financial and administrative support alone could not restore the nation to peak levels of health. This task also required active individual participation and personal action.22Zweiniger-Bargielowoska, Managing the Body, 155. As we have seen through the reports of the Medical Officers of Health, ignorance remained a significant cause of preventative sickness or disablement, but one that Newman believed could easily be prevented with sufficient “instruction in the principles and practices of hygiene.”23Newman, An Outline of the Practice of Preventive Medicine, 88. Expanded systems of public health created more opportunities to offer social reforms through education to parents for the sake of their children. Health visiting continued to serve as a major pillar of the continued campaign against infant mortality well into twentieth century. According to a 1923 survey of forty-four Great Towns, twenty-five of their Medical Officers of Health attributed the decline in infant mortality to “health visiting and child welfare” first and foremost; twenty-three of forty counties surveyed concurred.24Wheatley, “Discussion on Factors Contributing to the Recent Decrease in Infantile Mortality,” 755. George Newman agreed.25Newman, The Building of a Nation’s Health, 312. Health visits became so normative by the mid-twentieth century that nearly every mother received a visit at home within a few weeks of giving birth. These visits continued until the child reached school age. Today, health visits continue to play a regular role in British infant care under the National Health Service (NHS), assisting families ensure their children have a healthy start with regard to both physical and mental health.26“What Is a Health Visitor?”

The School Medical Service also continued to grow during the interwar years, though its operations, especially regarding feeding English children a nutritious diet, were somewhat stymied by the global depression in the late 1920s and early 1930s.27Durbach, Many Mouths, 152. Expenditures on meals in the interwar years first peaked in 1926−27 and then slowly rose annually until 1938–39, when the cost of the provision of meals peaked once again, at £942,803.28Harris, The Health of the Schoolchild, 93. Meanwhile, the number of children who underwent medical inspections in schools steadily rose from 1923 (4,001,354 total inspections) to 1938 (5,423,082 total inspections) as roughly a third of all children in elementary schools were inspected in any given year and as specialized or re-inspections became more common.29Harris, The Health of the Schoolchild, 104–5.

Thus, in evaluating the history of public health efforts in the early interwar years, historians have been conflicted. Some such as Martin Gorsky see the integration and expansion of the powers of the Medical Officers of Health during the interwar years as a “golden age” of public health, while others, like Jane Lewis, have taken a more cynical view of public health during the interwar period.30Gorsky, “Public Health in Interwar England and Wales,” 175–98. Lewis argues that public health in the early interwar years lacked “a firm philosophy to guide it in approaching health problems” and narrowed in its focus. She suggests that the Medical Officers of Health lost sight of their original duties as watchdogs for community health as their duties expanded to maintaining hygienic and sanitary environments, notification of infectious disease, observing the quality of food and water, and overseeing clinics for mothers and their children.31Lewis, What Price Community Medicine, 1, 3. Gorsky argues that these critiques are overstated.32Gorsky, “Local Government Health Services in Interwar England,” 389.

Like Gorsky, I am skeptical of a view of the interwar history of public health as a period of complete decline. The Ministry of Health faced extraordinary challenges brought on, in part, by the Great War, even as the state took on a greater role in promoting national health and fitness. With the outbreak of the global influenza pandemic of 1918–20, the treatment of a large population of maimed and wounded survivors of the war, and the emergence of concerns about chronic health conditions, British public health did become increasingly reactive rather than proactive in its practices and procedures during the early interwar years.33It should be noted that James Niven in Manchester was exceptional in these continued times of crisis. During the deadly 1918–19 global influenza pandemic, while many public health officials despaired that little could be done to slow the spread of the pandemic, Niven actively promoted public health measures to slow its spread. See my article, Harris, “H1N1 in the ‘A1 Empire,’” 614–15; also Hardy, The Epidemic Streets, 255. BBC Four dramatized Niven’s public health work during the 1918 influenza pandemic in Spanish Flu: The Forgotten Fallen, directed by Justin Hardy, which aired on August 5, 2009, in which Bill Paterson played James Niven. After his retirement in 1922, Niven also recalled the important work that the health visitors did during the influenza pandemic, and how they “distinguished themselves greatly by the manner they volunteered to nurse the sick, and to care for the families overwhelmed by influenza” in Niven, Observations on the History of Public Health Effort in Manchester, 88. However, the important mission to reduce infant mortality and improve children’s health continued apace. Looking back to Figures 0.2 and 0.3, we can see that both nationally and in our three-case study cities between 1919 and 1939 infant mortality rates continued to fall. Infant mortality rates fell from 84 per 1,000 live births in 1919 to 64 per 1,000 in Birmingham in 1939, and from 110 to 71 in Liverpool and from 98 to 61 in Manchester. The national infant mortality rate continued to decline as well, from 76 per 1,000 live births to 51 per 1,000 between 1920 and 1939.34Zweiniger-Bargielowoska, Managing the Body, 154. As I have used infant mortality a key metric to study the history of children’s health, this continued improvement, I argue, is an important indicator that children’s health continued to improve throughout the interwar years.

While it would “be wrong to conclude,” as Lara Marks reminds us, that the “sole explanation for the fall in infant mortality during this period” can be attributed to education and advice by health visitors or the work of the School Medical Service, this improvement in infant mortality was undoubtedly in part the result of an expansion, restructuring, and systemization of British public health.35Marks, Metropolitan Maternity, 187. With the greater state investment of both human resources and financial support in supplementing long-standing sanitary reforms with more targeted individualized approaches, the full potential of public health was brought to bear. The results, as seen in the dramatic decline in infantile mortality – a lagging feature of the demographic transition – were clear.