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128
Annual Report of the London County Council, 1914.
prevalence,exhibit a much more marked tendency to suffer from scarlet fever than children in "bad"
schools. This result is, at first sight, surprising, for it has long been generally recognised that the
correction between scarlet fever and poverty, with its associated dirt and overcrowding, is a close one.
The question was investigated some 20 years ago by Sir Shirlpy Murphy and was referred to in the
evidence he gave before the Royal Commission on Metropolitan W'lter Supply. He found, taking
groups of districts with differing degrees of poverty, that examination of their comparative mortality
from typhoid fever, diarrhoea, scarlet fever, measles, diphtheria, whooping cough, and infant mortality
showed excessive incidence of disease in the poorest districts, and this excessive incidence was much
more distinctly marked in the case of scarlet fever than in that of any of the other causes of death.J
The same phenomenon is observed if comparison be instituted between the poorer and the less
poor London borouarhs as regards notifications of scarlet fever, the figures relating to which have now
been available for more than twenty years, and have bpen published in successive Annual Reports of
the Medical Officer of the Council. An exceedingly interesting fact, therefore, emerges from
comparison of the "good" and "bid" schools, on the one hand, and the mortality and notification
figures for borough areas on the other hand ; for it transpires that while, when the elementary school
population alone is considered, the "good" schools are more seriously iuvolved than the "bad"
schools, when the entire population is considered the poor boroughs compare unfavourably with the
less poor boroughs.
The reason for this seeming discrepancy becomes, however, apparent when the populations
concerned are dissected out into ages. Thus comparison has been made between a group of poor
boroughs and a group of boroughs in which better social conditions obtain (vide diagram E). It will be
noted that, in the case of the poorer boroughs, the infants of one to two years of age suffer more than
twice as frequently from scarlet fever as those in the less poor boroughs. Infants from two to three
suffer in somewhat similar excess, and the same holds for the infants of three to four and four to five.
When tho age five tj six is reached the difference is less marked, and from six onwards to ten, the
incidence upon the children in the two groups of boroughs becomes practically identical. After thg
age of ten the children in the less poor boroughs actually suffer to a greater extent than do those in
the poorer boroughs.
Tuis analysis makes it clear that the excessive incidence of scarlet fever in the poorer boroughs
is, at any rate in large part, accounted for by the fact that the infants and children under school age
in these boroughs suffer to a much greater extent from the disease than the corresponding population
in the less poor boroughs, and it may be that this difference fully explains the difference in the
incidence of scarlet fever in the two groups of boroughs.
It still remains necessary, however, to explain how it comes about that, if consideration is
limited to the school age, examination of the figures for the child population as a whole (vide
diagram) shows that there is little or no difference between the richer and poorer boroughs, and yet
examination of the children in elementary schools classed as "good" schools shows a higher
incidence of scarlet fever than in schools classed as " bad " schools. This paradoxical result is
probably also fully accounted for when it is borne in mind that the total child population consists
of a population attending elementary schools and a population not so attending. As a matter of fact
it is common knowledge that children not attending elementarv schools suffer to a less extent than
elem3ntary school children from scarlet fever, and this fact doubtless explains why equality of incidence
of this dissase upon children of school age in the two groups of boroughs is not incompatible with a
much greater incidence of disease upon children in the " good " schools than upon children in the
" bad " schools.
It is, of course, the fact that in the poorest areas the very large majority of the children
attend public elemeutary schools ; in the less poor areas the percentage so attending is somewhat
lower; and in the least poor areas quite a considerable percentage of children do not attend these
schools.
It appears, then, that in considering incidence of scarlet fever in areas of differing degrees
of poverty in London, attention should be directed to three groups of persons and to three grades
of poverty :—
Children under school age Children of school age Persons over school age
Poorest areas Less poor areas Least poor areas.
The facts as to the incidence of disease in these several groups are indicated in the following
table, the sign + signifies excessive incidence and the sign — less marked incidence:—
Under school age. School age. Over school age.
Poorest areas + + + —
Less poor areas + + + +
Least poor areas — — + +
It will be seen that the children under school age suffer markedly in excess in the poorest
areas, and that persons over school age suffer markedly in excess in the least poor areas. In turning
now to consider the children of school age the fact must be borne in mind that those not in
elementary schools suffer comparatively lightly as compared with those in the schools. In the
poorest areas the last-named children form the large bulk of the population at school age and they
suffer less than the children under school age ; in the less poor areas the percentage of children in
elementary schools is still quite considerable, and these children suffer more than the children under
school age ; in the least poor areas, in which the percentage of children of school age is comparatively
low, the incidence of scarlet fever upon these children is not markedly higher than upon the
children under school age.
J Table B., p. 222, Appendices Roynl Commission on Metropolitan Water Supply, 1S93.