Review

Reviewed Work(s): The Great War and the British People. by J. M. Winter
Review by: Susan Cotts Watkins
Source: Population and Development Review, Vol. 15, No. 1 (Mar., 1989), pp. 147-149
Published by: Population Council
Stable URL: https://www.jstor.org/stable/1973410
Accessed: 20-04-2020 02:37 UTC

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 BOOK REVIEWS

J. M. WINTER
The Great War and the British People
Cambridge, Mass.: Harvard University Press, 1986. xiv + 360 p. $29.95.

This is a book about war that places the quick, not the dead, at its center. The
unintended and fortuitous benefits of the mobilization of a civilian war economy in
Britain during World War I "were the source of the disturbing paradox that the
Great War was both an event of unparalleled carnage and suffering and the occasion
of a significant improvement in the life expectancy of the civilian population, and
especially of the worst-off sections of British society" (p. 4). To explain the causes
of mortality decline among the civilian population, Jay Winter points directly to the
effect of war in creating a community consensus about health and the expansion of
the role of the state.
The first question demographers typically ask about a war is, "How many died?"
In this case the counting is not straightforward (for example, registrars general
counted soldiers who died abroad as permanent emigres). Previous estimates of
British war mortality range from 550,000 to 1,184,000; and "[m]ost of the writers
who addressed the seemingly simple question as to how many British and Irish men
died on active service in the First World War wandered into a statistical maze, escape
from which apparently was beyond them" (p. 66). Winter, however, both entered
and escaped this maze, and with his shirt on. He presents a plausible estimate of the
number (about 722,000) and age distribution of war deaths: about 1 in 8 of those
in uniform were killed; about 1 in 4 were wounded. Contemporaries were essentially
right in claiming that Britain lost an entire generation of the brightest and the best:
among students and graduates of some Oxford and Cambridge colleges, the pro-
portion of those in uniform who were killed was double the national average. The
men in uniform were, not surprisingly, disproportionately working-class, but those
who died were disproportionately the social elites.
The basic data are a set of life tables for the years 1913 and 1915-17, prepared
by the Prudential Assurance Company. These include both civilian and military
deaths, but by projecting prewar trends Winter is able to estimate life tables for the
civilian population; comparing these with life tables calculated from the Registrar-
General's tabulations of death by cause and age permits Winter to estimate mortality
improvements associated with the war. Between 1911 and 1921, life expectancy at
birth in England and Wales rose from 49 to 56 years for men, and from 53 to 60
years for women. The infant mortality rate fell from 107 deaths per thousand live
births (1905-10) to 87 (1917 and 1918), 80 (1919), and 72 (1920) (p. 141). In both
Scotland and England and Wales the wartime rate of change was greater than in
the 1920s (p. 143). There were particularly large declines in deaths from diarrheal
diseases; from "certain degenerative diseases," including stomach ulcers, diabetes,
and cirrhosis of the liver; from complications of pregnancy; and from "certain diseases
of infancy." Only for respiratory tuberculosis were mortality rates unambiguously
higher during the war. The influenza pandemic of 1918-19, which killed some
200,000 people in Britain, is considered to have been sui generis rather than war-

POPULATION AND DEVELOPMENT REVIEW 15, NO. 1 (MARCH 1989) 147

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 148 BOOK REVIEWS

related; consequently standardized death rates are recalculated by cause and age
without influenza mortality (p. 12 1).
Winter finds a disproportionate improvement in mortality among poorly paid
workers compared with occupied and retired workers. A narrowing of occupational
differentials in mortality in the decade before the war accelerated in the next decade.
In general, the worst-off groups gained most, while the best-off gained little if at all
relative to the population as a whole. "It is therefore possible to suggest that in the
war decade the demographic distance between the survival chances of different classes
and between different strata within classes was reduced" (p. 115).
Winter considers three avenues through which the wartime mobilization of the
civilian economy might have led to an improvement in the health of civilians:
improvement in medical care; such public health initiatives as standardized welfare
provision in national factories and the expansion of groups covered by the National
Insurance Act of 191 1; and improvements in nutrition. He minimizes the importance
of the first two (in Chapters 5 and 6), leaving improvement in standards of living
and health standards, which he argues are largely the consequence of improved
nutrition.
The argument that medical care or public health initiatives were unimportant
in the short run (about the long run he has little question that they were important)
is largely made on the grounds that mortality improved in areas that were seriously
deprived of physicians as well as in areas that were less deprived, and in areas where
public health initiatives were adopted easily as well as in those where they were
resisted (largely by the medical profession). Winter notes that the number of visitors
to health care facilities doubled during the war, and that grants to voluntary societies
and borough or county councils increased, but he doubts whether either factor exerted
much of an effect. I doubt it too, but the evidence is not compelling.
This leaves improvements in living standards, particularly nutrition, as the favored
explanation for mortality decline. Winter's findings thus support the thesis, put forth
most strongly by Thomas McKeown, about the effect of nutrition on mortality.
However, like McKeown's, this is a residual argument, but it is buttressed by other
evidence. In particular, Winter shows (i) that wages rose more than prices, with
particularly disproportionate increases in wages (and thus in the standard of living)
among those groups that had been at the bottom of the economic ladder before the
war-precisely the groups whose mortality declined rapidly during the war; (ii) he
argues that because many men were at the front, births declined during the war,
families were smaller, and there was more food to go around in many households;
(iii) and he cites the benefits of the opening of industrial canteens, the enforcement
of closing hours in pubs, and the payment of separation allowances to support the
families of servicemen.
While I am less certain than Winter that the evidence he presents supports the
conclusion that improvements in nutrition were responsible for improvements in
civilian health during World War I, this should not detract from an appreciation of
the skill with which he has marshaled diverse evidence to make his case. A more
definitive analysis would need very different kinds of evidence-for example, data
on household food budgets-which to my knowledge (and presumably to his) are
not available. Interestingly, Winter has given a convincing account of declines in
infant mortality that barely mentions one of the currently favored contributing causes,
breastfeeding, but does mention another, women's work. The growth in the labor

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 BOOK REVIEWS 149

force participati
deliveries, increa
benefits.
In whatever way the responsibility for the civilian mortality decline is allocated,
the state played an important role, either through policies resulting in improvements
in household income (and thus nutrition) or through institutional initiatives such
as the expansion of maternal and child health clinics and the network of health
visitors. In many cases state intervention began before the war but accelerated during
it; the main effects may have been, as Winter argues, in laying the groundwork for
subsequent interventions rather than in influencing mortality during the war.
Winter's most original contribution is his emphasis on the effect of the war in
stimulating attitudes favorable to institutional initiatives in health. These were, he
argued, seen as patriotic, a way in which those who were denied the right to defend
their country could show their patriotic fervor. Agitation about infant welfare had
a symbolic appeal; it "demonstrated that a nation which demanded the 'supreme
sacrifice' at the front demonstrated its true humanity by preserving infant and ma-
ternal life at home" (p. 191). As one medical officer put it, the establishment of
centers for antenatal and postnatal care was " 'a form of war-work that called for
the enlistment of many workers' " (p. 192). The proponents of public health measures
in this field attained political standing in wartime that they had not had before.
Winter's training as a historian makes this a richer book than most works of
historical demography. Historical demographers typically strip their data of historical
context, in order to permit their interpretation as "universal," rather than conditioned
by local and national circumstances. Thus, one knows little about Louis Henry's
natural fertility populations, and little about the Bavarian villagers analyzed by John
Knodel and Etienne van de Walle except that some women breastfed and others did
not. The more naked the demographic facts, the easier it is to transport them to
Indonesia or Sierra Leone; the more the facts come clothed in the specificities of
time and place, the harder it is to derive "lessons from the past."
Winter's analysis, in contrast to the standard fare offered by historical demography,
is quite sensitive to the specific conditions of England and to the period of World
War I. Does this mean that it is not possible to derive lessons from the past? I think
not. The lessons do not, however, come in a form that can be easily packaged for
export. British experience during World War I does not even predict French or
German experience (in both of these countries, civilian mortality rose), never mind
that of Lebanon or Cambodia. What can be extrapolated, however, is support for
looking at community institutions and community mentalites in attempts to under-
stand the decline, or failure to decline, of mortality. In Winter's analysis what is
central is not so much increases in private income as changes in the organization of
the economy, particularly the role of the state in distributing resources, and the
fervent support of the community for health initiatives on the home front. While
many developing countries have experienced wars of liberation, it may be that
development itself is analogous to the Great War. Winter's work suggests that we
ask whether the nationalism and the elaboration of state functions that have ac-
companied development in most Third World countries since World War II have
had effects oIn mortality similar to those they had in Britain during World War I.
Poplulation Stludies Center SUSAN CoTTs WATKINS
LJniversity of Pennsylvania

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