Sick, Not Dead: The Health of British Workingmen during the Mortality Decline (review)

James Riley here gives the reader two books for the price of one. Much of his study is given over to assessing the medical practices of friendly societies—a long-term project, some preliminary findings of which were earlier presented in Sickness, Recovery, and Death: A History and Forecast of Ill Health (1989). Building upon a wide range of archives, notably those of the Ancient Order of Foresters, Riley demonstrates how such workingmen’s medical clubs had become almost part of the medical establishment by his chosen period (roughly from 1870 through to the Great War), by which time the coming of the National Insurance system (1911) was making such institutions obsolescent. Alongside the Poor Law (for the pauper sick) and medical charities, the special role of friendly societies lay in serving the workingman—and, occasionally, from around 1900, the workingwoman, too. By 1900 more than four million workers were thus insured, receiving, in return for contributions of around a penny a week, access to the society’s contract physician, free medicines, and, surely most important, a cash benefit in lieu of wages when certified as sick.

In a chapter on the “political economy” of the societies, Riley confirms the picture earlier established by David G. Green’s Working-Class Patients and the Medical Establishment: Self-Help in Britain from the Mid-Nineteenth Century to 1948 (1985) of a late-Victorian buyers’ market in health care: there were droves of rank-and-file GPs chasing too few affluent paying patients. The consequence, as Riley emphasizes, was in some respects a cut-price medical marketplace, which inevitably bred mutual suspicion and fears of exploitation: no physician enjoyed being dependent on contract practice, having to compete annually in a Dutch auction to sell his services—sometimes against as many as thirty other applicants; while the societies’ officers were all too aware that their members were likely to take second place to the physician’s private patients.

Yet, as is also shown, in a fine discussion of the “moral economy,” the mutual aid societies operated in a surprisingly smooth manner. Very few physicians were actually dismissed, and the level of formal complaints lodged against them was low. It seems that the societies’ stewards and “courts” performed an effective policing function, checking up on neglectful physicians and investigating malingering members; patients caught at the pub, or even digging their potatoes, while on sick pay, were liable to be fined! Riley plausibly suggests that the once-belligerent artisan culture had given way by 1900 to a greater respect for expertise.

The second book that Riley gives us consists of an ingenious attempt to use friendly society data to illuminate the changing health of the British in the half-century before the Great War. The raw records and also the actuarial calculations that the societies generated amply confirm the well-known mortality decline of the period, but equally display a rising sickness rate. That, of course, should not be read as an absolute worsening of health, but merely as the inevitable consequence of people living longer in an era when deaths from infectious disease were in steep decline. Premature death had always been an effective way of keeping sickness down; higher survival ushered in more sickness. Mortality and morbidity must be uncoupled as health indicators.

Discussing the apparently rising “sickness rate,” Riley scotches Edward Shorter’s suggestion that the increase in visits to the physician was a product of attitudinal shifts, a heightened perception of trivial complaints, a decline in stiff-upper-lip stoicism. In one respect Riley is quite right: on the whole, benefit-society members drew upon the services of the physician only when they were so sick as to be unable to work (it stood to reason: wages were much higher than sickness benefits). Yet the conflict of interpretation may be more apparent than real: in talking of a lowered pain threshold or the cultural inflation of...