Irish Medical Responses to Problem Drinking from Institutionalisation to Public Health: Part II

In the second instalment of this two-part special, Dr Alice Mauger, Wellcome Trust Postdoctoral Research Fellow at the UCD Centre for the History of Medicine in Ireland explores the changing approaches of medical practitioners and psychiatrists to problem drinking in Ireland since 1922.

Read Part I here.

After the First World War, medical interest in the “drink question” began to wane and political barometers swung strongly towards attempts to limit drinking. Among the most infamous of these tactics was the United States’ prohibition experiment, which resulted in a nationwide ban on drinking from 1920 until 1933. Meanwhile, the newly formed Irish Free State government lost little time overhauling liquor regulations, restricting pub opening hours and decreasing the availability of pub licenses. While this demonstrated state concern about both levels of drunkenness and the money being spent on drink, the same government was slow to reflect on the treatment of alcoholism.  

New York City Deputy Police Commissioner watching agents 
pour liquor into sewer following a raid during the height of 
Prohibition. Source: United States Library of Congress's 
Prints and Photographs division.

A New 'Disease View'

Beginning in the United States, a new ‘disease view’ of alcohol addiction emerged after the abolition of prohibition in 1933. The fundamental difference between this new medical concept and its nineteenth-century predecessor was the perception of drink itself. While the earlier interpretation saw alcohol as an inherently addictive substance, posing a risk for everyone, the post-prohibition version portrayed drink as harmless for most but with the potential to cause disease in a minority of vulnerable or ‘defective’ individuals – labelled alcoholics.

In an era of mounting medical concerns over immunisation, tuberculosis and infant mortality, accompanied by the general rise of preventative medicine, this ‘disease view’ of alcoholism did not take hold in Ireland until after the Second World War. In the meantime, there was a marked decrease in alcohol consumption in Ireland during the first half of the twentieth century.

Alcoholism and Mental Hospitals

In 1945 new legislation broke ground, giving statutory recognition to the role played by mental health services in supplying addiction treatment. The Mental Treatment Act, 1945 specifically provided for the admission of ‘addicts’, including those addicted to alcohol, to mental hospitals. This signalled growing acceptance of alcoholism as a disease requiring treatment. It also cemented what was already a reality for the Irish psychiatric services. As mentioned in a previous post, Irish mental hospitals had been principal treatment centres for problem drinkers since the nineteenth century and by 1900, 1 in 10 admissions were attributed to ‘intemperance in drink’. 

In spite of these developments, it was not until the 1960s that psychiatrists began openly advocating the disease theory. This decade also saw the establishment of the first specialist wards for alcoholism in Dublin psychiatric hospitals like St John of God’s in Stillorgan and St Patrick’s Hospital on James’ Street. Concurrently, there was a marked rise in the number of alcohol-related admissions to psychiatric hospitals from 561 in 1958 to 1,964 in 1967.¹ It is uncertain whether these figures represented an increase in the actual numbers of alcohol-related cases presenting or in the numbers being identified. What is clear, however, is that by this point the role played by psychiatric services for alcoholism in Ireland had crystallised and psychiatrists had apparently grown more comfortable with this function.

Source: Wikimedia Commons

Dr John G. Cooney

Possibly the most avid individual advocate of the new disease view was Dr John G. Cooney, a consultant psychiatrist at St Patrick’s Hospital who became one of Ireland’s leading authorities on the psychiatric treatment of alcoholism.² Speaking at the North Dublin Medical Club Symposium in 1963, Cooney urged his medical colleagues to accept the disease view:

Too often doctors have allowed their view of alcoholics to be distorted by emotional factors. Commonly their own subconscious fears regarding alcoholism have been projected on to their alcoholic patients. If one is to treat alcoholism successfully whether in hospital of in general practice one must feel as well as believe that the alcoholic is ill and suffering from a disease just as surely as a diabetic is suffering from his excess blood sugar.³

Resistance to the Disease View

The theory’s central tenet, however, did not sit well with many Irish commentators. After all, the premise that alcoholism constituted an inherent ‘flaw’ in the individual was a difficult pill to swallow in a country with increasing psychiatric admissions for that very disorder. Illustrating this point in 1962, a consultant psychiatrist at St John of God’s, Dr Desmond McCarthy, complained:

One of the great difficulties in this country was that alcoholism was not accepted as an illness. It still carried a social stigma, a rather foolish way of looking at a serious disease. The basic illness was often hidden under other names for face-saving thus there were no reliable figures for alcoholism.⁴

Evidence of a persistent stigma around alcoholism in Ireland was produced as late as 1969. Reporting on an alcoholism seminar for general practitioners in Waterford that May, the Irish Times’ medical correspondent, David Nowlan wrote of the survival within the Irish medical profession of ‘medieval attitudes’. Nowlan described how one general practitioner had stood up at the end of the seminar and ‘stated quite categorically that alcoholism was a sin in the face of God and against God’s works deserving of only censure and moralistic indignation’.⁵

Social and Cultural Factors

By the 1970s, psychiatrists were devoting some space to the impact of social and cultural change in Ireland. According to Cooney, modernisation had brought with it a variety of new factors which were now influencing Irish drinking habits. These included increasing social mobility in rural Ireland leading to more money being spent on drink; the replacement of dimly-lit, all-male pubs with brightly-lit bars and singing lounges catering to younger married couples; expense account drinking in the cities following the patterns of London and New York; and the centrality of alcohol on all social occasions and in many business transactions. Cooney’s observations were not unfounded. The 1960s had seen a massive economic boom, resulting in greater disposable income and a dramatic climb in expenditure on drink. Inevitably, Cooney argued, ‘all this exposure to alcohol has led, in the opinion of many workers in the field, to an increase in alcoholism’.⁶

Campaign Poster for Public Health (Alcohol) Bill, 2015.
 With thanks to Alcohol Action Ireland

A Public Health Approach to Alcohol

Cooney’s concerns about increasing exposure to alcohol were illustrative of those in Ireland and elsewhere. The 1970s marked a turning point in attitudes towards drink in many countries. By now, epidemiologists were linking rising per capita consumption with a concurrent growth in alcohol-related harm, including deaths from liver cirrhosis and convictions for drunkenness and drink-driving. Alcohol therefore came to be presented, once again, as a problem for everyone rather than a minority deemed predisposed to alcoholism. Designated the ‘public health’ perspective, this approach gradually supplanted the disease concept. Yet, in spite of the efforts of its proponents, and its acceptance and promotion by the World Health Organisation, until quite recently governments have been reluctant to impose corresponding legislation. 

The passing of Ireland’s Public Health (Alcohol) Act in 2018 therefore represents a landmark in alcohol policy. It also reveals an unprecedented unity among medical responses to problem drinking today. Internationally, it has received strong backing from leading public health organisations and in Ireland, the Royal College of Physicians of Ireland have partnered with national charity, Alcohol Action Ireland, to form the Alcohol Health Alliance Ireland, for whom a central aim has been to support the Bill. Meanwhile, the President of the College of Psychiatrists in Ireland, Dr John Hillery, stated in November 2017: ‘the College supports the bill in its entirety, not a diluted version, to protect the mental health of our society’.⁷

Alice Mauger

Dr Alice Mauger

Dr Alice Mauger is a Postdoctoral Research Fellow at the Centre for the History of Medicine in Ireland in the School of History, University College Dublin. Her research project 'Alcohol Medicine and Irish Society, c. 1890-1970' is funded by the Wellcome Trust. The project explores the evolution of medicine's role in framing and treating alcoholism in Ireland. It aims to make a significant contribution to the medical humanities, exploring historical sources to better understand and contextualise Irish society's relationship with alcohol. She was awarded a PhD by UCD in 2014 for her thesis which examined public, voluntary and private asylum care in nineteenth-century Ireland. Prior to this she completed the MA programme on the Social and Cultural History of Medicine at the UCD Centre for the History of Medicine in Ireland, UCD. Both her MA and PhD were funded by the Wellcome Trust.

She has published on the history of psychiatry and alcoholism in Ireland including '"The Holy War Against Alcohol": Alcoholism, Medicine and Psychiatry in Ireland, c. 1890–1921’ and a full-length monograph: The Cost of Insanity in Nineteenth-Century Ireland: Public, Voluntary and Private Asylum Care (Palgrave Macmillan, 2017) which is available via open access and in hardcopy.

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1. John G. Cooney, ‘Rehabilitation of the Alcoholic’, Journal of the Irish Medical Association 63, no. 396 (1970), 219-22, on 220.

2. Cooney was responsible for the establishment of a specialist treatment programme for alcohol-related disorders at St Patrick’s, published extensively on the topic of alcoholism and was a founding member of the Irish National Council on Alcoholism.

3. John G. Cooney, ‘Alcoholism and Addiction in General Practice’, Journal of the Irish Medical Association 53, no. 314 (1963), 54-7, on 55-6.

4. ‘Problem of Treating Alcoholism’, Irish Times, 3 March 1962, 7.

5. David Nowlan, ‘Hidden Disease Dangers: Doctors Discuss Alcohol’, Irish Times, 17 May 1969, 4.

6. John G. Cooney, ‘Alcohol and the Irish’, Journal of the Irish Colleges of Physicians and Surgeons 1, no. 2 (1971), 54.

7. ‘Public Health (Alcohol) Bill for Discussion in Senate Today: College highlights Alcohol’s Role in Completed and Attempted Suicides and Mental Health Difficulties’, The College of Psychiatrists in Ireland Blog (21 Nov 2017).

A Prescription for Change: Training a Doctor in Nineteenth and Twentieth-Century Ireland

In this blog post, Natalie Baldwin, a graduate of UCD's MA in History of Welfare & Medicine in Society, explores the realities of training as a medical professional, past and present.

Today, when we think of a medical doctor, it is easy to imagine an intelligent, respected, hard-working and well paid members of society who enjoys a high social status. It is therefore tempting to assume this has always been the case, that a career in medicine has always been both socially and financially rewarding. It may be surprising, then, to learn of the ups and downs medical students and their families have faced since the nineteenth century. 

A Case of History Repeating Itself  

The Fitzgerald family kept a small but considerable archive of artefacts and documents relating to members of the family reaching back to the 1840s. When these were donated to the Royal College of Physicians of Ireland Archives, they presented an incredibly exciting opportunity for an inherently curious person like myself to get stuck in. As I began to work through this archive, what struck me most about the Fitzgerald family was that so many of its members entered into a career in medicine. What seemed to start with Alexis and his brother James in the 1850s resulted in a medical dynasty that still survives today. Two members of the family stood out especially. Dr James Fitzgerald was born in or around 1838 in Tipperary. He moved to Dublin in the 1850s to study medicine, a move that was perhaps in part motivated by the fact that his older brother Alexis did the same thing a few years earlier. Two generations later, his grand-nephew Gerald entered UCD, the reincarnation of the Catholic University of Ireland which James had attended, to study medicine. Like his great-uncle James, he was following a path set by his older brothers and by now, his father, as medicine had firmly taken root as the Fitzgerald family business. James and Gerald went on to leave Ireland once they graduated. For James, it was to join the Navy while Gerald was offered the chance to further his education and career by leaving for England and Scotland. Sadly, these were not the only striking similarities between the pair as both died prematurely back home in Ireland in their thirties.

Thinking about James as representative of a doctor’s education and career in the nineteenth century and Gerald as representative of the twentieth century, we will take a look at how the education, career, and social standing of a doctor in Ireland changed or perhaps, stayed the same.

Status Update

'A poor apothecary in a cart being drawn by his servant are 
overtaken by a wealthy couple in a horse-drawn carriage 
with a seat at the back for their servant'. 
Credit: ​WellcomeCollection​. ​CC BY

The decade or so preceding James’s entry into medicine saw many attempts to professionalise the sector. In trying to move medicine away from being considered a trade to a profession, this naturally had a knock on effect towards the social standing of the doctor. Generally, and particularly before the middle of the nineteenth century, medicine had a tripartite structure and like most structures, was hierarchical in nature. At the top there was the physician, followed by the surgeon with the apothecarist sitting on the bottom rung of the ladder. The three enjoyed differing levels of social status. Alongside the orthodox or ​regular practitioners, were the unorthodox practitioners or "quacks". These included druggists, bonesetters or any member of the medical community that occupied the fringes of society. The medical marketplace was already overcrowded, especially in England, and having to compete for patients alongside unqualified "quacks" naturally created some anxiety for the trained practitioner. 

The Medical Act, 1858 attempted to alleviate some of these concerns. The Act tried to regulate the education and training of doctors and required all practicing members to sign the registry of the General Medical Council (GMC). While it differentiated between regular and irregular practitioners by only allowing fully trained and qualified ones to sign the register, the Act failed to prevent "quacks" from actually practicing. Members of the public were still unlikely to be able to discern between the two. The Act went some way towards professionalising medicine by trying to control entry and setting a standard of training. This meant that registered practitioners could distance themselves from tradespeople by charging for a service rather than a commodity. However, the Act was considered a failure for many orthodox members of the community as it still meant they had to jostle their way through a saturated market rife with "quacks".¹

So what did all this mean for James and Gerald? Well for James, he started his studies just a few years before the 1858 Act came into effect. In fact, he graduated the following year. For students studying at this time, the terms of the Act specified that they would not be penalised and their training and education would be valid. Gerald did not begin his studies until 1930 but even so, the Medical Act of 1858 could have caused some worries of their own for him, even almost seventy years later. Unlike his great-uncle, Gerald began his medical career in post-independence Ireland. However, like his great-uncle’s experience, medical education was still under the influence of Britain and the control of the GMC. The Medical Act of 1858 threw up its own obstacles for the medical profession in the newly established Free State. For starters there was talk of setting up a separate medical register for the newly partitioned island. This created unease amongst the community with many highlighting the fact that Irish doctors relied on work in Britain and therefore needed to remain eligible to sign the general medical register upon graduation. Universities would suffer too if the numbers of medical students dropped as they relied heavily on their fees to keep the university as a whole afloat. Luckily for Gerald and those who studied in the few years before him, the issue was resolved in 1927 with the Medical Practitioners Act where it was agreed that Irish doctors could still sign the general medical register.

The Price of Education 

Despite the fact that medicine was clearly an economically precarious and overcrowded business, in nineteenth and twentieth-century Ireland, many students, or indeed their parents, were motivated to study medicine by the promise of social mobility and the chance to earn a place among the ranks of the middle classes.²

'A foppish medical student smoking a cigarette, 
a tankard  is on top of his medical books;  
denoting a cavalier attitude (1854)'. 
Credit: WellcomeCollection​. ​CC BY

Encouraging your child to attend a medical school was not without its financial sacrifices though. Factoring in the cost of lodgings, lectures, grinds, clothing expenses, reading materials and general maintenance costs, it is estimated that sending a student to Cecilia Street where James received his education, cost about £400-500.³ Bursaries were available for less well-off students attending Cecilia Street who wanted to study medicine but amounted to only £40 a year for up to two year’s study. In most cases, the cost of funding a medical student’s education fell to the parents. Nothing in James Fitzgerald’s personal notes indicated he was working to fund his studies so most likely he was put through university by his parents. James’s older brother Alexis was also a doctor and graduated four years before he did. Considering a doctor during the late nineteenth century would go on to earn about £90 to £120 a year, it seems less likely that parents were driven by the financial incentive of having a doctor in the family. We should also remember that the sacrifices began well before sending a student to university as in the second half of the nineteenth century receiving just a second level education placed you in the minority.⁴ For James’s grand-nephew Gerald, the financial costs of a medical degree had increased further. Gerald graduated from UCD in 1936. In the years before the outbreak of World War Two, the cost of obtaining a medical education was said to be approximately £1500.⁵

The financial situation may not have improved for James even after he qualified and secured a position as assistant surgeon in the Royal Navy. For starters, navy surgeons had to acquire their own kit of surgical tools. This seems unreasonable enough but when you consider that an assistant surgeon like James was paid only about £2-£3 per month,⁶ the economic incentive for becoming a doctor seems less and less appealing.

Upwardly Mobile

If the potential financial rewards were not especially inspiring, it would seem more convincing that the motivation for parents to encourage their children into a career in medicine was driven by the sense of respectability garnered through having a doctor in the family. Kelly likens this to the social standing Catholic families in the late nineteenth and early twentieth century attained from having a priest in the family.⁷ James and Alexis’s parents must surely have enjoyed a significant sense of respectability as not only did they have two doctors in the family, but a priest as well in their third son Fr Michael.

There may have been other factors though in motivating James’s and Gerald’s entry into the world of medicine. Kelly writes about how medical education in Ireland tied in with notions of manhood and its transformative power of turning boys into men. She also speaks of how its competitive nature further emphasised the traditionally masculine nature of the medical student.⁸ As James’s older brother Alexis studied medicine too, it is possible to imagine that this competitive manliness tied in with sibling rivalry and he simply wanted to copy his older brother’s example.

The Family Business

By the time Gerald decided to begin his journey towards being a doctor though, things had changed quite a bit for the Fitzgerald family. While the two generations prior had seen his great-uncles James and Alexis carve a path into medicine, Gerald was born into quite a different landscape. Gerald’s father Alexis was doctor and medical officer at Waterford District Asylum at the time of Gerald’s birth in 1913. Many students entered into medicine because it was the profession of their father. Over 11% of students who graduated from the Queen’s Colleges in 1872-1917 had a family background in medicine.⁹ However, it wasn’t just Gerald’s father that could have influenced his decision. Not only were his father’s two uncles doctors, but his own uncle James as well as his two older brothers Oliver and Patrick. So while James and Alexis in the mid-nineteenth century may have been driven by a desire for middle-class respectability, Gerald may likely have felt that medicine was the family profession. 

The Spectre of Emigration 

Leaving Ireland upon graduating medical school was a fate that befell both James and Gerald. Ireland saw high levels of emigration generally throughout the late nineteenth and early twentieth century. This was particularly acute though within the medical profession.¹⁰ With so many doctors emigrating to England from the medical schools in both Ireland and Scotland, these years ushered in a period of underemployment among doctors. Add an abundance of qualified doctors to the fact that there still remained some competition from the unregulated practitioners, and there was now increased pressure to find suitable and fulfilling positions for the medical graduate.¹¹

Out at Sea

'Naval officers and men on a ship, dressed in the 
uniform of nine labelled ranks of the Royal Navy'.
Credit: Wellcome Collection. CC BY  

James graduated in 1859. In a cohort of medical students studied by Jones from the period 1860-1960, the number working outside of Ireland ten years after graduation was found to be 41%. James was therefore not unusual in his path following graduation as the same cohort studied showed that for those not practicing in Ireland after graduation, the majority either set up their own practice in England or, like James, served in the military or within the British Empire.¹² It may seem unusual for a Catholic like James to have joined the Royal Navy but in fact, he was one of a growing number of men from Ireland who joined from the 1840s onwards. For them, life in the Navy particularly as a medic, offered an escape from Ireland and a chance to further their career in a way that staying at home couldn’t allow.¹³ So while it would seem that he may not have been well rewarded financially, perhaps the adventure was enough to keep him there for seven full years considering many assistant surgeons left after serving only three years.¹⁴ Although, considering his sick list seemed to mainly record him treating case after case of venereal disease and coughs and colds, life in the Navy undoubtedly wasn’t one non-stop adventure.

The Export Market

Ireland enjoyed a good reputation in the post-independence era for its medical schools but like students of James’s era, emigration was still prevalent for graduates owing somewhat to economic hardship in the post-war period.¹⁵ The hundred year period from 1860 to 1960, which included Gerald’s years of study, saw more students go through Irish medical schools than there were positions for at the other end. Essentially, the emigration of medical graduates was considered par for the course. It may therefore seem strange that universities in Ireland continued to oversubscribe students for their medical schools knowing full well that they would be exporting many but the universities, particularly the Catholic University, relied heavily on the contribution medical students’ fees made towards the running of the entire institution.¹⁶ Gerald moved to London in 1938, two years after he graduated from UCD. He had been awarded a travelling scholarship by the Mater Hospital to study neurology. He stayed in London for some time before eventually moving to Edinburgh to further his career again, this time to study psychiatry. He did not return to Ireland until about 1945 when he took up a post in the Mater Hospital.¹⁷ Like James, leaving Ireland had certainly afforded Gerald greater opportunities to develop as a doctor, gain independence, and broaden his skills.

The More Things Change…

What of today then? We could easily assume that a doctor in the twenty-first century has it much easier than James or even Gerald did. But perhaps things actually are not so different. While a doctor’s social status may have improved since James’s time, recent studies have shown that members of the medical profession report feeling under-respected. With increased competition from other healthcare practitioners echoing the struggle of the previous generations, and less and less professional autonomy, many doctors feel they do not enjoy the same level of status as the profession once did or as perhaps they expected to experience.¹⁸ There are regular reports in the news highlighting the fact that Ireland continues to produce doctors for export with many leaving for the UK, Australia and the US. Staff shortages are common place in Irish hospitals along with overcrowding from patients. Salaries for consultancy positions have not recovered to the levels they were before the economic recession.¹⁹ 

So if today’s doctor is overworked, underpaid, and under-respected, who would want to join such a profession? Well apparently, quite a lot of people. Places to study medicine in Irish universities are still some of the most competitive, typically requiring some of the highest CAO points. The introduction of the Health Professions Admissions Test (HPAT) some years ago attempted to ensure that well rounded candidates were offered places rather than just those that achieved the highest academic scores. School leavers and even mature students are clearly not deterred despite the various challenges – new and old – that beset the medical profession. Like James and Gerald, many could be following an already established family path into the profession. It is likely that for many, having to leave Ireland upon graduating is seen as an exciting opportunity rather than enforced emigration. Rather than being seen as a badge of social standing, there is also the possibility that an offer to study medicine is viewed as a mark of intellectual status. It is well known how hard a secondary school student must work to earn enough Leaving Certificate points to be offered a place. To actually complete the five to six years of medical training is definitely a remarkable achievement. For some, perhaps medicine is just in the blood; a path they were destined to follow, neither a trade nor a profession but simply a vocation.

Natalie Baldwin

Natalie Baldwin completed her MA on History of Welfare & Medicine in Society at the UCD Centre for the History of Medicine in Ireland in 2018/2019.

Acknowledgements

Research completed in collaboration with Harriet Wheelock, Keeper of Collections, Royal College of Physicians of Ireland Archive Collections.

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1. Anne Digby, ​Making a Medical Living: Doctors and Patients in the English Market for Medicine, 1720-1911 (Cambridge, 2002), pp 28, 31, 36-37.

2. Laura Kelly, ​Irish Medical Education and Student Culture, c. 1850-1950 (Liverpool, 2017), pp 200-203, 71, 73.

3. F.O.C. Meenan, ​Cecilia Street: The Catholic University School of Medicine 1855-1931 (Dublin, 1987), p. 24.

4. Kelly, ​Irish Medical Education, p. 74.

5. ‘​The Cost of Medical Education’, British Medical Journal, 6 September 1947, p. 392.

6. Jonathan Charles Goddard, ‘The Navy Surgeon’s Chest: Surgical Instruments of the Royal Navy during the Napoleonic War’, ​Journal of the Royal Society of Medicine, 97 (2004), pp 191-197.

7. Kelly, ​Irish Medical Education, p. 84.

8. Laura Kelly, ‘Irish Medical Student Culture and the Performance of Masculinity, c. 1850-1930’, ​History of Education, 46, no. 1 (2017) pp 39-57.

9. Kelly, ​Irish Medical Education, p. 73.

10. Greta Jones, ‘“Strike Out Boldly for the Prizes that are Available to You”: Medical Emigration from Ireland 1860-1905’, ​Medical History, 54 (2010), pp 55-74.

11. Digby, ​Making a Medical Living, p. 140.

12. Jones, “Strike out Boldly,’’ pp 56, 59.

13. S. Karly Kehoe, ‘Accessing Empire: Irish Surgeons and the Royal Navy, 1840-1880’, ​Social History of Medicine ​ 26, no. 2 (2012), pp 204-224, 207.

14. ‘Army and Navy Medical Service’, ​British Medical Journal 1, no. 275 (1866), p. 366.

15. Kelly, ​Irish Medical Education, p. 201.

16. Jones, ‘Strike out Boldly’, p. 68.

17. Edward A. Martin, ​A Historical, Biographical and Anecdotal Account of the Neurological Sciences in Ireland from the earliest days to 1975 (Dublin, 2012), pp 40-1.

18. Lipworth et al. Doctors on Status and respect: A Qualitative Study, ​Bioethical Inquiry, ​10 (2013) pp 205-206.

19. ​Irish Times, 26 Dec 2017; Irish Times, 26 Sept 2018.

Local Health Authority Day Nurseries by Angela Davis

Local health authority day nurseries in post-1945 England 

In this month's blog Dr Angela Davis (University of Warwick) considers the fate of local health authority day nurseries in England from 1945 to the 1970s. While the national trajectory during this period may have been one of decline, this trend masks considerable local variation with some authorities regarding the day nursery as an intrinsic part of the health service and others considering them, at best, marginal.

War Nurseries

Handing over the Women's Voluntary Service War Nursery,
Manor House, Wendover, Buckinghamshire, England, UK,
1941, © IWM (D 2424).

In a Ministry of Health Circular in 1945 the Minister of Health for England and Wales declared that the right policy to pursue would be to positively discourage mothers of young children under two from going out to work and to make provision for children between two and five by way of Nursery Schools and Nursery classes.

From the numerous and widely used local authority administered day nurseries, commonly known as ‘war nurseries’, which were open to all working mothers during World War Two (in 1944 there were around 1,450 full-time nurseries and 109 part-time nurseries), in the late 1970s the day nursery service had become a much more limited form of provision intended to prevent children being harmed by inadequate homes or parents and to avoid the last resort of resort of residential care, including children from difficult family backgrounds, one-parent households, and some handicapped children.

Local Variation

However these national trends figures mask the very real variation at the local level that took place. State-provided day nurseries remained the responsibility of Ministry of Health in the years after the war (responsibility was finally transferred to the Social Services Departments in 1971), and administered through the local health authorities. The local health authority day nurseries were under the ultimate control of the medical officer of health for the area and these medical Officers of Health had very different attitudes about the importance of the provision of day nurseries. While some thought the service was an intrinsic part of the health and welfare provision in their area others were keen to cease providing the service altogether. Throughout the period the provision offered by London Local Authorities was higher than anywhere else in the country. In contrast, the provision offered in rural areas was the most limited. In order to consider these local differences more fully, will look at three case studies – Coventry, Camden (London) and Oxfordshire.

London Borough of Camden

The London Borough of Camden was created in 1965 from the former area of the metropolitan boroughs of Hampstead, Holborn, and St Pancras, which had formed part of the County of London. In 1948 there were 23 day nurseries in the health division area 2, which most closely resembled the later borough of Camden. These nurseries had places for 1,398 children. The divisional health officer explained that many of the wartime nurseries that had been requisitioned for the duration of the war had since been returned to their original uses. As a result, the number of children on the waiting list, which numbered 3,121, far exceeded the number of places available and therefore a scheme of priorities for admissions to day nurseries has been drawn up to take into account of economic and health factors. The cost to parents at this time was negligible. A standard charge of 1s. a day was made for each child placed which covered the cost of the midday meal. However, even the following year, the tone of the reports was changing with the London County Council Medical Officer now stressing that the high cost of maintaining a child in a day nursery caused concern, and attempts were being made to effect economies. Instructions were issued as to economical ordering of supplies and preparation of meals. By 1951 it had become policy that the total day nursery provision should be kept at its existing level, although notably no expansion was planned. Moreover attendances at the nurseries were to be continually under review and closures and amalgamations were to take place when possible. The ratio of staff to children reduced. Nurseries were now to be closed on Saturdays and the priorities for admission were tightened.

Policy Reversal

Annual Report of the Medical Officer of Health
and Principal School Medical Officer for the
year 1965 by Wilfrid G. Harding (1966). Wellcome
Library, London's Pulse: Medical Officer of Health
Reports 1848-1972.

Interestingly, in 1953 there seemed to be a reversal in policy. The priorities for admission were softened. A third group was introduced, namely the children of working mothers whereby the parents income exceeded 9 pounds a week. Why did this occur? It seems clear that the council were concerned about falling attendances that had resulted from a central government order increase the charges for day nurseries with the charges for children at the nurseries was raised to a minimum of 4s. a day. As demand grew in the years that followed, however, the number of children admitted from priority group 3 was again reduced. Other groups were also seen as more needy, particularly those from ethnic minority backgrounds, but also children with disabilities. However there was no growth in the number of day nurseries to match the increased demand. In 1965, the report of the new Camden health authority, reported that the council had ten nurseries providing 541 places for children under five. This compared to the 23 nurseries with places for 1,398 that had existed in 1948.

Cutting Costs

So what do these reports from Camden reveal? Firstly, they indicate that provision declined rapidly after World War Two, but mainly from a desire to cut costs. Nowhere is it mentioned that the policy of the council was that the place of young children was to be with their mothers. The priorities for admission reflected this overriding economic concern. Priorities were tightened when the nurseries were over-subscribed and reduced when attendances fell. The authority seemed to be guided above all by a desire for the day nurseries to be cost effective and seemed to view them a worrying expense rather than an essential part of their service.

Coventry

Portrait of Sir A. Massey.
Wellcome Library, London.

But not all authorities viewed day nurseries in the same way. In his Annual Report from 1944 Arthur Massey, the Coventry Medical Officer of Health stated that, ‘There is no doubt that there is a useful place in the peace-time maternity and child welfare scheme for day nurseries, for they offer valuable medical, nursing and educational care to the children in attendance. Moreover they could provide for the occasional care of children of mothers needing respite from the continual round of domestic work’ (p. 7).

It is clear from the outset that Coventry envisaged a wider for their day nurseries than the belief of central government that they should only be for children in ‘special need’. In consequence every effort was made to keep the nine day nurseries that had existed during the war in operation in the years that followed.

Reducing Charges

Coventry health authority also reacted in a very different way to London in response to Ministry of Health Circular No. 23/52 which increased the daily charges of the nurseries. Like London, Coventry quickly saw a fall in numbers, but unlike London, who responded by opening up the nurseries to non-priority groups, Coventry responded by reducing the charges. Moreover, rather than aiming to simply maintain provision at the level of the early 1950s as London did, Coventry wanted to increase day nursery provision. They were certainly not seeking to reduce their number of nurseries. Indeed the poor state of the current nurseries, the need to build new nurseries, and the increasing demand upon places was a constant refrain in the annual reports. By the mid-1960s, the medical officer reported that they could no longer offer places even to those deemed of high priority. Moreover in his report from 1969 the then Medical Officer of Health Thomas Clayton clearly indicated that he would like to reduce the stringency of the priorities imposed, stating: ‘The slowly declining birth rate has as yet had little effect on the under 5 population and the static day nursery provision is gradually becoming more inadequate. (p. 38). Moreover, unlike in Camden, the Medical Officer could report in 1970 that the number of day nurseries in Coventry had remained at the same level as at the end of the war. In 1948 there were 9 nurseries with 88,650 attendances. In 1970 there were still nine nurseries with 89,437 attendances.

An Essential Part of Health Authority Provision

So from the Coventry experience we can see that some local health authorities took a far more active approach to the provision of day nursery provision than my other case studies. The Coventry Medical Officer of Health saw day nurseries as an essential part of health authority provision in the area. Rather than seeking to reduce the service or being concerned about the cost of providing day nurseries, he was constantly wanting to expand the number of nurseries and places he could offer, and indeed make them available to children without ‘special needs’. Moreover, he was clearly frustrated with the lack of encouragement he received in this ambition from central government.

Oxfordshire

A Nursery School: Watlington Park Children
in Wartime - Five Lithographs by Ethel Gabain.
© IWM (Art.IWM ART LD 263).

The provision of day nurseries in Oxfordshire was considerably lower than in either Camden or Coventry. From the seven war nurseries that had been open throughout the county in 1945, only 2 remained in 1948, accommodating about 80 children.

The Medical Officer noted that they were ‘primarily intended for mothers who are forced by economic circumstances to go out to work. By 1951, there was only one day nursery provided by the county, in Banbury, accommodating 40 children. In 1960 the Medical Officer of Health was questioning the nursery’s continued existence. While the nursery did stay open, it was clearly not viewed as an essential service.

Better off at Home with Mother

The reason for this ambivalence may be in the Oxfordshire local health authority’s attitude towards the institutional care of children. They clearly felt that young children were better off with their mothers and in his 1966 report stated: ‘attendances under the age of two and a half are discouraged’ (pp. 18-19). However, the annual reports also documented the growing demand for day nursery care in Oxfordshire, which the Medical Officer of Health attributed to the increasing urbanisation of Oxfordshire. However, even in 1970, there remained only one nursery in the County. So it is clear that day nursery provision was considered as being rather marginal to the Oxfordshire local health authority. They were unsure about whether they should provide such a service and indeed whether young children should be in day nurseries at all.

Variable Provision

The provision local health authority day nurseries in postwar England was highly variable. It depended on the different material conditions and make-up of the populations in different areas, but also upon on local policies and personalities. For example the Medical Officer in Coventry championed day nurseries in a way that was not seen in Camden and which may account for the continued level of nursery places throughout the decades after the wars.

Angela Davis

Dr Angela Davis, Centre for the
History of Medicine, School of
History, University of Warwick.

Angela Davis is a Senior Research Fellow (Wellcome University Award) in the Department of History at the University of Warwick. Her research interests concern parenthood and childcare in Britain and Israel and the use oral history. Her book Pre-school Childcare, 1939-2010: Theory Practice and Experience was published with Manchester University Press in 2015.

You can listen to a podcast below of a talk by Angela, 'Developing Bodies and Minds: Children's Experiences of Preschool Childcare, Britain c.1939-1979',  given as part of the CHOMI Seminar Series, 29 January 2015.