London School of Hygiene & Tropical Medicine

Like others, she drew parallels between the COVID-19 crisis and the mobilisation of Britain’s civilian population during the Second World War.  There are certainly similarities. As then, ordinary citizens feared for their lives.  As then, the health system was under tremendous pressure to provide intensive care beds.  As then, restrictions were placed on individuals’ freedom and the state worried about morale.  And as then, the government made massive financial commitments and took extraordinary powers to manage the situation.

But probe further and it’s the differences, not the similarities that are more striking.  It’s worth thinking about these, both because they bring home what is really novel about today, and because they tell us something about the true legacy of World War Two for public health.

Unlike today, fear of death was felt by people of all ages.  Of course, the armed forces were most in harm’s way, but the aerial bombing of cities menaced children, adults and older people alike.  With COVID-19 though, all the evidence suggests that it’s the elders who are most threatened.  In countries which have tested widely, the case fatality data shows a clear difference between young and old, with risk of death highest amongst the over-80s.  We should also remember that because of rising life expectancy, Britain in 2020 has a much larger population of octogenarians, nonagenarians and centenarians than in 1939.  In that sense, today’s focus of care and concern is very different.

Also unlike now, Britain was well prepared for the wartime crisis.  The Johnson government has received much flak for not acting quickly enough after the news from China arrived in January.  Despite the existence of a Biological Security Strategy, effective preparations were not made and policy-makers have been running to catch up.  This was very different from 1939.  The threat of war had been on the minds of government and people throughout the 1920s and 1930s, and it loomed ever larger with Hitler’s aggressive actions in Central Europe.  This meant planning was well advanced when war actually came.

The greatest concern was the effects of aerial bombing.  People could recall the limited bombing of London in the 1914-18 conflict, while more imminent horrors were brought home by newsreel images of destruction in the Spanish Civil War, immortalised in Picasso’s ‘Guernica’ (1937).  Just as today’s mathematical modellers are forecasting the likely effects of COVID-19, so the 1930s planners modelled the probable casualties of a Blitz on London.  Calculations were based on the numbers of deaths per tons of bombs dropped, which were periodically modified with new data about German rearmament.  An Air Raid Precaution department was active from 1935, and by the eve of war government was anticipating a ‘knock-out blow’ would fall on London, leading to 600,000 deaths and 1.2 million casualties.  This proved to be a wild overestimate - the real figures were 43,000 civilian deaths and 140,000 injured.  Nonetheless, it informed plans for mass evacuation from the big cities, propaganda to avert widespread panic, and state control of the hospital service.  Britain even had 1.5 million gas masks ready for distribution by 1937 - a stark and rather morbid contrast with today’s scramble for face masks.

In the early phase of the war, evacuation began with about 1.5 million schoolchildren, expectant mothers and younger children leaving London and other big cities.  Billeted with families in small towns and country areas, the experience proved difficult for many.  Evacuees felt bored, constrained and isolated from friends and family. 900,000 had returned home by Christmas 1939, after the bombing failed to materialise.  Though very different, this may tell us something about the difficulties of sustaining consent for a lockdown over the long term.

Other public health impacts of evacuation were unexpected.  There was much discussion of ‘enuresis’ – widespread bed-wetting amongst younger children.  Child psychologists reflected on the emotional effects of parental separation, while the government lodged bulk orders for ‘mackintosh’ under-sheets.  Middle-class reception families were often surprised to discover the condition of their fellow citizens.  Not only were the shoes and clothing of the urban evacuees shockingly poor, but many children also had body lice and were under-nourished.  Just as in today’s debates about protecting marginal workers, the crisis confronted the nation with some unpalatable truths.

What about the plans for propaganda to avert mass panic?  Memories of First World War ‘shellshock’ coupled with the new science of psychology had convinced the government that collective neurosis was a real threat.  The famous ‘Keep Calm and Carry On’ poster was one result, with over a million ready for distribution in September 1939.  Ironically though, when it turned out that morale remained high, the print run was pulped for fear it would seem patronising.  Slightly later came the ‘Coughs and Sneezes Spread Diseases’ posters, depicting scenes from the underground, factory and office in which characters forcefully sneezed without covering their faces.  The tagline ‘Keep Britain Fighting Fit’ revealed the agenda of maintaining productivity alongside good health.  Central government also ramped up publicity for diphtheria testing and immunisation, finally driving down this childhood disease. 

Another lasting impact on health came from the Emergency Medical Service (EMS), organised in 1938 to prepare for the anticipated deluge of patients.  Hitherto Britain’s hospital system was a pluralistic melange of independent charity hospitals, local government asylums and isolation hospitals, and Poor Law workhouse infirmaries.  Beds, nurses and specialists were patchily distributed, and access was a confusing mix of free care, cheap insurance and charging, with many gaps in the safety net.  Essentially the EMS meant state takeover, empowering government to organise bed capacity, direct staffing and designate hospital activities.  Although Labour ‘s election victory in 1945 was decisive to the birth of the postwar NHS, there is also no doubt that by demonstrating state medicine could successfully combine efficiency with caring, the EMS was its parent.  Here is a final salutary lesson of history: after a long period of anxiety and privation, Britons expected a fair and decent aftermath.  Our NHS was the result.