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INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
medicine. As Jerry Morris discusses in his accompanying commentary11 it remains as necessary today as it was in 1934.
5 Spence JP. The Purpose and Practice of Medicine. Oxford: Oxford
University Press, 1960, pp. 142–57.
6 Hart PD’A, Wright GP. Tuberculosis and Social Conditions in England.
London: National Association for the Prevention of Tuberculosis, 1939.
References
1 Pemberton J. Malnutrition in England. University College Hospital
Magazine 1934;Jul–Aug:153–59. (Reprinted Int J Epidemiol 2003;
32:493–95.)
2 Comments. Children’s allowances during unemployment. Lancet
1938;i:356–57.
3 Stewart J. ‘The Battle for Health’ A Political History of the Socialist Medical
Association, 1930–51. Aldershot: Ashgate, 1999.
4 Orr JB. Food, Health and Income. London: Macmillan, 1936.
© International Epidemiological Association 2003; all rights reserved.
7 M’Gonigle GCM, Kirby J. Poverty and Public Health. London: Gollancz,
1936.
8 Medical News. Committee Against Malnutrition. Lancet 1938; p. 527.
9 The Registrar-General’s Decennial supplement England and Wales 1931 Part
2a Occupational Mortality. London: HMSO, 1938.
10 Royal College of Physicians of London. Interim Report: Social and
Preventive Medicine Committee. 1943.
11 Morris JN. Commentary: Minimum incomes for healthy living: then,
now—and tomorrow? Int J Epidemiol 2003;32:498–99.
International Journal of Epidemiology 2003;32:498–499
DOI: 10.1093/ije/dyg212
Commentary: Minimum incomes for healthy
living: then, now—and tomorrow?
JN Morris
I have not seen John Pemberton’s article,1 published in the
summer of 1934, before. Qualifying as a doctor from University
College Hospital (UCH) in the spring of that year, and typically
broke, I departed straightaway to a general practice in the
country. There within 3 days, and solo, I was delivering the
reluctant wife of the local policeman … Anyhow, I returned
safely to UCH in the autumn of that year as House Physician
(Resident) to Thomas Lewis, the great Heart man, whose
clinical clerk I had previously been in a life-changing experience
for close on a year. Soon, some of us, residents and students,
started a Socialist Study Group on the future of health services.
The Dean, however, would not have any such ‘political activity’,
so we renamed it the Hippocratic Club. But John Pemberton in
his article seems to have got away with it. I am lost in admiration for this truly pioneer effort.
There was growing concern during the 1930’s depression
years over the health and nutrition of the poor, and particularly
the unemployed,2–4 whence the British Medical Association’s
(BMA) Committee. This consisted of Health Officers, nutritionists, an eminent paediatrician, and so on. Their absorbing report
was published as a special supplement in the British Medical
Journal (BMJ) of 25 November 1933. It consists mainly of tables
of model diets, with their minimal costs, for a range of families
and individuals, based on current knowledge of minimal
nutritional needs for ‘health and working capacity’. (Memo to
Public and Environmental Research Unit, London School of Hygiene and
Tropical Medicine, Keppel Street, London WC1E 7HT, UK. E-mail:
[email protected]
BMA and BMJ: What about an update? The time could scarcely
be more opportune.)
Remarkably, there was no discussion in the report, not even
a mention, of the practical implications of the costs of the
approved diets. This was all the more surprising as the secretary
of the committee, a local Health Officer, was already engaged in
the research that was to become a classic of social medicine.5
Nor did the accompanying BMJ editorial on The Feeding of the
Nation6 rectify this silence. One must wonder about ‘pressures’.
There is a PhD surely here in-waiting.
Such silence however was not good enough for Pemberton, a
medical student in his junior clinical year by my reckoning, and
he waded in as social-medical analyst with the article now
reprinted.1 That the unemployed could not afford the recommended diets is demonstrated, and he proceeds to discuss
evidence on malnutrition and health.
I must not digress to consider the nature and quality of the
diets proposed in accordance with the knowledge of the 1930s.7
But just one brief example—the family of father, mother, and three
children under 16 on which Pemberton focuses (Diet no. 16), by
my assessment, seems to consume about 10% of today’s consensus on fruit and vegetables.
That family may be taken as representative. Unemployed,
their statutory benefit in 1933 for the five of them amounted to
29 shillings and 3 pence a week (say £1.50 sterling). The diet
recommended would cost 22 shillings and 61⁄ 2 pence (say £1.15
sterling), i.e. about three-quarters of the total weekly benefit.
Quite unrealistic.
How do statutory minimum incomes today compare? What
progress has been made in the intervening 70 years? The direct
MALNUTRITION IN ENGLAND
comparison of unemployment benefit will be with today’s JobSeeker’s Allowance (JSA). For such a family of a couple and
three children under 16 this figure is now £185.15 per week.8
The purchasing power of these figures for 1933 and now can be
compared approximately by standardizing for the Retail Price
Index over the period. Today’s level thereby, in real terms, is
about 3.5 times greater than the earlier one. The current figure
will be supplemented a fifth by children’s benefits, and there
could possibly also be Housing and Council tax benefits.8
The 1933 figures too could be increased by sundry extras.2
In general, the increase in unemployment pay is about the
same rate as the increase in average earnings of manual
workers.9–11
Interestingly, today’s official minimum defining child poverty,
the elimination of which is an historic official commitment, is
far higher than the JSA. This minimum is defined as income
below 60% of the national median after housing costs—for our
model family £257 per week.12
A plea for rationality—pro guesswork
A fundamental issue arises: the correspondence of these sundry
figures of the 1930s and today to needs for health. The situation
is that none of these figures is based on any discernible
assessment of such needs and whether they can be met. It is
evident from the coincidental BMA report that the figure for the
1930s scarcely begins to qualify. There is no comparable information relevant to the JSA. The child poverty figure is indeed a
measure of inequality and not at all of such capabilities.
499
week. A group of us in the London School of Hygiene and Tropical
Medicine are now investigating such needs and costs in old age.
Multiple risks, of course, arise out of making assumptions on
lifestyle, attitudes, and knowhow that can be prompted by such
ratings. And about the education and other social and personal
policies that would be needed to change behaviour and fulfil the
health objectives.16
Much piloting plainly is indicated before we could make
practical suggestions on implementation of such minima for
everybody. Rationality apart, there is a principle of great social
moment here: greater equality of access, so of opportunity, to
health.16 Another dividend would be the opening up of discussion, a clearing of the fog, on how Government settles, and
should settle, the standard of living of millions of people that it
presently determines by its structure of benefits costing billions
of pounds.12 Standards thus also of quality of life and of level of
health.
I am grateful to friends for their help.
References
1 Pemberton J. Malnutrition in England. University College Hospital
Magazine 1934;July–August:153–59. (Reprinted Int J Epidemiol 2003;
32:493–95.)
2 Titmuss RM. Poverty and Population. London: Macmillan, 1938,
pp. 227–45.
3 Morris JN, Titmuss RM. Health and social change: the recent history
of rheumatic heart disease. Med Officer 1944;72:69–71, 77–73, 85–87.
4 Drummond JC, Wilbraham A, Hollingsworth D. The Englishman’s
Food. Jonathan Cape, 1957, pp. 442–48.
—and to public health/social medicine
Is it not time for us to intervene in this area that we have
avoided for so many years? More than half a century of
research has now provided consensual knowledge of major
determinants of personal health in nutrition, physical activity,
housing, and psychosocial relations/social inclusion. Some of this
knowledge is already officially accepted by Government.13,14 All
these can be costed, as we sought to do in relation to the
innovation of the National Minimum Wage (NMW).15 The level
of this was settled by Government without apparent input from
the health community.
The figures for the NMW and the aggregate minimum costs
for the healthy single young working men we studied are as
follows:12,15
Take-home pay for a 38-h week, at 18–21 years
= £121.00; at 22 years plus = £137
Our assessment of the minimum costs of healthy living (now
including 5% for contingencies and personal choice—we were
criticized for neglecting this) is currently, mid 2002, £148.00 per
5 M’Gonigle GCM, Kirby J. Poverty and Public Health. London: Gollancz,
1936.
6 Ibid, BMJ, 980.
7 Smith D. The social construction of dietary standards: the British
Medical Association—Ministry of Health Advisory Committee on
Nutrition. Report of 1934. In: Maurer D, Sobal J (eds). Eating Agendas.
Berlin, New York: Aldine de Gruyter, 1995, pp. 279–303.
8 Department of Work and Pensions, Quarterly.
9 Routh G. Occupation and Pay in Great Britain 1906–79. London:
Macmillan, 1980. Passim.
10 Office for National Statistics. Personal Communication. 2003.
11 New Earnings Survey. Office for National Statistics. London: Stationery
Office, 2002.
12 Morris JN. Are we promoting health? Lancet 2002;359:1622.
13 Department of Health. Saving Lives: Our Healthier Nation. Cm4386.
London: Stationery Office, 1999.
14 The NHS Plan: Technical Supplement on Target Setting for Health Improve-
ment. London: Department of Health, 2001.
15 Morris JN, Donkin AJM, Wonderling D, Wilkinson P, Dowler EA. A
minimum income for healthy living. J Epidemiol Community Health
2000;54:885–89.
16 Rawls J. A Theory of Justice. Oxford: Clarendon Press, 1972, pp. 60–83,
90–95.