Public health: Introduction

Poor housing, overcrowding and high levels of disease, often held to have been exacerbated by the massive influx of Irish migrants, were certainly perceived as problems by those with power and authority in the Victorian city and by politicians at Westminster. Despite prevailing laissez faire[1] attitudes, the development of municipal intervention in various aspects of the urban environment reveals a genuine crisis in urban living conditions with an increasing gap between public expectations and the realities of urban life.  Much as they might have wished to, neither local nor national politicians could ignore urban living conditions:

1. The increasing amount of statistical and other information was discussed and publicised by local societies and used as propaganda by medical men and others with first-hand experience of life in the slums. Edwin Chadwick[2] was the best-known propagandist, but at the local level many influential people became increasingly aware and concerned about conditions of urban life.
2. Such evidence was unlikely to have been enough on its own to persuade ratepayers and their elected representatives to pass legislation and spend money improving housing and sanitation for the working class. Self-interest was at the heart if political action. Concerned about events in Europe, politicians genuinely believed that poor living conditions could lead to mass disturbances and urban violence.
3. Closer to home, the impact of cholera in 1832 and 1848 brought home, especially to the middle classes, the fact that disease could affected all classes. The poor were blamed for the disease, but it was in the interests of the middle classes to improve conditions and prevent it recurring. Intervention was also rationalised through economic self-interest since a reduction in disease and improvement in housing would bring about a more efficient workforce and therefore benefit industrialists and entrepreneurs.
4. But there were also important constraints. The contrast between political reaction to Chadwick's contribution to the Poor Law Report in 1834 and reaction to his 1842 public health report[3] was stark. In 1834 legislation rapidly followed the Report. However, it took six years to produce the public health legislation Chadwick wanted. In 1834 Chadwick was putting into words the commonly held assumptions of a broad spectrum of society, whereas in 1842 he was radical and original. The reasons for the differing response and the delay in legislation were largely to do with the variegated issues raised by the public health question. Derek Fraser synthesised them into four types of factor: technical; financial; ideological; and, political

If things were so bad why did neither central nor local government seem to do anything about it? There are various reasons for this situation. Derek Fraser has identified several but the following points [some of which he makes] need to be examined:

Inefficient local government

Today services like sewage disposal, street lighting and paving is provided by one local authority. Before 1835 many of the growing industrial towns did not have a Royal Charter and therefore did not have a Town Council. Where councils existed they were often corrupt and inefficient; self-perpetuating rather than elected and unaccountable for the ways in which they used the local rates. In some towns power was in the hands of the parish vestry that was elected by property owners.

• Local government reform occurred with the Municipal Corporations Act 1835. It provided for elections every three years by the ratepayers of the town councils. It also allowed rates to be levied for street lighting, fresh water-supply and sewage disposal but this took a local Act of Parliament.
• Most towns before 1835 tried to deal with 'nuisances' like water supply and drainage. These were the Improvement Commissions. The problem was that each Commission dealt with a specific area of health not the whole package. There was consequently confusion and lack of co-ordination.
• The chaotic nature of local government militated against effective reform.

Added to this was self-interest. Various groups in towns acted against any interference with the existing situation:

1. Water companies and builders were in search of profit. Water companies, for example, only supplied water to those areas of a town where the householders could afford the fees.
2. Builders exploited the demand for cheap housing and paid little attention to drainage, ventilation or water supply.
3. Private landlords were reluctant to pay for sanitary improvements largely because of the cost and their reluctance to accept any responsibility for the cleanliness of the working classes.

Ignorance

Knowledge of town planning was limited and this led to jerrybuilt houses. There is also the suggestion that middle class families were ignorant of the real conditions in which the working classes lived. Middle class houses were built on the edge of towns and were worlds apart from the inner-city slums.

Laissez-faire

Whose responsibility was public health? The laissez-faire attitudes of the period meant that central government did not see it as their responsibility and so did nothing.

Whatever the reasons, the second half of the nineteenth century saw unprecedented activity in the passing of both bylaws and national legislation affecting urban living conditions. Local legislation was in practice more important than that passed by the national Parliament: national acts often included what had previously occurred at a local level.

 

Principal public health and housing legislation in Britain 1848-1914

1848 Public Health Act [England and Wales]

1851 Lodging Houses Act [England and Wales] -- Shaftesbury Act

1855 Dwelling Houses Act

1858 Public Health Amendment Act

1866 Sanitary Act

1866 Labouring Classes' Dwelling Act [England and Wales]

1868 Artisans' and Labourers' Dwellings Improvement Act [Torrens Act]

1872 Public Health Act [England and Wales]

1874 Working Men's Dwellings Act [England and Wales]

1875 Public Health Act [England and Wales]

1875 Artisans' and Labourers' Dwellings Improvements Act [Cross Act]

1879/80 Artisans' and Labourers' Dwellings Improvements Act

1882 Artisans' Dwellings Act

1885 Housing of the Working Classes Act

1890 Housing of the Working Classes Act

1890 Public Health Act

Although the Public Health Act 1848 did not effect any major changes in urban areas, it was the culmination of a concerted public health campaign in England and Wales, marking acceptance of the fact that public health was an issue of national importance. Not until the Sanitary Act 1866 were local Authorities obliged to provide a proper water supply, drainage and sewerage system, and even this Act lacked teeth to enforce its powers. Many towns acted independently: Manchester, for instance, took control of the city's water supply in 1851. But powers to force Local Authorities to act to improve water supply and sanitation did not become effective until the 1875 and especially 1890 Public Health Acts.

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[1] Laissez-faire comes from the French and roughly translates as ‘let it be’ or ‘leave it alone’. There was an important contemporary debate on what the proper role of the state, locally and nationally, should be. One school argued that there should be a ‘minimal state’ in which the state should intervene in the lives of individuals as little as possible.

[2] R.A. Lewis Edwin Chadwick and the Public Health Movement 1832-1854, Longman, 1952 is an essential work on Chadwick and should be read in conjunction with S.E. Finer The Life and Times of  Sir Edwin Chadwick, Methuen,  1952.  These  should  now  be supplemented  with A. Brundage England's "Prussian  Minister". Edwin Chadwick and  the Politics  of  Government Growth 1832-1854, Pennsylvania  University Press, l988.

[3] Edwin Chadwick Report  on  the Sanitary Condition of the Labouring Population, 1842, new  edition, M.W. Flinn (ed.), 1965.

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.