Sick, Not Dead: The Health of British Workingmen During the Morality Decline.

By James C. Riley (Baltimore and London: Johns Hopkins University Press, 1997. xvii plus 349pp.).

In the nineteenth century friends and network of kin were no longer adequate in times of illness. To supplement the aid they gave, British workingmen founded organizations of their own, called friendly societies. These societies, which dated back to the middle of the eighteenth century, expanded rapidly and enrolled an estimated two-thirds of all adult workingmen at the end of nineteenth century. The researches of local historians in England show that by the 1870s membership of friendly societies comprised a cross section of those in the population who worked with their hands. Also, many workingmen joined whose employment was irregular. Membership in these societies was obtained by paying a weekly fee of at least four to six pence, which would cover medical aid, compensation for lost income during episodes of sickness and burial benefits. These weekly costs were relatively modest. A workingman with commonplace skills usually made sixteen to twenty shillings a week, making the fee 1.7 to 3.1 percent of his wage.

In a fascinating and detailed book James C. Riley studies two of these friendly societies, the Ancient Order of Foresters (AOF) and the Oddfellows in England. Contrary to what one would expect from their names, both societies were regarded as representative of the working classes in nineteenth century Britain. This is also confirmed by the author. James C. Riley's book is divided into two main sections. One deals in detail with the social and economic history of the friendly societies. The other section is demographic and deals with the mortality and morbidity of workingmen during the mortality decline and the epidemiological transition. By combining evidence from the 1891 census of England and Wales and the experience of friendly societies members in the years around 1891, Riley tackles the paradox of falling death rates and increasing sickness times which workingmen experienced after the turn of the century.

Perhaps a little more effort could have gone into molding the two sections closer together. Now, the book gives the impression of being two separate volumes. This is not necessarily negative - in its present form the book can be enjoyed both by demographers and social historians. Sick, Not Dead is well-written and attentively documented in footnotes. James C. Riley carefully explains the results from his analyses in the demographic section so that readers unfamiliar with, e.g., regression analyses are never lost. An appendix details the analyses which should satisfy any number cruncher.

To their members, the AOF and the Oddfellows served two important purposes. First, the society gave economic support to a sick member and his family. Membership guaranteed medical care from a qualified physician or a surgeon. In case of a fatal outcome the society also helped cover funeral costs. Second, and perhaps most important to its members, the society filled a social role. Membership gave an identity and separated the workingman from paupers on poor-relief. Society meetings, usually held in taverns, provided opportunities to socialize, eat and drink with comrades. Membership guaranteed that the workingman was visited on a regular basis in times of sickness and distress by other members and officials from the society. Even if these officials' main roles were to check if the workman was eligible for receiving benefits or not, they were still considered as welcomed visitors. To be alone in times of sickness was a sure sign of marginalisation.

The society contracted physicians or surgeons to attend its members. Up until the 1890s the workingmen got the better end of the bargain when contracts were negotiated. Doctors were plentiful while paying patients were not. Societies like the Foresters therefore managed to keep physicians' fees at a minimum, while securing frequent visits to their members and large doses of drugs. Riley admits the difficulty in assessing whether workingmen received the same qualitative care as private patients but without any evidence of a "downsized" medical attendance, he concludes that members received proper treatment according to contemporary standards. Also, members never voiced complaints about physicians' skills during what were often very outspoken society meetings. If they complained, and if the contract with the physician was broken, it was because he had failed to visit the sick workingman according to what had been agreed upon. However, all this changed in the 1890s when friendly societies assumed a much more subordinate role toward physicians. Medical men and medical associations had become much stronger and the bargaining power shifted in their favor. The National Insurance Act of 1911 marked the end of friendly societies as a driving force in medical care for British workingmen. Members of the AOF and Oddfellows had, up until now, managed to hire doctors at fees adjusted to what working people could afford to pay, and sometimes for less than they could afford. According to Riley, they paid more for tea than for medical care. Their health had also benefitted considerably. Members of AOF and Oddfellows had lower mortality than other workingmen in Britain. In Riley's own words: "The point is not whether doctors cured them more quickly. They did not. The point is that doctors may have prevented them from dying."

In the second section of his book Riley examines the mortality and morbidity transitions in Britain. Mortality declined in the decades following the 1870s at the same time as sickness time increased. However, it did not increase because people gradually fell sick more often or counted more episodes as sickness. It increased because sickness lasted longer. This is very much in line with what we learn from the theory of the "Epidemiological transition." A shift from infectious diseases to chronic disorders in higher age groups would tend to increase sickness time at the same time as mortality decreases. However, Riley brings forward a modified interpretation. Tuberculosis and other respiratory diseases were still important factors among British workingmen after the turn of the century. They no longer died of these diseases, but experienced longer episodes of sickness. Riley therefore proposes a morbidity transition with a time lagged disease panorama from that of the mortality transition.

Perhaps the most innovative and challenging chapter in Riley's book is the last, number 9. Admittedly speculative, this section sets out to measure the determinants of sickness time and mortality by combining evidence from the 1891 census of England and Wales and the author's own calculations based on the material from the friendly societies. Using regression analysis and ordinary least square method Riley is convincingly able to show that there is very little overlap between the factors that lowered mortality and those that reduced sickness time. Medical services mattered significantly for reducing sickness, but relatively little for mortality. Adding population to towns tended to increase mortality and reduce sickness time, the most unfavorable combination. Overcrowding in dwellings on the other hand had much more impact on morbidity than on mortality. Areas with more public health workers enjoyed the most favorable outcome, lower mortality and less sickness time. Perhaps one of the most unexpected results from Riley's analysis is the connection between higher wages and health. Previous research emphasis a positive relationship - higher wages give better health. Riley finds the opposite pattern. Higher wages were meant to compensate the men who earned them for higher risks, e.g., miners. But the compensation was either insufficiently large or it was not spent in ways that countered the higher risks. Consequently, areas where wages were higher experienced more deaths among AOF members.

James C. Riley's book challenges many of the currently accepted ideas about the mortality and morbidity decline. If there is relatively little overlap between factors affecting mortality and sickness time, how can historical demographers then use mortality as an indicator of changes in sickness? This is common practice in most demographic studies on health in the past. Riley also casts doubt on the mainstream interpretation that higher life expectancy is explained by a rising standard of living measured in terms of increasing real wages. He questions the common notion that cultural forces determine the sickness threshold, i.e., that an increase in sickness time can be explained largely by our increased readiness to see a physician or changes in the definition of ill-health. Riley finds very small differences between AOF-members' willingness to seek medical advice for the puniest of ailments in comparison with people in our modern society.

Riley's reasoning in the second section of the book is also a delicate balancing act, where he sometimes succeeds and sometimes fails. On one hand he makes statements about the health of the population at large in late nineteenth and early twentieth century Britain. On the other hand, he readily admits that his case is based upon AOF and Oddfellows members which were not a cross-section of British society. The friendly societies did not include paupers and day-laborers, nor did they count people from the middle classes and the bourgeoisie among its members. On one hand he says that sickness rates from AOF members should not be compared with those of other groups in other times without careful attempts to see how differences in rules affect practice. On the other hand he writes that "AOF experience is a representative microcosm of the experience of adult males in general." It is sometimes unclear to the reader if he is talking about AOF-members or Britains' adult male population.

However, even though Riley's book is limited only to the experiences of workingmen in the friendly societies, it is still a very important contribution to our limited knowledge of sickness and health in the past. Much of what we believe to be true is based on mere speculation. Friendly societies organized two-thirds of British workingmen at the end of the nineteenth century, which is a substantial part of the population. Regardless of the extent to which we can generalize on the health of the British population at large, the book challenges several of the present theories of the mortality decline and the health transition. James C. Riley's book brings forward new facts, points to several new fields of research and prompts us to reexamine previous findings. Sick, Not Dead is highly recommended.

Anders Brandstrom Umea University, Sweden