Urban growth: Disease in the Victorian city

It was unhealthy to live in Victorian cities, though chances of illness and premature death varied considerably depending on who you were, where you lived, how much you earned and how well you were fed. Social class mattered. Not all towns had equally high mortality rates and death rates in the countryside could match those in middle class suburban areas of cities[1].

Contemporary opinion was most concerned about infectious diseases even those more people died from 'other causes' than from all infectious diseases combined. Such diseases as typhus and influenza were both endemic and epidemic: they killed large numbers of both rural and urban dwellers but affected the young and malnourished of the urban slums. Smallpox became less important, in part because of the vaccination developed by Edward Jenner in the 1790s. Typhus fever was endemic in London and epidemics occurred in all towns in 1817-19, 1826-27 and 1831-2. Influenza epidemics occurred in 1803 and 1831. As towns grew, polluted water became an increasingly pressing problem and was the cause of many diseases from infantile diarrhoea and typhoid fever and especially cholera.

1. Infectious diseases were spatially concentrated: deaths from tuberculosis, typhus and cholera focused mainly on inner-city slum districts.
2. The main nineteenth century killer of adults was tuberculosis. Few families were not touched by the effects of TB and even in 1900 it was responsible for around 10 per cent of all deaths nationally, despite a significant decline from 1850. Spread by a bacillus through droplet infection from coughs or saliva, tuberculosis is not highly contagious but its spread is encouraged by a combination of poverty, malnutrition and overcrowded living conditions. Though not immune, the middle classes were better able to withstand tuberculosis than the poor, malnourished working class.
3. Typhus and typhoid fever were not separately diagnosed until 1869. They have completely different methods of transmission. Typhus, spread by body lice mainly to adults, is encouraged by poor living conditions. Endemic in the nineteenth century, it became epidemic during economic depressions and poverty crises and was strongly associated with poor residential areas. In contrast, typhoid fever was spread by a bacillus contained in sewage-contaminated water, milk or food and is directly related to poor sanitation and hygiene. It could be spread through the water supply to all parts of a town, but inner-city areas were most likely to be hit hardest.
4. Contaminated water and food also spread cholera, but unlike typhoid it occurred only in specific epidemics introduced from Europe in 1831-2, 1848-9, 1853-4 and 1866 and was not otherwise present in Britain. Epidemic mortality could be high in affected areas but in general it was much less important than other infectious diseases. However, cholera did attract considerable public attention both because of its high mortality rate and the fact that it struck all classes, though as with typhoid fever it was the poor who suffered most.
5. Children were particularly vulnerable to most infectious diseases, but especially from the effects of diarrhoea and dysentery, diphtheria, whooping cough, scarlet fever and measles. Infant mortality remained high and by the end of the nineteenth century still accounted for a quarter of all mortality.

What was the impact of such high rates of infectious disease? Death was only one, and not necessarily the most important, of the many effects of disease. For a poor family struggling to pay rent and buy food, illness [whether fatal or not] imposed additional strains: medical bills to pay; medicines to buy; extra heating costs; and the problem of childcare if the mother was taken ill. If the primary wage earner was off work the crisis would be more acute as not only did outgoings rise but incomes also fell. Short-term crises were met by pawning clothes, borrowing from kin and raising short-term loans. Prolonged illness increased costs and reduced income to such an extent that it could cause or increased malnutrition for the whole family, leading to further illness or to eviction for non-payment of rent. Families might then have to move to inferior accommodation or to be separated from one another in the workhouse. There is little doubt that the high level and concentration of infectious disease was a significant extra burden for working class families in the Victorian city.

In certain respects the health of the urban population began to improve as a result of a number of changes occurring after 1890.

• The Public Health Act 1890, though it did not introduce many new principles, was more effective than previous legislation in ensuring that towns took responsibility for the basic provision of pure water supply and proper sanitary conditions.  The Housing Act 1890 placed emphasis on slum clearance, a programme that was only really beginning to have an effect by 1914.
• The development of town planning began to stress environmental considerations that influenced the layout of some suburban developments and created a healthier environment. This only had an effect if individuals were able to move from the inner-city areas to the new garden suburbs.
• Advances in medical knowledge and technology began to make real inroads into diseases that had been barely understood in 1830.
• The development of a state welfare policy towards health created a buffer that prevented some of the worst impacts of disease in family life. The impact of the embryonic welfare state was patchy before 1914. In 1911 Lloyd George introduced the first national medical insurance scheme that was intended, in part, to replace schemes previously run by individual friendly societies.
• General increases in standards of living and especially improvements in diet and nutrition throughout most of the population led to greater resistance to disease and lower mortality.

There had been some improvement in the quality of life for those living in urban communities between 1830 and 1914. However, the major determinant of health was still social class: the working class as a whole were less healthy than the middle class.

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[1] On health see G.M. Howe Man, environment and disease in Britain, Penguin, 1976 and R. Woods and J. Woodward (eds.) Urban disease and mortality in nineteenth-century England, Batsford, 1984. F.B. Smith The People's Health 1830-1910, Croom Helm, 1979 is a valuable study of social problems and the limited resources of nineteenth century medicine.