Public and Environmental Research Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. E-mail: jerry.morris{at}lshtm.ac.uk
I have not seen John Pembertons 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 1930s depression years over the health and nutrition of the poor, and particularly the unemployed,24 whence the British Medical Associations (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 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 examplethe 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 todays 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 6 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 comparison of unemployment benefit will be with todays Job-Seekers 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. Todays level thereby, in real terms, is about 3.5 times greater than the earlier one. The current figure will be supplemented a fifth by childrens 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.911
Interestingly, todays 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 costsfor our model family £257 per week.12
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A plea for rationalitypro guesswork |
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and to public health/social medicine |
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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 1821 years = £121.00; at 22 years plus = £137
Our assessment of the minimum costs of healthy living (now including 5% for contingencies and personal choicewe were criticized for neglecting this) is currently, mid 2002, £148.00 per 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.
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References |
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2 Titmuss RM. Poverty and Population. London: Macmillan, 1938, pp. 22745.
3 Morris JN, Titmuss RM. Health and social change: the recent history of rheumatic heart disease. Med Officer 1944;72:6971, 7773, 8587.
4 Drummond JC, Wilbraham A, Hollingsworth D. The Englishmans Food. Jonathan Cape, 1957, pp. 44248.
5 MGonigle GCM, Kirby J. Poverty and Public Health. London: Gollancz, 1936.
7 Smith D. The social construction of dietary standards: the British Medical AssociationMinistry 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. 279303.
8 Department of Work and Pensions, Quarterly.
9 Routh G. Occupation and Pay in Great Britain 190679. 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.[CrossRef][ISI][Medline]
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 Improvement. 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;54:88589.
16 Rawls J. A Theory of Justice. Oxford: Clarendon Press, 1972, pp. 6083, 9095.