Public Health 1854-1914

The cause of public health was at a low ebb after the enforced retirement of Edwin Chadwick in 1854, but even so some progress was being made.

• The Vaccination Act 1853 required parents and guardians to arrange for the vaccination of infants within four months of birth. Even though there were no provisions for enforcement by the 1860s about two-thirds of children born were vaccinated and the death rate from smallpox fell as a result.
• The Nuisances Removal Act 1855 was a consequence of the cholera epidemic of 1853-54. It required local authorities to appoint sanitary inspectors and gave magistrates the power to order the ending of nuisances and to the local authorities powers to enter a nuisance at the expense of the occupier.

There was, however, a great difference between Parliament passing acts and enforcing an effective policy against the opposition of local authorities and property owners who saw sanitary reform as a source of unjustified expense. For all the efforts that had been made progress was very slow. The death rate between 1841-45 and 1861-65 actually rose slightly and as a result it is fair to conclude that the general position remained much the same.

Public health was a far more complex problem than the pioneers of the 1840s had envisaged. For Chadwick public health was simply a matter of better sanitation and water supply. In reality the problem had far wider environmental causes -- pressure of population, bad housing and poor nutrition -- and Chadwick had steadily underestimated the importance of medical questions, especially what could be achieved by preventative medicine. In the twenty years after 1850 the progress that was made in public health matters was largely on the scientific and medical side. Indeed it can be argued that by 1870 the analysis of the causes of health problems had run considerably ahead of the existence of effective machinery for remedying them. Of major importance were:

1. The statistical analysis of mortality by William Farr in the Registrar-General's department after 1839.
2. Improvements in understanding how diseases were transmitted. Important independent investigations were made during the cholera epidemic of 1848-9 by John Snow in London and William Budd in Bristol. They both diagnosed the cause of cholera as a living organism spread in drinking water and breeding in the human intestine.

The eclipse of the career of Edwin Chadwick coincided with the rise of national celebrity of John Simon [pronounced See-mon][1]. Sir John Simon [1816-1904] was born in the City of London on 10 Oct. 1816, was sixth of the fourteen children of Louis Michael Simon (1782-1879), a member of the Stock Exchange, who served on the committee from 1837 till his retirement in 1868. His grandfathers were both Frenchmen, but having emigrated to England, each had there married an Englishwoman. Both his parents were very long lived, his father dying within three months of completing his ninety-eighth year, and his mother, Matilde Nonnet (1787-1882), within five days of completing her ninety-fifth year.

After three or four years at a preparatory school at Pentonville, John Simon spent seven and a half years at a private school at Greenwich kept by the Rev. Dr. Charles Parr Burney, son of Dr. Charles Burney. He then went to Rhenish Prussia to study with a German surgeon for a year. The familiarity with the German language that he thus acquired was of great advantage to him later. He was intended for the medical profession, and on his return from Germany he was in the autumn of 1833 apprenticed for six years to Joseph Henry Green, surgeon at St. Thomas's and professor of surgery at King's College, his father paying a fee of 500 guineas. In 1838 he became M.R.C.S. and in 1844 was made hon. F.R.C.S. In 1840, when King's College developed a hospital of its own, he was appointed its senior assistant surgeon. He held this post till 1847, when he was made lecturer on pathology at £200. a year. He eventually became surgeon at St. Thomas's Hospital, his ‘old and more familiar home,’ where with progressive changes of title he remained officer for life (Personal Recollections, privately printed, 1903). He became a great leader and teacher in pathology. In 1862-3 Simon was one of those who successfully urged the removal of the hospital from the Borough to the Albert Embankment. In 1876 he retired from the post of surgeon and was made consulting surgeon and governor of the hospital.

Ambitious of eventually becoming a consulting surgeon, Simon did not at first devote himself to his professional work with undue rigour. He spent his spare time on non-professional pursuit on metaphysical reading, on Oriental languages, on study in the print-room of the British Museum. Such distribution of interest left the impress of literary ability and culture on his future writings and tastes (Dr. J. F. Payne in Lancet, ii. 1904). As early as 1842 he had written a pamphlet on medical education, and contributed the article ‘Neck’ to the Cyclopædia of Anatomy. In 1844 he gained the first Astley-Cooper prize by an essay on the thymus gland (published with additions in the following year), and wrote for the Royal Society a paper on the thyroid gland (Phil. Trans. vol. 134), the value of which that society promptly recognised by electing him a fellow in January 1845, at the early age of twenty-nine.   The current of Simon's thoughts and activities was wholly changed by his appointment in October 1848 as first medical officer of health for the City of London at a salary of £500. a year (eventually £800.). Liverpool was the first town in England to appoint a medical officer of health; London was the second. Simon, whose continued study of pathology at St. Thomas's Hospital gave him great advantage as a health officer, set to work at once with characteristic thoroughness, and presented a series of annual and other reports to the City commissioners of sewers which attracted great attention at the time, and may still be read with profit. They were unofficially reprinted in 1854, with a preface in which Simon spoke strongly of ‘the national prevalence of sanitary neglect,’ and demonstrated the urgent need of control of the public health by a responsible minister of state. These views Simon kept steadily before him throughout his official career.

The government in 1848 had created the general board of health. It was reconstituted in 1854, and by a further act of 1855 the board was empowered to appoint a medical officer. Simon accepted the post in October 1855. The board was subject to successive annual renewals of its powers, and the new office was one of undefined purpose and doubtful stability. In 1858 the board was abolished, its duties being taken over by the lords of the council under the Public Health Act (1858), which to disarm opponents was framed to last for a single year. Simon thus became medical officer of the Privy Council. The act of 1858 was only made permanent in 1859 in face of strong opposition. Simon always held in grateful remembrance Robert Lowe, then vice-president of the council for education, whose promptitude and vigour saved the bill.  Simon made to the general board of health several valuable and comprehensive reports: on the relation of cholera to London water supply (1856), on vaccination (1857), on the sanitary state of the people of England (1858), and on the constitution of the medical profession (1858). These are reprinted in full in his Public Health Reports (vol. i. 1887). As medical officer of the Privy Council he instituted in 1858 annual reports on the working of his department, treating each year special subjects with broad outlook and in terse and graphic phrase. The most important parts were reprinted in Public Health Reports (vol. ii. 1887). During this period (1858-71) Simon was implicitly trusted by his official superiors, was allowed a free hand, and rallied to his assistance a band of devoted fellow-workers, who helped to make the medical department a real power for good.

In August 1871, in accordance with the report of the royal sanitary commission which was appointed in April 1869 to consider means of co-ordinating the various public health authorities, the old poor law board, the local government act office (of the home office), and the medical department of the privy council were amalgamated to form one new department, the local government board. Simon became chief medical officer of the new board in the belief that his independent powers would be extended rather than diminished. But neither (Sir) James Stansfeld , president of the board, nor (Sir) John Lambert], organising secretary, took his view of his right of initiative and administrative independence. Simon protested in vigorous minutes and appeals, which were renewed when George Sclater-Booth became president in 1874. In the result, after a fierce battle with the treasury, his office was ‘abolished,’ and Simon retired in May 1876 on a special annual allowance of £333l. 6s. 8d. He was less than sixty years old, and his energies were undecayed, so that the cause of sanitary progress was prejudiced by his retirement.  Simon received the inadequate reward of C.B., and was also made a crown member of the medical council, on which he did much good work until his resignation in 1895. In 1881 he was president of the state medicine section of the International Medical Congress held in London. With his friend, J. A. Kingdon, F.R.C.S., he was mainly responsible for the establishment by the Grocers' Company of scholarships for the promotion of sanitary science. Much of Simon's work was deeply affected by the cholera outbreaks of 1848-9 and 1853-4. They added greatly to his problems, but made his work much better known and his scientific authority steadily grew. Like other reformers he saw the problems of the city as moral as well as material. Until the social evils in which the poor lived were removed, he argued, the working classes could not enjoy decent family life nor acquire civilised social habits. It was justifiable to achieve this that the powers of local authorities to assume powers that they had never contemplated.

From his appointment to the Board of Health in 1855 till he resigned in 1876 Simon worked in the service of central government. The emphasis of his work shifted to statistical investigation and exact scientific enquiry as head of the able medical team that he gathered around him. He maintained that the knowledge obtained would result in appropriate practical action. In practice, until the early 1870s, scientific knowledge ran ahead of the practical solutions taken to remedy them. Between 1855 and 1858 Simon worked under the General Board of Health. The Public Health Act 1858 transferred the medical department to the Privy Council, a situation made permanent a year later. As medical officer Simon was given the duty of compiling annual and special reports that were to be presented to Parliament. This gave him the opportunity of drawing to public attention those problems that needed to be tackled.

His reports were of major importance in developing state intervention in public health issues. In 1857 Simon had published his Papers relating to the History and Practice of Vaccination. Ten years later the law was strengthened by a new act that both tightened procedures and providing ways of improving the vaccine. In the Vaccination Act 1871, following a very serious smallpox epidemic, the Boards of Guardians were required by law to appoint a paid vaccination officer. Other infectious diseases that the reports gave attention were smallpox, which re-appeared in 1865-6, typhoid, scarlatina and diphtheria. There were studies of 'industrial' diseases like the lung conditions produced among miners, potters and steel-grinders. An ineffective Adulteration of Foods Act was passed in 1860, the precursor of more far-reaching legislation in 1872 and 1875, by which local authorities had to employ public analysts to test food. The Alkali Act 1863 was the first of a series of enactments to deal with acid gas pollution.

The eleventh report of 1866 considered the need to consolidate the laws and administrative agencies relating to public health. The solid foundation of scientific and medical knowledge that had not existed in the Chadwick years, meant that effective legislation was now possible. The threat of cholera helped produce the Sanitary Act 1866, seen by Eric Evans as 'Simon's crowning achievement'. The Act

• gave to local authorities increased powers to provide house drainage and water supplies
• stricter provisions were made for the removal of nuisances
• additional powers were given to regulate communicable diseases
• it made the specific duty of authorities to inspect their districts and to suppress nuisances
• in case of failure to do this and upon complains being made, the Home Secretary had the power to send an inspector and, if neglect was established, to order the authority to act

Badly drafted as this legislation was, it did contain the vital principle of uniform and universal provision of sanitary protection, with compulsory powers of enforcement on local authorities.

In 1869 the Liberal Prime Minister William Gladstone set up a Royal Commission to look into sanitary laws and administration. It reported in 1871 and its recommendations were embodied in the Public Health Act 1872. In 1871 the Local Government Board took over the duties of the Poor Law Board and of the Privy Council and the Home Office for public health and sanitary matters. The 1872 Act rationalised sanitary authorities throughout the country and made compulsory the appointment of medical officers of health. Finally, in 1875 came the major consolidating Public Health Act, covering the whole field of public health, sanitation and nuisance prevention. It was accompanied by legislation in related fields:

1. An act of 1875 regulating the sale of foods and drink
2. An act of 1876 on the pollution of rivers
3. An act of 1879 consolidating the law on contagious diseases in animals
4. The Diseases Prevention Act 1883 no longer pauperised the recipient of treatment in hospital with infectious diseases
5. The Infectious Diseases Notification Act 1889 persuaded a large number of local sanitary authorities to establish isolation hospitals, a situation extended into rural areas by the Isolation Hospitals Act 1893

Practical reforms took a long time to implement and the medical and scientific work, associated with Simon, was actually cut back in the next decade. The new Local Government Board was dominated by the old Poor Law officials an they took a different view from Simon of their duties. They took resolute action to keep Simon and the medical scientific view he represented out of policy making in favour of the merely administrative principles inherited from the Poor Law. This had the effect of contracting the power of central control that had been developed in the 1860s and to reduce national supervision over disease. As a result Simon found he could not implement the policies in which he believed and in 1876 he resigned.

The early phase of public health reform was dominated by Edwin Chadwick, the later phase by Sir John Simon. Both left office disillusioned by their inability to implement reforms in the ways they wished. Paradoxically Chadwick resigned because of criticism of too much central control and Simon because of too little. In some respects the parameters of the public health debate had shifted by the early 1880s. National administrative structure and enforcement agencies were in place. Public attention, however, shifted to concentrate on the larger cities, particularly on London that suffered problems of its own, quite apart from its sheer size. The issue became one of housing.

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[1] Royston Lambert Sir John Simon 1816-1904, MacGibbon & Kee, 1963 is the major biographical study.