INFANT MORTALITY, SCOTLAND (Hansard, 16 February 1944)

§ Major Markham (Nottingham, South)
It is with considerable diffidence that I, an Englishman, rise to speak on a Scottish subject, but it is one in which, I think, all humanity is interested, namely, the question of infant mortality. Hon. Members will remember that up to 1941 Scottish infant mortality was rising very rapidly, and this House showed considerable concern at the position. The House welcomed very much the statement of the Secretary of State for Scotland on 8th July, 1942: I have been very concerned, as we all are, about our infantile mortality figures. The figure per 1,000 births rose from 68 … in 1939—and that in itself was a high figure—to 78 in 1940, and 83 in 1941. I have asked the Department of Health's Scientific Advisory Committee, under the Chairmanship of Sir John Boyd Orr, to consider and report quickly, if they can, the causes of this rise and to suggest remedial measures."—[OFFICIAL REPORT, 8th July, 1942; col. 787, Vol. 381.] That statement was warmly welcomed. The House welcomed the fact that the Committee was to be set up, to go into the latest situation in regard to infant mortality. Yet in the introduction to the Report we find that "the Committee has confined itself to pre-war conditions." My first question is, Who changed the terms of reference? This House was given one set of terms of reference, the Committee has had another. The House was under the impression that the Committee would 303 go into infant mortality right up to date, yet the Committee has limited its investigations to pre-war conditions. The changes in diet, housing, employment, medical services, and so on have had a profound effect during the war years, and it would have been of very profound assistance, not only to Scotland but to England, Wales and Northern Ireland, and, indeed, to the Empire generally, if this Committee had carried out its terms of reference as the Secretary of State for Scotland announced them in this House.
I will refer to the Report, for convenience, as the Boyd Orr Report, although I understand, from the "Aberdeen Free Press" of 4th February, that Sir John Boyd Orr has denied that he had anything to do with the sub-committee which drew up the Report. One of the reasons given in this Report as to why the Committee has not gone into the war situation is that there is little information published for the war years. That, I suggest, is definitely untrue. There is a wealth of information available, not only as regards Scotland but as regards England and Wales, which would have done admirably for comparative purposes, and also as regards the United States, New Zealand, Australia, and so on.
I would remind the Minister that on 20th January, in this House, I asked for certain statistics up to August, 1943, and I was very pleasantly surprised at the wealth of information the right hon. Gentleman gave, not only in the course of that answer, but which he sent to me privately after. Much information relating to the war years was available, and I suggest that it is definitely untrue to suggest that there was no information which the Committee could have considered for that period. My second point is in regard to the Minister's foreword, and my purpose here is to be helpful and constructive. I am not concerned in damning anybody in this Report. I genuinely want to help. The Minister, in his foreword, says: for the first time all the known comparisons are carefully marshalled. That, I suggest, is untrue. There is no detailed comparison with other countries including Iceland, and I suggest Iceland deliberately because Northern Scotland and Iceland have to a large extent the same climatic conditions. There is no comparison with the great American cities which I suggest might be compared with 304 Glasgow, or any detailed comparison with Australia, and, of course, no diagnosis of war time fluctuations in any of these countries. Then the Minister goes on: A medical committee of great experience and authority under the chairmanship of one of the leading scientists of our time, has diagnosed the cause or causes of the lamentable place Scotland takes among the great nations in the saving of infant life. I suggest that that statement is not strictly accurate. My final quarrel with the Minister's introduction is this. He says: Remedies and alleviations must be found for our infantile mortality position in the immediate post-war years. The question obviously is—why not now? This question is urgent and important, and to adopt this attitude of "Let us see what happens after the war" is, to my mind, quite incredible on a vital problem of this importance.
May I now refer to the Report, and here I should like to say that I criticised some points in connection with this Report in the "British Medical Journal," for 5th February, and sent a copy of my letter to the Minister. My first point is that the statistical basis of the Report is poor. It is very evident that there was not a very good statistician at the service of this Committee. There are errors, very crude errors, such as I have never seen before in any Government publication, and perhaps one of the astonishing things is the fact that some of the comparative tables—from Table 1 to Table 29—are for the period 1934 to 1938, and I cannot understand why so ancient and limited a period should have been selected. The information for the immediate war years and early years of the war was available. The curious thing is that the section of the Report which deals with stillbirths does use information and statistics relating to the war years. If they could be used for stillbirths they could have been used on infant mortality as a whole. I will not go into the statistical errors in detail, but will furnish a list to the Minister if he will promise to circulate an errata slip to the Report through the usual channels. I would rather like to see that done.
But I do wish to refer to two statements—major errors. On page 30 of the Report it says: Statistics relating to the percentage of the insured population unemployed in English cities are not available. 305 Every Member of the House knows that we had a magnificent struggle around these figures in pre-war years. The figures are available in the Ministry of Labour Unemployment Index right up to 1939. They were the bases of many discussions in this House over the distressed areas, and the reason why these statistics were not given to the Committee shows how sadly they were lacking in real statistical assistance.
Another astonishing statement, on page 61, is that the rich both in England and Scotland have infantile mortality rates approaching the limit of what is attainable with present knowledge of how to control environment. Considering that the English rate (Class I, page 16) is 33 per 1,000 and that for Scotland demonstrably higher, it is obvious that these figures will have to be reduced to a third before they approach or equal the New Zealand or Dutch figures for comparable classes. Actually, Chicago, New York, New Zealand, Utah and Iceland have already got a rate of 29 per thousand, and therefore there is a suggestion of deep pessimism in this passage of the Report unwarranted by the facts. Another statement on page 62 is that: It is difficult and of doubtful value to make comparisons between the present Scottish services and those in other countries because the nature of the services varies and detailed information is difficult to procure. There is the suggestion of a closed mind in such a sentence as that. It says in effect that Scotland is so perfect that they need not go anywhere else and that they can reduce their infantile mortality figures to a third of the present rate without considering what other areas have done. I would remind the House that not a single visit was paid by any member of the Committee, nor was any oral evidence taken. No effort was made, with the exception of a few letters sent to the United States, Australia and New Zealand, to find out what other countries were doing and yet the Minister says in his foreword: All the known comparisons are carefully marshalled. The statement that detailed information is difficult to procure is untrue. There is a wealth of information available here in London, and the Committee charged with this responsibility should have gone further and sought more widely for the remedies for this appalling situation in Scotland. May now I deal with the gaps in the Report? In the first place, there is 306 no mention of changes due to war conditions, such as reduction in unemployment and poverty and changes in diet, and diet is of some importance. There is no reference to national bread and to the fact that calcium and vitamin B1 have been added to it, and yet the tables in the Report would seem to say that the diet in Scotland is still deficient in these two important elements. There is no reference to problems caused by evacuation, or the effect on infantile mortality of the fuel shortage. There is no mention of alcoholism, which has a certain impact on infantile mortality. There is no mention of vitamin E, the reproductive vitamin which is important. I remember the old rhyme: Vitamin E, Vitamin E, That's the stuff for you and me. It kills all the hopes of dear Marie Stopes, And produces the seed for a good familie. To omit all reference to vitamin E in a nutritional report on infantile mortality is deplorable. Another gap is that there is no information regarding the difference between the infantile mortality rates in ordinary homes and institutions. That would have been extremely useful. There is no mention that in other countries the rate is as low as 29 per cent. Most of the overseas comparisons are from six to 10 years old.
When we come to Scottish conditions, there is no mention of the new Simpson Memorial Hospital at Edinburgh, which has air-conditioned wards. One would like to know whether they are successful or not. There is no mention of "Infant Life," which is a publication of the American Children's Bureau and possibly the most important publication issued in America dealing with infantile mortality. It has a circulation of hundreds of thousands, if not millions. It is the publication on which the instruction of expectant mothers is based in the United States, yet the Committee apparently has not seen it, and does not know of its existence. I repeat that when the Minister says that "all the known comparisons are carefully marshalled" and that the Committee "has diagnosed the cause or causes of the lamentable place Scotland takes," such a statement demands some explanation. The Report, too, should have given some attention to environmental conditions, including smoke and fog.
There is not the slightest doubt that smoke and fog combined play a very large 307 part in general bad health and in infant mortality. If you compare the winter sickness and death rates against the summer, the winter is always 50 per cent. higher and very often 100 per cent. This Report says that the winter has very little effect on infantile mortality. Throughout the world you will find this swing from winter to summer, and there is obviously something in the climate which affects infant life. For that reason the Americans have tackled this problem from the point-of-view of air conditioning and have made a great success of it. There is also the question of fuel, which the hon. Member for Gorbals (Mr. Buchanan) raised in the House the other day. It is very important, from the point-of-view of the proper warmth of the mother and child in those most important days, and the ideal temperatures are several degrees higher than those in the average Scottish home. I am now on my last two minutes or I would have liked to quote from the report of the Medical Officer of Health for Nottingham, 1942, on this question of smoke and fog, but perhaps hon. Members will look that up for themselves.
May I finish by making nine constructive suggestions to the Minister? They are these. First of all, that when he considers infantile mortality from the point of view of a broad programme, he should give attention to these questions of environmental conditions, and that temperatures for all new-born babies should be kept as far as possible to 70 to 75 degrees night and day, which is the American ideal, and has helped greatly to reduce infantile deaths there.

§ Dr. Haden Guest (Islington, North)
Is that in the Glasgow tenements?

§ Major Markham
That is an ideal to be aimed at. It can be worked. The next point is that all premature infants should be reported within an hour, and that there should be electrically-heated ambulances to bring them into hospital and scientifically heated wards or incubators. That may be a policy of idealism, but it must be aimed at if you want to keep mortality down. Then there should be intensive training for special nurses to deal with premature infants on the lines of the Chicago development. Clinics and infant welfare services should be improved 308 by making them clean, warm and comfortable. Next, the Minister should set up a committee of non-medical men to go into these environmental factors in infant life—

Dr. Morģan (Rochdale)
Why?

§ Major Markham
With special consideration to recent developments in the United States. Next, he should press ahead with housing and heating and ventilation appliances. The next point is that he should embark upon a national campaign for adolescent and expectant mothers on the lines of the Chicago campaign, and finally—and this is perhaps the most controversial thing I have said—he should break down the old fallacy that the Scots are a hardy race. They are not a hardy race. Their infantile mortality is higher than almost any other part of Europe. The expectation of life is four years less than the average Englishman's. Their death rate is higher. He should get the Scot to admit frankly that 5,000 Scottish children die every year from dirt, cold, and ignorance.

§ The Secretary of State for Scotland (Mr. T. Johnston)
I would have welcomed a discussion on this matter, but there is not enough time left and I have a wide field to cover.

§ Mr. Buchanan (Glasgow, Gorbals)
We have been promised a day for discussing this question. It is most unfair of the hon. and gallant Member to come in for half-an-hour when the Government have promised us a full day to discuss the matter.

§ Major Markham
This was arranged before the hon. Member raised it in the House.

§ Mr. Johnston
In any case the Government's promise to afford facilities through the usual channels for an adequate discussion on this matter still stands. May I, as briefly as I can, seek to cover some of the difficult points which the hon. and gallant Member has raised? First of all, the composition of the Scientific Advisory Committee, who co-opted the Boyd Orr Committee, is Sir John Boyd Orr himself, Professor Carl Hamilton Browning, Professor Crew, Professor Daly, Sir John Fraser—the most eminent surgeon we have—Professor David Murray Lyon, Sir Alexander MacGregor—Medical Officer of 309 Health for the largest city in Scotland—Professor MacKie, Sir Edward Mellanby—the secretary of the United Kingdom Medical Research Council—and Professor Tulloch. This is the parent body which selected or co-opted the Boyd Orr Committee. Who did they co-opt? They co-opted Doctor Baird—Regius Professor of Midwifery at Aberdeen—Doctor Douglas—chief Maternity and Child Welfare Officer of the Department of Health for Scotland. I will say something about their qualifications in a moment.
They co-opted the matron of the hospital, the Simpson Memorial Maternity Pavilion, Royal Infirmary, Edinburgh, which has had, since 1939, the very air conditioning experiments to which the hon. and gallant Member referred. She was a member of this Committee, so she did know about the experiments in Chicago without requiring to go there and see them. Other members of the Committee were Dr. Stanley Graham, Visiting Physician, Royal Hospital for Sick Children, Glasgow; Dr. James Hendry, Regius Professor in Obstetrics and Gynaecology at the University of Glasgow; Dr. Isabella Leitch, Deputy Director, Imperial Bureau of Animal Nutrition, Aberdeenshire; Dr. Jean Mackintosh, Regional Medical Officer for Maternity and Child Welfare, Aberdeen; Dr. Peter McKinlay, a very eminent statistician; Dr. Charles McNeil, Professor of Child Life and Health, University of Edinburgh; Dr. Margaret Scott-Dickson, Maternity and Child Welfare Department, Dundee; Dr. Elenora Simpson, The James MacKenzie Institute, St. Andrews; and, lastly, Dr. Nora Wattie, Senior Child Welfare Medical Officer for Glasgow.
I submit that nobody could have selected a more eminently qualified Committee than this. This Committee gave the reason why they did not analyse the war-time trend. They said that the reason governing their decision was that there was little published information for the war years. That is true. They said that the most important environmental conditions of diet, housing, employment and medical services are highly abnormal in most areas. That, also, is true. It is impossible, they said, to judge to what extent any of the changes which have incurred since 1939 are likely to be permanent.
310 From my point of view it would have been highly desirable that the Committee should have analysed war-time trends, if possible, because the trend is going down. Scotland, last year, had the lowest infant mortality in her history. [An HON. MEMBER: "What was it?"] It was 65 per 1,000. The point is that the Committee did not analyse the downward trend in the war years because, as they said, of the difficulty of getting a comparison, of getting accurate statistical data which would warrant conclusions being drawn from it. The hon. and gallant Member asked why the Committee did not pay a special visit to America and New Zealand. Well, the obvious answer is in the Appendix, if the hon. and gallant Member will look at it. There he will see an enormous list of the qualifications which five members of the Committee have as regards their knowledge of these things abroad. For example, Dr. Douglas, the chief maternity and welfare officer of the Department of Health, has qualifications and has knowledge of New Zealand, and other members of the Committee have been to Scandinavia and have knowledge of conditions there. There is another member who has actually got the air conditioning apparatus which the hon. and gallant Member so highly commended.

§ Dr. Haden Guest (Islington, North)
Which he obviously knew nothing about.

§ Mr. Johnston
An hon. Gentleman said, What about coal? It is true that Sir William Beveridge draws attention to the fact that Scotland consumes about 13 per cent. less coal than the English household, but Titmuss goes out of his way to show that fuel conditions are not the cause of the whole of infant mortality in Holland, for example, and draws attention to the fact that the rate in Iceland, a very cold climate I should think, is 28.3 per thousand live births, and therefore in his judgment this question of heating the household is not a primary factor. The hon. Gentleman has referred to the New Zealand figure. We have to take great care in using foreign, colonial and Dominion comparisons. It is true that the New Zealand figure is 29, but that figure excludes the Maori figure, which is 97. I have not time to go into all these comparisons but let us compare like with like. It is hardly fair to exclude coloured populations and so on from your statistics and then compare them with 311 purely white figures of this sort. In July, 1939, our unemployment figure in Scotland was 11.5. In January, 1944, it is down to one, and I believe one of the component parts in causing the reduction in the infant mortality rate is the fact that there is a bigger income and that more purchasing power is coming into the home.
I should like to say a word or two about what we are trying to do. We are doing a great deal. Our maternity homes have gone up 50 per cent.—and that is a big figure—during the war time, and we have 108 other maternity beds that we might use, which have been kept in very rural areas. If the women of the 312 country want the use of these 108 maternity beds they will get them. Lastly, the local authority associations, which have been consulted, are doing everything they can, and have promised to do everything they can, by increasing the intakes of orange juice, vitamin tablets and the rest of it, and by requisitioning more of the large houses in particular areas—