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The differential infant death-rate
78 n a m e for t o - d a y ' s activities of t h e P u b l i c H e a l t h Service, t h e c o n d i t i o n s of t h e p a t i e n t ' s h o m e a n d of t h e p a t i e n t ' s work place m u s t surely be a c c e p t e d as b e i n g of f u n d a m e n t a l i m p o r t ance to his health. (" T h e h e a l t h of t h e p e o p l e d e p e n d s p r i m a r i l y u p o n t h e social a n d e n v i r o n m e n t a l conditions in w h i c h t h e y live a n d w o r k . " ) I f t h e family d o c t o r is to be r e - c r e a t e d a n d A s s u m p t i o n B is to be i m p l e m e n t e d , i n c o r p o r a t i n g t h e s e activities w i t h t h e w o r k of t h e m e d i c a l p r a c t i t i o n e r is p r o b a b l y of m o r e i m p o r t a n c e t h a n t h e p o i n t as to w h e t h e r t h e a d m i n i s t r a t i v e u n i t of t h e h o s p i t a l services s h o u l d p l a n t h e advisory clinic services. T h e n again, t h e r e is n o t h i n g to s u g g e s t any c h a n g e in c o n d i t i o n s of w o r k or outlook w h i c h will lead to t h e state in w h i c h " t h e d o c t o r m u s t try, in short, to b e c o m e t h e general adviser in all m a t t e r s c o n c e r n e d w i t h h e a l t h (no less t h a n w i t h disease) on w h i c h a d o c t o r is so well qualified to a d v i s e . " T h e s e are a few m i n o r criticisms of a s c h e m e w h i c h if p u t i n t o effect affords t h e first step t o w a r d s a unified h e a h h o r g a n isation, a step w h i c h , because of c o m p r o m i s e , n e e d arouse n o t so m u c h a n t a g o n i s m as to kill it, and, f o l l o w i n g t h e d o c t r i n e of t h e inevitability of gradualness, offers h o p e of progress b y e v o l u t i o n , n o t r e v o l u t i o n . Based o n t h e p r e m i s e t h a t a c o m p r e h e n s i v e h e a l t h service m u s t necessarily b e a d m i n i s t e r e d b y one h e a l t h a u t h o r i t y , t h e s c h e m e c o m p r o m i s e s b y m a k i n g u s e of t h e locally elected councils of c o u n t i e s a n d c o u m y b o r o u g h s , eitEer alone or in c o m b i n a t i o n , leaving little b u t d e l e g a t e d powers for the m i n o r authorities, a n d those p r o b a b l y only f o r a time. T h e Central Council for Health Education intends holding two Summer Schools during 1944, one fit Whitelands College, Bade College, Durham, from July 24th to August 3rd, and the other at Chelsea Polytechnic, London, from August 9th to 19th. T h e programme will cover all aspects of health education (including sex education) and should be of value to teachers, youth leaders. educational and medical administrators, nurses and health visitors, social and industrial welfare workers, etc. T h e mornings will be devoted to lectures which will lay the necessary foundation of basic knowledge, while the evening lectures will relate this knowledge to a wider philosophical, historical, and social context. In the afternoons there will be demonstrations and discussions arranged by the various organisations specialising in different fields of health education, and seminars for students with particular interests. Many applicants had to be rejected from the 1943 School owing to lack of accommodation. Those wishing to receive early notification of the forthcoming schools should send their name and address on a postcard to Mr. Cyril Bibby, Central Council for Health Education, Tavistock House, Tavistock Square, London, W.C.1. T h e model African township being built near Nalrobi, Kenya, embodies many of the latest ideas in town planning. T h e scheme is the first to be started since Kenya was given a grant of £500,000 for African housing. T h e new houses are to be built in a triangle round a village green, from which the radiating streets will give glimpses of some of Kenya's famou; vistas. T h e green will be a focal centre for the township with a social centre, a post office, a welfare clinic, a shopping centre, and a public garden. T h e houses themselves will be lald out on grass plots. T h e r e are twenty different designs for the house units, but all kitchens will be built on the same plan with a raised fireplace to obviate stooping while cooking. Local woods and stone will be used to a large extent in the building of the houses. Vehicular traffic will be kept away from the houses, and children's playgrounds will be provided for in such a way that there is no danger from traffic. At one corner of the triangle there will be playing fields, and soil from the buildin~ foundations will be used to form terraces for spectators. In Tanganyika Territory a sum of £2,250 has been voted for a small experimental African housing scheme. T h e she will be near D a r e s Salaam and will incorporate a communal Eating House. The Unfit Made Fit is the title of .~n attractive and wellillustrated booklet tmblished for the British Council by Sir Isaac Pitman & Sons, Ltd., at a price of Is. net. T h e author of the text is Dr. Harold Balme, who describes simply and graphically the work of rehabilitation centres. Brief case-histories abe given. Photographs show the exercises and occupational therapy used in various stages of recovery from knee injuries, fractured spine. injurie.s to the limbs and extremities, etc. This booklet, in the series, " Britain Advances," will be followed later by a book on mothercraft and one on factory welfare. If these are up to the standard of The Unfit Made Fit, they should be well worth the price of a shilling.
P U B L I C H E A L T H , April, 1944
THE DIFFERENTIAL
INFANT DEATH-RATE*
By RICHARD M . TITMUSS I s u p p o s e t h a t m e d i c a l officers of h e a l t h are m o r e c o n c e r n e d w i t h the statistical aspects of b i r t h a n d d e a t h t h a n m o s t o t h e r m e m b e r s of tb.eir profession. So, as a layman, I a m a little diffident a b o u t s p e a k i n g dogmatically o n t h e p r o b l e m of i n f a n t m o r t a l i t y . T h e rate at w h i c h i n f a n t s die is not, h o w ever, s i m p l y a n d solely a technical p r o b l e m for doctors only. I t c o n c e r n s all of us w h o h a v e t h e interests of t h e c o m m u n i t y at heart. T h a t is m y only qualification for s p e a k i n g to y o u t o - d a y - - t h a t a n d a s o m e w h a t m o r b i d a n d Unhygienic i n t e r e s t in t h e dus W a n d f o r g o t t e n a n n u a l reports of y o u r predecessors. An U n e q t m l W o r l d T o the s t u d e n t , one of the m o s t s t r i k i n g aspects of vital statistics is t h e m a n n e r in w h i c h they s h o w t h a t we live in a v e r y u n e q u a l society in a tragically u n e q u a l w o r l d . Infant m o r t a l i t y p r o v i d e s society w i t h t h e first m a j o r i n d e x of t h e reaction of a n e w h u m a n life to its s u r r o u n d i n g s . I t is a m e a s u r e of m a n ' s ability" a n d willingness to c o n t r o l his e n v i r o n m e n t . T h e characteristics of a c o m m u n i t y i n all g r a d a t i o n s , f r o m t h e aboriginal of Australia to t h e civilised S c a n d i n a v i a n , b e g i n to i m p r e s s t h e m s e l v e s as soon as t h e c h i l d starts its separate existence a p a r t f r o m its m o t h e r . T h i s existence begins w i t h explosive force. A t n o p e r i o d in after-life does t h e r e o c c u r a n y s h o c k like t h a t a c c o m p a n y i n g birth. F o r in the great systems of t h e body, in the physiological processes of respiration, circulation, h e a t regulation, a n d digestion, t'~ere is a n i n s t a n t a n e o u s a n d drastic change, a n d t h e failure of t h e child to m e e t t h e n e w d e m a n d s o n h i m - - - o r of t h e c o m m u n i t y to p r o v i d e a d e q u a t e p r o t e c t i o n - - - c a n r e s u l t only in death. I n f a n t m o r t a l i t y is i n d e e d t h e p r i c e of a d a p t a t i o n paid b y each g e n e r a t i o n w h e n e n t e r i n g life, a n d t h e toll of i n f a n t d e a t h s is to-day, j u s t as it has always b e e n , a b r o a d reflection of t h e degree of civilisation a t t a i n e d b y a n y g i v e n community. L e t m e give y o u one example. I n S t o c k h o l m , w h e r e t h e f a t h e r ' s i n c o m e exceeds £ 6 0 0 p e r a n n u m t h e total i n f a n t d e a t h - r a t e is 11 p e r t h o u s a n d births. I n B o m b a y , t h e rate a m o n g families h o u s e d in one r o o m or less, was, in 1931, 529 p e r 1,000 births. O n the o t h e r h a n d , w h e r e i n B o m b a y the family h a d four or m o r e r o o m s t h e d e a t h - r a t e in 1"936 was 9 8 - - a figure lower t h a n t h a t for t h e w h o l e of t h e City of G l a s g o w in the s a m e year. W h e n , therefore, we discuss t h e p r o b l e m of different societies a n d different cultures, it seems to m e t h a t facts of this class are w o r t h a good m a n y s u b j e c t i v e generalisations. T h e First Months of Life T h e i n f a n t d e a t h - r a t e is, as I have said, a b r o a d reflection of t h e k i n d of society of w h i c h we are m e m b e r s . T h i s is true, n o t only of n a t i o n a l u n i t s , b u t of social g r o u p s w i t h i n a n a p p a r e n t l y h o m o g e n e o u s c o m m u n i w . B u t I h a v e a suspicion t h a t in f u t u r e we m a y have to qualify t h e use of this i n d e x as a m e a s u r e m e n t of social progress. I have b e e n led to this Eelief b y t h i n k i n g a b o u t t h e r e m a r k a b l e figures a t t a i n e d b y some A m e r i c a n c i t i e s - - f o r instance, Chicago. Under the l e a d e r s h i p of Dr. B u n d e s e n a n i n t e n s i v e i n f a n t welfare c a m p a i g n h a d f o r c e d t h e d e a t h - r a t e d o w n to t h e s t r i k i n g figure of 35 in 1939. B e a r i n g in m i n d t h e variety of racial g r o u p s a n d t h e c o n s e q u e n t r a n g e of social a n d e c o n o m i c p r o b l e m s , it seems to m e that, at a guess, t h e r e m u s t he some social groups in Chicago w i t h rates as low as 20 p e r 1,000 births. I t is, however, difficult to find an entirely satisfactory a n s w e r to the q u e s t i o n w h y Chicago c o m p a r e s so f a v o u r a b l y w i t h cities in this c o u n t r y like L i v e r p o o l a n d G l a s g o w c o n t a i n i n g similarly m i x e d racial g r o u p i n g s . I suggest t h a t p a r t of t h e a n s w e r m a y b e f o u n d in t h e fact t h a t in Chicago a c o m p l e t e l y artificial e n v i r o n m e n t is p r o v i d e d d u r i n g t h e first m o n t h s of a c h i l d ' s life. T h u s t h e i n f a n t is at b i r t h isolated f r o m t h e social a n d e c o n o m i c e n v i r o n m e n t w h i c h h e has i n h e r i t e d t h r o u g h his parents, B u t as this p r o t e c t i o n against the h a z a r d s of b a d h o u s i n g , u n d e r - n u t r i t i o n , ignorance, inability to p u r c h a s e * Substance of a paper read before the Metropolitan Branch,
PUttLIC HEAL'I'll, April, 1944 medical skill, and other factors is slowly w i t h d r a w n as the child grows up, what happens then ? D o we find that the death-rate at higher ages, say at 5 or 15, in Chicago compares m o r e nearly w i t h that in Liverpool or Glasgow ? Or do we find that the child has been given a stronger start, a m o r e resistant structure, to withstand the blasts of an unfavourable e n v i r o n m e n t ? Unfortunately, we cannot know the answers to these questions just yet, but it is clearly a subject which should receive study in the next few years. When, however, as in this country, we find that the environm e n t in later life is broadly the same as during uterine and early extra-uterine life, we see that initial advantages are never lost. A lower infant death-rate is followed by a lower deathrate at 1-5, at 5-14, and so on through adolescence and m i d d l e age. T h i s biological fact can be observed if we study the consequences of a fall in the national rate during the last 10O years f r o m 150 to 50 p e r 1,000 births. T h i s remarkable achievement in the saving of infant l i f e - - a n a c h i e v e m e n t paralleled, I may add, by the rest of Western c i v i l i s a t i o n - has been attributed to i m p r o v i n g social conditions, public health measures and other factors.
Nize of Family T h e s e influences have, of course, played an important part, but one factor is generally forgotten. In 50 years the birthrate has been cut in two. Broadly, this has halved the size of the family. I n addition, therefore, to a rise in economic standards the parents themselves have materially contributed to higher levels of living by a restriction in the size of their families. Instead, therefore, of, say, four children to care for there are now only two. In terms of housing, education, clothing, nutrition, and other factors this biological phenom e n o n m u s t have had i m p o r t a n t effects on the rate at which y o u n g children die. A n increasing proportion of children are being planned according to the circumstances of the parents. Clearly all this m u s t influence the chances of survival of the children already born. It is unfortunate that we cannot estimate the relative importance of the decline in the birth-rate on infant mortality. W e could only do so if we knew the true infant death-rate--i.e., the death-rate for first and subsequent births (live and still) according to the age of the m o t h e r and the interval between births. Effect of SociM Class T h e fact that we do not know the true infant death-rate makes it difficult to assess the part played by social conditions in producing m a r k e d social class differences. T h e latest social class data we have is that for the 1931 census published in 1938 by the Registrar-General. As you probably know, the Registrar-General divides the whole population into five large social g r o u p s : (1) m i d d l e and u p p e r classes; (2) intermediate comprising elements of (1) and (3); (3) skilled l a b o u r ; (4) semi-skilled l a b o u r ; and ( 5 ) u n s k i l l e d labour. During 1930-2, w h e n the rate for all classes was 62, the class rates were 33, 45, 58, 67 and 77. T h u s Class (5) exceeded Class (1) by 133%. T o w h a t extent were these differences due to differences in the birth-rate ? W e cannot answer this question with any certainty, as the last and only report on fertility by social class relates to 1911. Nevertheless there is evidence of a correlation between poverty and fertility. But I believe that this correlation has weakened considerably since 1911. I n 1911 the birth-rate for Classes (1) and (2) was already v e r y low, and during the next 20 years the national birth-rate fell considerably. T h i s fall could have been accounted for only by significant declines in fertility among Classes 3-5. Before I t u r n to the question of changes in infant mortality during this period let us first break d o w n the 1931 rates according to age at death. W h a t this breakdown discloses is that the excess in the death-rate of Class 5 over Class 1 was 50% during the first month, 205% at 1-3 months, 287% at 3-6 months, and 439% at 6-12 months. T h u s the range of inequality widens w i t h increasing age. We can also approach this p r o b l e m by dividing causes of death into two g r o u p s : (I) those that have nothing to do with the post-natal environm e n t - - t o ante-natal, con-natal, and nee-natal factors, and to deficiencies in genetic e q u i p m e n t ; and (2) causes of death
79 which are due mainly to environmental factors. In the first group (premature births, congenital rrialformations, injury at birth, convulsions, congenital debility) we find that Class 5 exceeded Class 1 by 61%. In the second group (measles, w h o o p i n g cough, diarrhoea and enteritis, tuberculosis, bronchitis and p n e u m o n i a and o t h e r infectious and parasitic diseases) the Class 5 excess was 453% . I t has been suggested by some that this excess infant mortality is due to hereditary factors b o u n d up with the existence of a social p r o b l e m group. But it seems to m e that if the physical o~ttfit at birth of children born to Class 5 parents differed vastly f r o m that of children b o r n to those in Class 1, t h e n this difference should be revealed in the first group of diseases and in the first m o n t h s of life, as well as in the second group and in the last six m o n t h s of the first year of life. Need for D e e p e r Study W h e n I examined, as I did in m y book, the changes in these death-rates since 1911, I f o u n d no significant alteration in the gap during the first m o n t h of life, but a w i d e n i n g of the range at 6-12 months. W e do not, of course, know what has h a p p e n e d since 1931. T h e total national rate has declined f r o m 62 to around 50. W e cannot say w h e t h e r this decline has changed the position to any marked degree. N o r do we know w h e t h e r changes in the birth-rate since 1931 have also contributed to the decline. I n the field of vital statistics there are still many gaps in our k n o w l e d g e : for instance, we know nothing about class differences in still-births and in pre-natal mortality. Vqe know very little s h o a t the effects of housing conditions w h e n the influence of other factors such as social status is held constant. National statistics have taken us part of the way towards u n d e r s t a n d i n g the social implications of infant mortality. Some of the lessons are clear, or should be. But it seems to me that if we are to extend our range of knowledge on the social and economic factors implicit in mortality differences, we shall need more intimate studies. In other words, invdstigations, both field and statistical, should be undertaken to cover selected communities (both urban and rural) w h e r e it is possible to obtain data on the great range of factors b o u n d up with family life and levels of living. W h a t I should like to see in the future is a statistical and intelligence d e p a r t m e n t attached to every Medical Officer of Itealth. T h e r e is here an i m m e n s e field for study on questions affecting m o r b i d i t y as well as mortality--i.e., housing conditions, size of family, occupational hazards, social status of wife and husband, hereditary factors, age at marriage, geographical and social mobility, birth order and age of the m o t h e r at birth, m o d e of infant feeding, access to medical knowledge, ventilation and heating of tke h o m e , clothing, and m a n y other factors. T h e r e is, I find, a wealth of sociological and medical data buried a m o n g the records of M a t e r n i t y and Child Welfare and Public Health Authorities. I n the m~in this mass of unused material is never anMysed, nor is it standardised for the requirements of the statistician. ~\.Ioreover, each and every local authority has its own record card. Records and returns of medical officers are not uniform, and until some standards are laid down m u c h of the data for one c o m m u n i t y cannot he c o m p a r e d with that for another. I can only conclude by quoting Professor ~V[ajor G r e e n w o o d , who r e m a r k e d " all this light on contemporary social conditions shoulcl not be im ~ prisoned between the covers of a blue book, but should illumine our understandings and our hearts, teaching as to work for a better E n g l a n d . "
The Therapeutic Requirements Committee of the Medical Research Council has made the following amendments in the entries in War Memorandum No. 3: Ascorblc Acid: reclassified B (essential for some purposes but not for others; to be used with strict economy); it should be prescribed only in the presence of medical indications for its use; not to be used as a supplement to normal diet. Cod-liver Oil: reclassified A (essential or readily available), gitaminized Oil: reclassified B; this preparation is in short supply and should be used only when cod-liver oil is not tolerated.
P U B L I C H E A L T H , April, 1944
THE DIFFERENTIAL
INFANT DEATH-RATE*
By RICHARD M . TITMUSS I s u p p o s e t h a t m e d i c a l officers of h e a l t h are m o r e c o n c e r n e d w i t h the statistical aspects of b i r t h a n d d e a t h t h a n m o s t o t h e r m e m b e r s of tb.eir profession. So, as a layman, I a m a little diffident a b o u t s p e a k i n g dogmatically o n t h e p r o b l e m of i n f a n t m o r t a l i t y . T h e rate at w h i c h i n f a n t s die is not, h o w ever, s i m p l y a n d solely a technical p r o b l e m for doctors only. I t c o n c e r n s all of us w h o h a v e t h e interests of t h e c o m m u n i t y at heart. T h a t is m y only qualification for s p e a k i n g to y o u t o - d a y - - t h a t a n d a s o m e w h a t m o r b i d a n d Unhygienic i n t e r e s t in t h e dus W a n d f o r g o t t e n a n n u a l reports of y o u r predecessors. An U n e q t m l W o r l d T o the s t u d e n t , one of the m o s t s t r i k i n g aspects of vital statistics is t h e m a n n e r in w h i c h they s h o w t h a t we live in a v e r y u n e q u a l society in a tragically u n e q u a l w o r l d . Infant m o r t a l i t y p r o v i d e s society w i t h t h e first m a j o r i n d e x of t h e reaction of a n e w h u m a n life to its s u r r o u n d i n g s . I t is a m e a s u r e of m a n ' s ability" a n d willingness to c o n t r o l his e n v i r o n m e n t . T h e characteristics of a c o m m u n i t y i n all g r a d a t i o n s , f r o m t h e aboriginal of Australia to t h e civilised S c a n d i n a v i a n , b e g i n to i m p r e s s t h e m s e l v e s as soon as t h e c h i l d starts its separate existence a p a r t f r o m its m o t h e r . T h i s existence begins w i t h explosive force. A t n o p e r i o d in after-life does t h e r e o c c u r a n y s h o c k like t h a t a c c o m p a n y i n g birth. F o r in the great systems of t h e body, in the physiological processes of respiration, circulation, h e a t regulation, a n d digestion, t'~ere is a n i n s t a n t a n e o u s a n d drastic change, a n d t h e failure of t h e child to m e e t t h e n e w d e m a n d s o n h i m - - - o r of t h e c o m m u n i t y to p r o v i d e a d e q u a t e p r o t e c t i o n - - - c a n r e s u l t only in death. I n f a n t m o r t a l i t y is i n d e e d t h e p r i c e of a d a p t a t i o n paid b y each g e n e r a t i o n w h e n e n t e r i n g life, a n d t h e toll of i n f a n t d e a t h s is to-day, j u s t as it has always b e e n , a b r o a d reflection of t h e degree of civilisation a t t a i n e d b y a n y g i v e n community. L e t m e give y o u one example. I n S t o c k h o l m , w h e r e t h e f a t h e r ' s i n c o m e exceeds £ 6 0 0 p e r a n n u m t h e total i n f a n t d e a t h - r a t e is 11 p e r t h o u s a n d births. I n B o m b a y , t h e rate a m o n g families h o u s e d in one r o o m or less, was, in 1931, 529 p e r 1,000 births. O n the o t h e r h a n d , w h e r e i n B o m b a y the family h a d four or m o r e r o o m s t h e d e a t h - r a t e in 1"936 was 9 8 - - a figure lower t h a n t h a t for t h e w h o l e of t h e City of G l a s g o w in the s a m e year. W h e n , therefore, we discuss t h e p r o b l e m of different societies a n d different cultures, it seems to m e t h a t facts of this class are w o r t h a good m a n y s u b j e c t i v e generalisations. T h e First Months of Life T h e i n f a n t d e a t h - r a t e is, as I have said, a b r o a d reflection of t h e k i n d of society of w h i c h we are m e m b e r s . T h i s is true, n o t only of n a t i o n a l u n i t s , b u t of social g r o u p s w i t h i n a n a p p a r e n t l y h o m o g e n e o u s c o m m u n i w . B u t I h a v e a suspicion t h a t in f u t u r e we m a y have to qualify t h e use of this i n d e x as a m e a s u r e m e n t of social progress. I have b e e n led to this Eelief b y t h i n k i n g a b o u t t h e r e m a r k a b l e figures a t t a i n e d b y some A m e r i c a n c i t i e s - - f o r instance, Chicago. Under the l e a d e r s h i p of Dr. B u n d e s e n a n i n t e n s i v e i n f a n t welfare c a m p a i g n h a d f o r c e d t h e d e a t h - r a t e d o w n to t h e s t r i k i n g figure of 35 in 1939. B e a r i n g in m i n d t h e variety of racial g r o u p s a n d t h e c o n s e q u e n t r a n g e of social a n d e c o n o m i c p r o b l e m s , it seems to m e that, at a guess, t h e r e m u s t he some social groups in Chicago w i t h rates as low as 20 p e r 1,000 births. I t is, however, difficult to find an entirely satisfactory a n s w e r to the q u e s t i o n w h y Chicago c o m p a r e s so f a v o u r a b l y w i t h cities in this c o u n t r y like L i v e r p o o l a n d G l a s g o w c o n t a i n i n g similarly m i x e d racial g r o u p i n g s . I suggest t h a t p a r t of t h e a n s w e r m a y b e f o u n d in t h e fact t h a t in Chicago a c o m p l e t e l y artificial e n v i r o n m e n t is p r o v i d e d d u r i n g t h e first m o n t h s of a c h i l d ' s life. T h u s t h e i n f a n t is at b i r t h isolated f r o m t h e social a n d e c o n o m i c e n v i r o n m e n t w h i c h h e has i n h e r i t e d t h r o u g h his parents, B u t as this p r o t e c t i o n against the h a z a r d s of b a d h o u s i n g , u n d e r - n u t r i t i o n , ignorance, inability to p u r c h a s e * Substance of a paper read before the Metropolitan Branch,
PUttLIC HEAL'I'll, April, 1944 medical skill, and other factors is slowly w i t h d r a w n as the child grows up, what happens then ? D o we find that the death-rate at higher ages, say at 5 or 15, in Chicago compares m o r e nearly w i t h that in Liverpool or Glasgow ? Or do we find that the child has been given a stronger start, a m o r e resistant structure, to withstand the blasts of an unfavourable e n v i r o n m e n t ? Unfortunately, we cannot know the answers to these questions just yet, but it is clearly a subject which should receive study in the next few years. When, however, as in this country, we find that the environm e n t in later life is broadly the same as during uterine and early extra-uterine life, we see that initial advantages are never lost. A lower infant death-rate is followed by a lower deathrate at 1-5, at 5-14, and so on through adolescence and m i d d l e age. T h i s biological fact can be observed if we study the consequences of a fall in the national rate during the last 10O years f r o m 150 to 50 p e r 1,000 births. T h i s remarkable achievement in the saving of infant l i f e - - a n a c h i e v e m e n t paralleled, I may add, by the rest of Western c i v i l i s a t i o n - has been attributed to i m p r o v i n g social conditions, public health measures and other factors.
Nize of Family T h e s e influences have, of course, played an important part, but one factor is generally forgotten. In 50 years the birthrate has been cut in two. Broadly, this has halved the size of the family. I n addition, therefore, to a rise in economic standards the parents themselves have materially contributed to higher levels of living by a restriction in the size of their families. Instead, therefore, of, say, four children to care for there are now only two. In terms of housing, education, clothing, nutrition, and other factors this biological phenom e n o n m u s t have had i m p o r t a n t effects on the rate at which y o u n g children die. A n increasing proportion of children are being planned according to the circumstances of the parents. Clearly all this m u s t influence the chances of survival of the children already born. It is unfortunate that we cannot estimate the relative importance of the decline in the birth-rate on infant mortality. W e could only do so if we knew the true infant death-rate--i.e., the death-rate for first and subsequent births (live and still) according to the age of the m o t h e r and the interval between births. Effect of SociM Class T h e fact that we do not know the true infant death-rate makes it difficult to assess the part played by social conditions in producing m a r k e d social class differences. T h e latest social class data we have is that for the 1931 census published in 1938 by the Registrar-General. As you probably know, the Registrar-General divides the whole population into five large social g r o u p s : (1) m i d d l e and u p p e r classes; (2) intermediate comprising elements of (1) and (3); (3) skilled l a b o u r ; (4) semi-skilled l a b o u r ; and ( 5 ) u n s k i l l e d labour. During 1930-2, w h e n the rate for all classes was 62, the class rates were 33, 45, 58, 67 and 77. T h u s Class (5) exceeded Class (1) by 133%. T o w h a t extent were these differences due to differences in the birth-rate ? W e cannot answer this question with any certainty, as the last and only report on fertility by social class relates to 1911. Nevertheless there is evidence of a correlation between poverty and fertility. But I believe that this correlation has weakened considerably since 1911. I n 1911 the birth-rate for Classes (1) and (2) was already v e r y low, and during the next 20 years the national birth-rate fell considerably. T h i s fall could have been accounted for only by significant declines in fertility among Classes 3-5. Before I t u r n to the question of changes in infant mortality during this period let us first break d o w n the 1931 rates according to age at death. W h a t this breakdown discloses is that the excess in the death-rate of Class 5 over Class 1 was 50% during the first month, 205% at 1-3 months, 287% at 3-6 months, and 439% at 6-12 months. T h u s the range of inequality widens w i t h increasing age. We can also approach this p r o b l e m by dividing causes of death into two g r o u p s : (I) those that have nothing to do with the post-natal environm e n t - - t o ante-natal, con-natal, and nee-natal factors, and to deficiencies in genetic e q u i p m e n t ; and (2) causes of death
79 which are due mainly to environmental factors. In the first group (premature births, congenital rrialformations, injury at birth, convulsions, congenital debility) we find that Class 5 exceeded Class 1 by 61%. In the second group (measles, w h o o p i n g cough, diarrhoea and enteritis, tuberculosis, bronchitis and p n e u m o n i a and o t h e r infectious and parasitic diseases) the Class 5 excess was 453% . I t has been suggested by some that this excess infant mortality is due to hereditary factors b o u n d up with the existence of a social p r o b l e m group. But it seems to m e that if the physical o~ttfit at birth of children born to Class 5 parents differed vastly f r o m that of children b o r n to those in Class 1, t h e n this difference should be revealed in the first group of diseases and in the first m o n t h s of life, as well as in the second group and in the last six m o n t h s of the first year of life. Need for D e e p e r Study W h e n I examined, as I did in m y book, the changes in these death-rates since 1911, I f o u n d no significant alteration in the gap during the first m o n t h of life, but a w i d e n i n g of the range at 6-12 months. W e do not, of course, know what has h a p p e n e d since 1931. T h e total national rate has declined f r o m 62 to around 50. W e cannot say w h e t h e r this decline has changed the position to any marked degree. N o r do we know w h e t h e r changes in the birth-rate since 1931 have also contributed to the decline. I n the field of vital statistics there are still many gaps in our k n o w l e d g e : for instance, we know nothing about class differences in still-births and in pre-natal mortality. Vqe know very little s h o a t the effects of housing conditions w h e n the influence of other factors such as social status is held constant. National statistics have taken us part of the way towards u n d e r s t a n d i n g the social implications of infant mortality. Some of the lessons are clear, or should be. But it seems to me that if we are to extend our range of knowledge on the social and economic factors implicit in mortality differences, we shall need more intimate studies. In other words, invdstigations, both field and statistical, should be undertaken to cover selected communities (both urban and rural) w h e r e it is possible to obtain data on the great range of factors b o u n d up with family life and levels of living. W h a t I should like to see in the future is a statistical and intelligence d e p a r t m e n t attached to every Medical Officer of Itealth. T h e r e is here an i m m e n s e field for study on questions affecting m o r b i d i t y as well as mortality--i.e., housing conditions, size of family, occupational hazards, social status of wife and husband, hereditary factors, age at marriage, geographical and social mobility, birth order and age of the m o t h e r at birth, m o d e of infant feeding, access to medical knowledge, ventilation and heating of tke h o m e , clothing, and m a n y other factors. T h e r e is, I find, a wealth of sociological and medical data buried a m o n g the records of M a t e r n i t y and Child Welfare and Public Health Authorities. I n the m~in this mass of unused material is never anMysed, nor is it standardised for the requirements of the statistician. ~\.Ioreover, each and every local authority has its own record card. Records and returns of medical officers are not uniform, and until some standards are laid down m u c h of the data for one c o m m u n i t y cannot he c o m p a r e d with that for another. I can only conclude by quoting Professor ~V[ajor G r e e n w o o d , who r e m a r k e d " all this light on contemporary social conditions shoulcl not be im ~ prisoned between the covers of a blue book, but should illumine our understandings and our hearts, teaching as to work for a better E n g l a n d . "
The Therapeutic Requirements Committee of the Medical Research Council has made the following amendments in the entries in War Memorandum No. 3: Ascorblc Acid: reclassified B (essential for some purposes but not for others; to be used with strict economy); it should be prescribed only in the presence of medical indications for its use; not to be used as a supplement to normal diet. Cod-liver Oil: reclassified A (essential or readily available), gitaminized Oil: reclassified B; this preparation is in short supply and should be used only when cod-liver oil is not tolerated.