Revolutions in public health: 1848, and 1998?BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7158.587 (Published 29 August 1998) Cite this as: BMJ 1998;317:587
- aDepartment of History, University of Notre Dame, 219 O'Shaughnessy Hall, Notre Dame, IN 46556-0368, USA
- bDepartment of Public Health, University of Liverpool, Liverpool L69 3BX
- Correspondence to: Professor Hamlin
This autumn marks the 150th anniversary of the Public Health Act for England and Wales, the beginning of a commitment to proactive, rather than a reactive, public health. The act began a series of legislative measures extending through the Victorian era and into this century in which the state became guarantor of standards of health and environmental quality and provided means for local units of government to make the structural changes to meet those standards.
That public action can substantially improve the health of the general population now seems obvious, and it also seems obvious that public authorities owe their citizens that improvement. Both were controversial in the 1830s and 1840s. For centuries European governments had reacted to epidemics with decrees. With medical boards to advise them, they set their military forces to protecting borders and ports, whitewashed towns, fumigated dwellings, and burnt bedding. The threat of unusual disease prompted these reactions, and they were relaxed when the epidemics passed.1 Normal disease—infant mortality of more than 50% in inner city wards, annual mortality of over 30/1000 in some towns—prompted no such reactions.
Unless we are familiar with some of the cities of the developing world, most of us are probably unable to fathom the enormity of the unplanned urbanisation of the 19th century: roughly 3 million people(slightly over 30%) were urban in 1801 in England and Wales, compared with 28.5 million (almost 80%) in 1901. Growth rates in some textile boom towns, like Bradford from 1811 to 1831, exceeded 60% per decade; this despite the fact that towns were acting as a sink for human life. In Liverpool average life expectancy by class ranged from 15 years for the unemployed or poor to 35 years for the well to do.2–6
Yet that growth was accompanied, if belatedly, by an urban sanitary revolution. Many of us are its beneficiaries. To facilitate the building of sanitary systems, especially water supplies and sewerage,was the main purpose of the 1848 act, but it also established local and central units of government that would take responsibility for health,at least for those aspects affected by the built environment. It represented a commitment to the long term, to be made not by sanitarian boffins in Whitehall but by more or less ordinary (though usually upper middle class) townsmen who were suddenly to be given powers to obtain 30 year mortgages for these networks of pipes.
150 years ago the Public Health Act for England and Wales marked the start of a commitment to proactive, rather than a reactive, public health in which the state became guarantor of standards of health and environmental quality and provided means for local government to meet those standards
The driving force bechind the act, Edwin Chadwick, began inquiries into public health as a means of reducing the costs of public relief
The act that finally emerged was a stripped down version of the original proposal and concentrated on provision of a constant water supply and efficient removal of sewage
Although riddled with compromise one is now struck by the practical wisdom and revolutionary implications of the legislation
The recent green paper on public health, Our Healthier Nation, reflects the heritage of this legislation in seeing health improvement as a process involving central government, local communities, and individuals
Acknowledging a need for public health: the great sanitary inquiries
Among the hardest of a historian's jobs is to understand how people move from hope for a different future to practical actions that secure it. In public health, fear had a large part. So too did ambition and perseverance.
Edwin Chadwick was the widely hated architect and enforcer of the new poor law of 1834. Its principle was to make the conditions under which public relief could be given so unpleasant that most would refuse to request it.7 Ever under pressure to cut costs, Chadwick began to focus on the causes of indigence: prevention was cheaper than relief. By 1838 he was looking mainly at one cause: acute infectious diseases that were fatal to male breadwinners, leaving families dependent on relief. These diseases, Chadwick insisted, had physical causes in poor urban drainage, which left towns covered in a residue of filth that contaminated the air in some ill defined way and caused disease.8
Sir Edwin Chadwick
The man who revolutionised public health, Edwin Chadwick (1800-90), had no training in medicine or sanitary engineering or public administration. He trained as a barrister and solicitor,
worked as journalist, and absorbed principles of public administration as a disciple of Jeremy Bentham.
As (initially) a junior member of the 1832 royal commission on the poor law, Chadwick transformed policy analysis: he documented conditions far more comprehensively than had his predecessors and, equally, was creative in discovering acceptable solutions to longstanding conflicts.He was the main architect of the new poor law of 1834 and, as its administrator, was said to be the most hated man in England. Issues of poor law administration led him into education and law enforcement as well as public health.
Chadwick's personality was his success and his undoing: he was tenacious in pushing a reform by all available means until action was taken, but he was overbearing and unresponsive to the views of others. He did not negotiate or converse but lectured at people,again and again, until they acted. With no faculty for accommodating differences of opinion, he failed as a practical politician,notwithstanding his ability as a political analyst. After his expulsion from the General Board of Health in 1854 he never again served in public administration.
The focus on physical causes and acute disease was defensible but was also politically adroit, for it diverted attention from the claim of an increasingly vociferous group of medical men, many of them local poor law medical officers, that the harsh policies of the poor law were themselves the cause of much illness. The other half of the vicious circle— that deprivation might itself cause the disease that left so many dependent— Chadwick suppressed: if hardship produced illness, a poor law founded on disincentives to seek relief was counterproductive and morally indefensible.910
In autumn 1839, as a result of a request made in the House of Lords by the cooperative Bishop of London, Chadwick was charged with documenting the extent of those insanitary conditions and of the disease they presumably caused, and to explore remedies in policy and technology,initially in England and Wales and then in Scotland. Chadwick's superiors were happy to let him get on with the report; they found him impossibly inflexible as a policy administrator.
The grand report finally appeared in summer 1842.310–13It digested the returns of the vast staff of poor law officials and “eminent” urban medical men who had been persuaded to report on conditions in their towns. Its focus had broadened. It seemed that insanitary conditions caused social as well as biological disease, a psychological degradation that led desperate people to invest their hope in alcohol or, worse, in revolution. A public gift of good sanitation might be the key to a happy, healthy, and docile proletariat—a welcome prospect to a government that expected revolution daily. And it was a route to stability that seemed to interfere with none of the grand structures of incentives that political economists insisted must order society.10
Public Health Debates, 1847-8 On the background of legislation
“In consequences of these vast changes in the social condition of the country, large masses of the population were suffering irreparable injury from the want of proper sanitary precautions.”
R A Slaney. Hansard's Parliamentary Debates 3rd series, 96 1848 Feb 10, 412.
On the epidemiology of sanitation
“If you trace down the fever districts on a map, and then compare that map with the map of the commissioners of sewers, you will find that wherever the commissioners of sewers have not been, there fever is prevalent; and, on the contrary, wherever they have been,there fever is comparatively absent.'”
Lord Morpeth, quoting Thomas Southwood Smith. Hansard's Parliamentary Debates 3rd series, 91 1847 Mar 30, 621.
On the results of sanitation
“By such measures they would be able to change … the condition of large bodies of the population of great towns, and to make them contented and cheerful. “By a measure of this nature they would do much to increase the security of property.” R A Slaney. Hansard's Parliamentary Debates 3rd series, 98 1848 May 8, 770.
Among the disease and degradation detailed in the report were sketches of a comprehensive solution. It would involve new technologies, particularly sewers (with egg shaped cross section to encourage self scouring), and new legal and administrative structures that would bring communities the expertise and authority needed to build these works. In spring 1843, at Chadwick's request and with Chadwick as a behind the scenes adviser, Sir Robert Peel's government issued a Royal Commission on the Health of Towns. Its tasks were to document the sanitary situation of 50 of the largest towns in England and Wales (London, recognised as a unique case, was left out) and to work out technical details. Dividing the territory into districts, the commissioners themselves visited towns to interview councillors and improvement commissioners and to administer the lengthy questionnaires that Chadwick supplied. They became convinced that much more could be done and that many towns were far too sanguine about the conditions they tolerated.
From inquiry to legislation
Even more important than the social and technical data it accumulated, the commission succeeded, remarkably quickly and comprehensively, in creating a will to act. An alternative was thinkable. The very exercise of local self scrutiny, in conjunction with a visit from a concerned, authoritative, and yet non-threatening official, allowed such an outlook to blossom. The commissioners often found more than good intentions—local efforts to build sewers, bring in water, regulate building, remove wastes, etc—but these had been hampered by lack of money, expertise, or legal authority. When towns did act it was usually only to provide partial services: greatest need did not bring forth greatest action. As we reflect on the Victorian achievement in public health, it is easy to overemphasise the opposition of special interests and underemphasise the great gap between acknowledging a problem and solving it. If any specific proposal for change was likely to seem objectionable to someone, there was, none the less, a remarkable willingness to admit that serious problems existed and that change was both needed and possible: without that the changes would not have occurred.
In February 1845 the commission published its second and final report. It reiterated the need for public health reform, asserted in general terms the viability of Chadwick's technical solutions—universal constant water supply, networks of high velocity sewers, recycling of wastes—but gave only the broadest suggestions about what public policies would actually accomplish these ends.
And that, of course, was what vexed the drafters of legislation in the Tory government in the spring and summer of 1845. They were led by Lord Lincoln, member of the royal commission who was in charge of the Office of Woods and Forests, which was made the dumping ground for urban sanitation. There were, even to the iconoclast Chadwick, no clear answers to the problem of what legislative means would best achieve sanitary ends. Chadwick himself was seeking to privatise sanitation,promoting a Towns Improvement Company to raise capital to build the coordinated sanitary systems he had developed. The linkage of capitalism and urban improvement was not new; sanitation required capital, whether it came as shares of water companies or loans to public bodies. Surely, he argued, his efficiencies of system and scale would bring a surer and better return. But he was getting nowhere.
By midsummer Lincoln had a bill ready. It was too late for parliamentary action; he hoped only for comment. That he got, over 100 pages' worth, from the Health of Towns Association, a cross party organisation founded at the end of 1844 to lobby for comprehensive public health legislation.1415 The corn law schism of the Tory party and the Irish famine made progress impossible in 1846. A Whig version of the bill, developed by Lincoln's successor, Lord Morpeth, became fouled in detail in 1847. What passed in 1848 was a stripped down version.
Public health was not a party matter, nor was the need for comprehensive sanitary legislation controversial. But there were no models, no good way to choose among several defensible alternatives, and the legislation was necessarily complicated. In practice, everything was negotiable. The comments of the Health of Towns Association on Lord Lincoln's bill, together with parliamentary debates give us a sense of what was bewildering even for the proponents of public health.
It was evident to all that health improvement required effective working together of local and central units of government and experts.Because the focus was water and sewerage, Lincoln would define the administrative unit as a river basin and set up a group of commissioners in each. Because it was also integrated urban improvement, Morpeth would give responsibility to the newly reformed municipal corporation or some similar general unit, allowing that entity jurisdiction over surrounding areas, but only for drainage issues. There was much talk of who should initiate projects for sanitary improvement, who should plan them, who should carry them out,and who should confirm their adequacy. There was also the vexed issue of who should pay—occupiers, on the grounds that they were benefiting from a health giving service, or owners, on the grounds that sanitation was a capital improvement.
A compromise emerges
If central government were to become a guarantor of standards of health (well into 1848 most participants in the parliamentary debate assumed that would be the case), what part of central government should do that? Drawing on the model of prison administration, Lincoln and the Tories saw the Home Office or some other cabinet office as planning the needed works and enforcing standards. Influenced by Chadwick, Morpeth and the Whigs were wary of too much parliamentary accountability in technical matters. As models, they looked to the Privy Council (traditionally responsible for mobilisation against epidemics) or the Poor Law Commission—administrations independent of parliamentary interference.
Finally, in a campaign concerned mostly with improving public health through public works there was a question of what place medicine—a local medical officer of health—would have in sanitary reform.1016
What emerged was a compromise. It was not, either at the time or in retrospect, an ideal law, or even probably the best that parliament in 1848 could have passed. Pressure on parliamentary time made it more important that the law was unobjectionable than that it was effective. Smoke prevention and insanitary burial grounds, both seen as important health problems, were jettisoned. Metropolitan London was left out, as it would require special legislation because of its size. Scotland and Ireland were left out, although it was appreciated that they suffered the same problems, because their laws and institutions for dealing with disease and welfare were too dissimilar from those in England. Following the precedent of Liverpool, which had hired Dr William Duncan as its medical officer of health through a private act, the 1848 act made such an appointment optional, though what such an officer was to do remained vague.1017
Public Health Debates, 1847-8 Support for the bill
“I can assure hon. Members … if they read the accounts of the loss and waste of health, and life, and happiness and strength, which are going on—not within the portion of society possessed of the means of ease, or persons in the sphere in which we generally move, but persons whose lot is cast in hardships and privations—hardworking mechanics and labourers, living in toil and suffering—if hon. Members had the opportunities of ascertaining the sufferings of those persons from the want of sanitary regulations, they would not object.” Lord Morpeth. Hansard's Parliamentary Debates 3rd series, 93 1847 Jun 18, 738-9.
Opposition to the bill
“The people were clever enough to manage their own affairs” “There was a mania now for sanitary measures. In fact, there was an insanity in sanity.” A Muntz. Hansard's
To retain some independence from parliamentary interference, Morpeth bargained away most of the provisions to guarantee health. In the bill that finally passed, groups of ratepayers (at least 10%) could request a local board of health. If an inspector agreed that this was practicable the General Board of Health—initially Chadwick, Morpeth, and the evangelical social reformer Lord Ashley (soon to succeed as the seventh Lord Shaftesbury)—would set one up. Where mortality exceeded 23/1000 the General Board of Health could impose a board, but it was reluctant to do so without substantial local enthusiasm. For a town, the main benefit of adopting the act was that it acquired, far more cheaply and easily than by the alternative means of a private act of parliament, the legal powers to make itself healthier.
Partly because of Chadwick's reputation as a rigid enforcer of the poor law and partly because the great towns would tolerate no intermediary between themselves and parliament, many viewed the bill as punitive. Their concern was not mainly with the objectives of sanitary reform but with arbitrariness, inequity in rating, and unaccountability. Objections were directed as much against the technocratic approach of the Francophile Chadwick (who, everyone knew,would be the main person in charge) as at likely changes in local power relations. The critics were quite as afraid of what their neighbours would do with new powers as they were of a distant and dictatorial central government.
Under such pressures, the bills that Morpeth introduced in 1847 and 1848 changed in tone from forcing to facilitating. Unexpectedly, public health legislation had evolved into an instrument of local democracy. The new local boards of health had the opportunity to undertake a wide range of infrastructural reforms that would improve health but also make a community more attractive, efficient, and comfortable. They had strong powers to act summarily against nuisances. Long term loans allowed them to plan public works systematically instead of building them piecemeal out of annual income. In the name of efficiency and to protect ratepayers, their plans were subject to the General Board of Health's approval, and thus to Chadwick's sometimes heterodox views on sanitary technology. They could not discharge their surveyor, the executive officer the act obliged them to appoint, without permission of the general board—an unacceptable condition for some. In practice, however, they were free to follow their own agendas of health improvement. By 1854, when Chadwick was pushed out of power, over 300 towns had petitioned to adopt the Public Health Act, and it had been applied in 182. The board had sanctioned over a million pounds of loans for sanitary improvement.18
Not all adopting towns acted quickly or well in the pursuit of health.Chadwick's successors often found themselves cajoling, embarrassing,or threatening towns that persisted in tolerating unhealthy conditions.In the next half century the legislation of 1848 was much amended.Local governments acquired broader powers but also greater obligations.Local officials, including medical officers of health, became obligatory and their duties and qualifications more precisely defined.Particularly after passage of the great consolidating Public Health Act of 1875, much of what had been permissive became imperative.1921
Building on the foundation of 1848
Historians' assessments of the Public Health Act of 1848 have changed over the years. A generation ago it was a courageous if flawed and tragic episode in the growth of comprehensive state responsibility. Now, in an age of devolution and of public participation in health improvement, one is struck by the practical wisdom and revolutionary implications of legislation so riddled with compromise. Our Healthier Nation, the government's recent green paper on public health, reflects the heritage of Victorian public health legislation in seeing health improvement as an ongoing process involving central government, local communities, and individuals.
Public Health Debates, 1847-8 On health as justice
“not as a matter of compassion, but as one of justice—whether the poor man's property—his health, his strength,his sinews, his power to labour—the poor man's only property—were not to be protected as well as the property of the rich. If they did not protect that property, did they do the poor man justice?”
R A Slaney. Hansard's Parliamentary Debates 3rd series, 96 1848 Feb 10, 413.
On the duties of the state
“in matters that are physical and material, matters which concern the health and life of large masses of our population who are pent up and crowded in towns and cities, in the case of evils which cannot be remedied otherwise than by some superintending, intervening, central authority—it would, I think, be a waste of words to attempt to prove that authority not only has a right, but that it is its duty, to interfere.”
Lord Morpeth. Hansard's Parliamentary Debates 3rd series, 91 1847 Mar 30, 623.
In matters of environmental health and the fight against many epidemic infectious diseases, the legislative tradition that the act of 1848 began was a successful, if gradual, working out of the dynamics of that interaction. If central government could not create health, it could enforce standards and could, through legal, financial, and technical structures, facilitate and guide the local self determination that would improve health. In the years after 1848 sanitation served as a mobilising motif for a whole series of changes. After 1858 the local boards of health simply became “local boards,” responsible for local government in general. Yet a close link between local government and responsibility for health remained. Nudged on by Chadwick, and by the epidemiologists, planners, and engineers who were his successors, local boards achieved not only the set of environmental technologies that we now regard as adequate sanitation—good water and safe and effective means of disposing of wastes—but other environmental changes such as green spaces, better ventilation of dwellings and streets, and even better road surfaces. Had one asked a medical practitioner in the 1830s whether these changes would benefit health, the answer would have been yes; yet the prospect of communities throughout the nation taking steps to make them universal public services would have seemed remote if not ludicrous. In the late 1830s one of Chadwick's friends asked who would pay for all this sewering and watering: however laudable,such changes were inconceivable.
The benefits of these changes go far beyond the original purpose of preventing what were later understood to be faecal-oral diseases and are almost impossible to measure. Chadwick, however guilty he may have been of dehumanising those who lacked basic sanitation, was surely right in understanding that comfort and convenience can be foundations of concepts of dignity and agency, and that they are among the structural changes that can give people the sense of power to act,individually or communally, to improve their health. 2223
Although the green paper Our Healthier Nation makes clear that improvements in public health are invariably public achievements in the broadest sense and although it outlines some problems such as cancer and heart disease that need addressing, it gives us little help in figuring out how public action will make the next revolution in public health happen.2428 As with sanitary engineering in the 19th century, improvements in health may come from public action in areas not recognisably medical—education,transport, law enforcement, and environmental management.
Foci of public health in the 1840s
A comprehensive concern with public health did not everywhere have its origin in urban sanitation. That focus was uniquely English. Elsewhere, during the same period institutions of public health were driven by other issues and took quite different forms:
Central Europe—Quarantine, medical police
France—Statistical analysis of mortality, recognition of mortality associated with prostitution and occupation
Scotland—Improvement of poor relief
Ireland—Coordination and expansion of provision of infirmaries and fever hospitals for a mobile population
We are, then, in much the same fix as Chadwick and Lords Lincoln and Morpeth in the middle 1840s. The public participation and political processes that there must be do not guarantee any successful outcome.We cannot mine the 1848 experiment for lessons or models to apply to contemporary problems. Mostly what we get from it is confidence that great consequences can grow from small pieces of legislation and that communities and nations can transform themselves for better health,investing prodigious amounts of money and energy in doing so, but that they do not do so automatically and necessarily. The range of moral,legal, political, technical, and financial problems they faced was staggering, as are those we now face. The creation of an environment in which those problems can be overcome requires legislation that is both creative and courageous. If we are as lucky as the Victorians were in this respect we will be fortunate indeed.