Chapter 1: the impetus for public health reforms

The cholera epidemic 1832: cholera-phobia riots

- 30 recorded 'cholera-phobia' riots in towns and cities throughout Britain - worst riot: Liverpool - between 29 May and 8 June 1832, 8 major street riots - not directed at authorities but at fears cholera victims who were adimtted to hospital & died there were murdered by doctors to provide their bodies for dissection - e.g. 1826 - 33 bodies found on the Liverpool docks ready to be shipped to Scotland for dissection & 2 year later, a local surgeon, William Gill was found guilty of running a grave-robbing system in order to provide bodies of dissection - riots to be seen in the context of general political and social unrest: (1831-32) pressure amongst people & politicians for the reform of the parliament was intense - meetings urging reform were held in all major towns and cities, accompanied by marches and rioting - result: PLAA

1842 Report (Report on the Sanitary Condition of the Labouring Population of Great Britain, 1842)

- Chadwick asked to report on living conditions & health of paupers in the towns & the country - advised removal of waste, implementation of proper drainage systems & appointment of district medical officers - people believed they were being "bullied into health"

The moral and physical condition of the working classes of Manchester (1832)

- Dr James Kay reported on Manchester conditions in each area in 1832 - one of the first detailed reports on a specific group of workers & made connections between dirt and disease - questioned moral condition: dirty living = dirty habits - set scene for subsequent investigations

Growth of role of government: Local Government Act (1858) & Public Health Act (1858) - what were its reforms?

- General Board of Health was abolished - powers of the General Board of Health were given to a new Local Government Act office - medical department of the Privy Council was set up. - local boards of health were given powers to take preventative action and appoint officials.

Changing attitudes to public health reforms: economic imperatives - overall conclusion/agreement?

- agreed that cost of public health reforms = cost of losing a productive worker to one of these 'dirty' diseases economic benefit derived from a fit workforce which as worth the money: - e.g. 2nd Boer War - army recruit showed up the poor physical condition of working men in industrial towns

The cholera epidemic 1832: gov reaction

- central gov set up temporary board of health - advised local govs to set up own board of health, suggested: - houses to be whitewashed and limed - people with cholera quarantined - food and clothes given to poor & set up temporary fever hospitals - result/probelm: local board reports only gathered information, not disease prevention or cures - boards of health disbanded once epidemic ended

Increasing understanding about the causes of disease: germ theory

- discovered by Louis Pasteur - not until 1860s - scientists interested in decaying matter and maggots & flies that lived on it & development of microscopes (inventor: Joseph Lister, built 1830) enabled them to observe microorganisms in rotting material (smaller than flies & maggots) Two ideas: - decaying material created microorganisms - microorganisms in the air were attracted to decaying material

Growth of role of government: Public Health Act (1875)

- every part of the country had to have a public health authority. - every public health authority had to have at least 1 medical officer and 1 sanitary inspector to ensure that the laws on e.g. food adulteration, housing & water supplies were enforced - local authorities were given wide powers to lay sewers and drains, build reservoirs, parks, public baths and public conveniences. - improvement: gov now completely committed to public health provision & to the people it governed - turning point in regulation of house building: by permitting sanitary authorities to make by-laws that controlled building standards and plans - able to lay down e.g. street widths & provision of open space

Growth of role of government: Local Government Act (1858) & Public Health Act (1858) - why were the two Acts needed so soon after the Public Health Act 1848?

- gradual acceptance by local authorities of the need for more powerful local public health bodies BUT there was considerable hostility towards Chadwick (needed to leave & a more acceptable way of centralising public health provision had to be found) - solution: splitting the powers of the old GBofH between the Local Government Act Office and the Privy Council medical department. - one of the main functions of the old General Board of Health: to approve loans to local authorities for public health projects - now, permission of the Local Government Act Office was needed in order to carry out public works. - improvement: central government directly became involved in the administration of public health in the localities for the first time. - by 1868, 568 towns set up boards of health and began implementing public health reforms.

Drainage systems and water supplies (technological advance): sewerage

- human and industrial waste piled up on land & rivers offered an easy and cheap solution to the problem of disposal (disposed into the sea eventually) - faced with public health requirements not to allow piles of filth to accumulate - local authorities reluctant to move away from traditional method - before: solids accumulated and only a heavy storm would flush the sewers clean (due to rough walls, intermiitent volumes of water) - 1842, John Roe invented a system of flushing gates to control the flow of liquids through sewers - iron gates only opened when sufficient amount sewage accumulated to enable the force of water to clear it away - 1870s-1880s - hydraulic pumps to ensure a constant flow of water through the sewers & make them virtually self-flushing. - discharging untreated sewage into natural water system became a problem due to increased understanding about the transmission of disease - breakthrough in 1912: scientists at Manchester Uni developed the sewage treatment system where the sewage was biologically treated to make it safe

Changing attitudes to public health reforms: raising social concerns - increasing scientific knowledge

- increased understanding about the causes of water-borne and sanitation-related diseases - led to increased public awareness about the need for clean water, sewerage and drainage in general - 1865, Louis Pasteur (1822-95) proved conclusively that germs caused disease and were not caused by it encouraged the emergence of Health and Sanitation Committees to pressurise councils and the government to take action: - e.g. 1844 the Health of Towns Association was established: carried out a propaganda campaign for public health legislation & members gave public lectures, published and distributed informative pamphlets

Reasons why Public Health became an issue in 19th Century: poor housing

- industrial revolution resulted in dense overcrowding causing urban communities to respond by using up and adapting existing 'vacant' living space and by building new dwellings - cellars and attics were filled with working people and their families & were used as workplaces - most housing for those moving to live and work in the cities had to be newly built - many were poorly built, with floors being nothing but bare boards over beaten earth

Reasons why Public Health became an issue in 19th Century: living conditions

- influx of thousands of people into small market towns & cathedral cities who had one or more industries located there had a catastrophic effect on the existing housing and sanitation provision - explosion of 'filth diseases': typhoid, diphtheria, tuberculosis, scarlet fever & (most dreaded one) cholera - other 19th Century killers, e.g. Measles and whooping cough became endemic

Reasons why Public Health became an issue in 19th Century: civil registration

- of births, deaths & marriages - introduced in 1837 - revealed a young, fertile and actively reproducing population in most urban centres - urban birth rates were above death rates so natural increase from the 1840s - increase from internal migration

Changing attitudes to public health reforms: raising social concerns - artists

- paintings and engravings of rural & urban poor - bought by the middle-class - idyllic rural poor vs. distrubing urban poor - attention from authors writing about the destitute (e.g. Dickens an admirer of Sir Luke Fildes) - inspired novels, visual representation - those who were illiterate could understand (less significant than novelists)

Impact of epidemics on the health of the nation (disease)

- population living in overcrowded, unsanitary conditions and without easy access to supply of clean water housed body lice - spread typhus fever from which many died: - cholera hit Britain in 4 massive epidemics: 1831-2, 1848-9, 1853-4 and 1866 - the first epidemic killed 31 000 and second 62 000 - typhus epidemics in 1837 and 1839; an outbreak in 1847 killed 10 000 people in north-west England alone - smallpox raged 1837-40, killing over 12 000 people in 1840 alone - influenza, scarlet fever, tuberculosis, and measles were endemic and were often killers

Increasing understanding about the causes of disease: miasma theory

- previously it was thought that there was a link between dirt and disease, but were unsure what that link was - 19th Century: most popular explanation was 'miasma' or bad air (an old theory, from the Middle Ages) - disease was caused by the presence of miasma - a poisonous gas in which minute particles of decaying matter were suspended that could not be seen by the naked eye - it was characterised by foul smell - one would could get ill by breathing miasma as it carried disease - solution: clean them up, improve housing and sanitation, and public health would automatically improve

The cholera epidemic 1832: cure for cholera?

- problem: had no known cause or cure - contagionist theory: suggested cholera was spread by contact with cholera victims - if true it meant that houses, streets or even whole cities had to be put into quarantine - opponents pointed to the potential loss of trade & increase in poverty and unemployment, argued not all in same household fell ill with cholera - theory false - miasmic theory: actions based on this theory - removal of heaps of excrement BUT the connecting of sewers to rivers and other water courses was not step in right direction

Drainage systems and water supplies (technological advance): water supply

- provision of water was in the hands of private companies for most of 19th century - some companies did invest in modernising, using the latest equipment and taking up-to-date advice - 1802, Lambeth Waterworks expanded its operations to supply Kennington & replaced its wooden pipes with cast iron ones - many water companies built reservoirs to enable a reliable supply of water to be pumped to houses. - major problem: water companies in London & elsewhere extracted drinking water from rivers that were polluted by industrial and faecal waste - more knowledge needed that disease was water-borne in order to make effective improvements & will of people & gove needed to view it as a neccessity to ensure successful change

Reasons why Public Health became an issue in 19th Century: poor sanitation

- river was where excretion went in and also was the main source of water for many - most housing lacked drainage, sewerage and a regular water supply - lavatories were usually outside, in the courtyards and alleys, and emptied into cesspits - water was needed for washing, cooking and drinking; not only was water in short supply but it was expensive - middle-class had water piped to their houses & some have vs. poorer classes queued with buckets and saucepans to buy what they could afford when the water company turned on the supply

The cholera epidemic 1832: amount of deaths

- unsuitable housing, lack clean water & removal of waste became serious problems (health worse than in earlier centuries) - cholera spread though Britain quickly & painfully 4 epidemics: - (1831-32) 32 000 deaths - (1848-49) 62 000 deaths - (1853-54) 20 000 deaths - (1866-67) 14 000 deaths

Drainage systems and water supplies (technological advance): flushing toilets

- water to flush away (usually into rivers and waterways) had been intermittent since Neolithic times - (industrial Revolution) due to advances in technology, flushing toilet became a feature in many people's lives - invented by Sir John Harrington & refined/sold by Joseph Brammah and Thoms Crapper in 19th Century - breakthrough in 1775 by Alexander Cummings, a toilet bowl - while it removed human waste from homes into sewers, the sewers led directly to rivers & other water courses - accumulation of disease

What was the Victorian attitude towards death?

- were familiar with death. - some urban areas, 1 in 4 babies died before their first birthday - brother and sisters expected one sibling to die - buried their dead - London had 200 acres of cemeteries - every year around 50 000 dead were added and sheer quantity of burials - made overcrowding a public health hazard

How much did the British population grow from 1781-1871? By 1939?

13 million to 31 million (1781-1871) By 1939 - 48 million

What was the connection between public health and disease?

A poor diet, lack of sufficient clean clothing, or even a change of clothing, and crowded, dirty accommodation created condition in which disease flourished Poor families were prone to infection - influenza, measles, and scarlet fever were killers in the 19th Century Diphtheria, tuberculosis and typhus were common Improving health of the community, especially the health of the poor, proved to be problematic: - needed appropriate technical skill & knowledge of sanitary engineering - needed appropriate medical knowledge about the cause of disease - needed the willingness on the part of the public, local authorities and & parliament to legislate and conform to that legislation

Connection between the Poor Law and public health.

Chadwick's study Conclusion 1: in areas inhabited by thousands healthy living conditions impossible by current standards - change was necessary Conclusion 2: personal habits less of an influence on disease than overall circumstances - Overcrowding - Poor ventilation - Poor water supply

Changing attitudes to public health reforms: raising social concerns - novelists

Dickens & Gaskell - created vivid pen-pictures of working-class living conditions in mid-Victorian Britain. Dickens focused on London (first-hand experience, poverty) - books were enormously successful - wide readership as books were serialised & readily accessible instaed of published in single volumes, e.g. A Christmas Carol, Oliver Twist Gaskell witnessed the poor around Manchester (where she lived) - wrote about impact of poor living conditions in 'Mary Barton' (1848) Conditions described by them reflected in Henry Mayhew's findings

Pre-Industrialisation: did Britain suffer from public health?

Few pressing public health problems. No drains or sewerage systems; no clean piped water; no effective measures to prevent the spread of disease Sometime edicts and directives were issued by government & town councils regarding e.g. the removal of waste from the streets & the emptying of privies. There were periodic outbreaks of bubonic plague. While some lived in crowded conditions in London & provincial towns, the vast majority of people sparsely lived in rural areas - no perceived need for e.g. a national public health system

How did Prince Albert die?

From typhoid in 1881 Growth and development of bacteria did not care about social or economic status in society

By how much did the British population increase from 1811-41? (most rapid period of growth)

Increased by 200%

Reasons why Public Health became an issue in 19th Century: rising, mobile population

Population exceeding the amount needed to sustain the new population: (1801-51) population living in towns increased from 33% to 50% - indvidual parishes, esp. London where ⅓ of 1 million migrants settled, were overwhelmed - growth can lead to overpopulation Death rate declining due to: - medical industry producing vaccine against smallpox - chemical industry producing soap which was cheap & readily available; - agricultural industry producing food which was better in quantity & quality (thus gov has to maintain higher level of public health) Birth rate rose: - fewer people were dying young which meant that more people survived into their 20s & 30s to have babies - before (in 1840s Manchester), 57% of babies died before the age of 5

1844 Report (Report of the Royal Commission into the Sanitary Condition of Large Towns and Populous Districts, 1844)

Questionnaires sent out to the 50 towns with the highest annual death rates & studied by commissioners who had also made visits to the worst areas - 42 were found to have bad drainage and 30 poor water supply Recommended that: - Central gov be given extensive powers to inspect and supervise local sanitary work - Local sanitary districts be set up, with authority over drainage, sewerage, paving and water supplies - Local sanitary districts be give powers to raise money for sanitary schemes through local rates

Public Health Act (1936)

addresses matters e.g. sanitation, baths, washouses, notification of diseases 1919-39 - completion of process where local authorities took over control of water supplies by 1935, 80% of England and Wales supplied with water by local authorities - generally safe, but typhoid epidemics in Dorset caused sewerage contamination without Sanitary Act, no power to control this development as local authorities had immediate responsibility

Changing attitudes to public health reforms: raising social concerns - newspapers

commented/reported on public health matters: - e.g. local outbreaks of scarelt fever & typhoid reported in 'Leeds Mercury' & occasionally connections between poor living conditions + disease national newspaper greatest imapct on changing attitudes of those in power to bring about change: - e.g. 'The Times' headed a campaign for effective sewerage of London as a result of the 'Great Stink' (1858)

Changing attitudes to public health reforms: economic imperatives - cost of public health reform...worth it?

cost to the nation of the Poor Law was escalating (e.g. maintaining workhouses & paying for relief): - local officials set this against the cost of public health reform, many could see a reduction in the poor rate as a result of providing good drains & clean water - cutting investements in poor law reforms, less taxes - in favour

Growth of role of government: Sanitary Act (1866)

key figure: John Simon, London's 1st medical officer local authorities responsible to improve public health (given sanitary powers) - given power to improve or demolish slum dwellings - if authorities failed to act, gov could do the work & charge them 1st time that state could compel (instead of advise) local authorities to act - gov involvement - most significant

Growth of role of government: Public Health Act 1848

key figures: Chadwick, Lord Shaftesbury, Lord Morpeth General Board of Health esatblished act was permissive - did not apply everywhere - e.g. 10% of ratepayers had to be asked for a Board of Health (in order to be set up) - applied only to where people wanted it - little opposition - lack of universality - didn't apply to Scotland or London displays that gov was willing to act & intervene to help the poor - generated pressure for further reform - significant to kickstart process but no major development due to the Act

Changing attitudes to public health reforms: economic imperatives - who's paying for clean water?

major consideration in which sections of society would be paying for clean water and drains for all: - initially it was householders - informed middle class usually paid out for their own comfort and health - no means clear that they would also pay for the poor to have similar facilities - solution: local authorities to step in & take over responsibility for the public health - happened but slowly as economic and political imperatives altered attitudes of those in position to bring abot change