The impetus for public health reforms

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Impact of a rising mobile population

  • Consequences of industrialisation. 
  • Death rate fell:
    • The medical industry-vaccine prevented small pox.
    • The agricultural industry-food that was better.
    • The chemical industry-cheap soap  to buy and easy to wash-clean.
  • Birth rate rose because:
    • no youn deaths- survived into 20s and 30s to have children.
    • More babies living to adulthood- their children would have more children too.
  • Marriage rate rose because:
    • In rural areas, farmers employed fewer live-in servants.easier for men and women  to begin life together on their own and marry earlier.
    • In industrial areas, unskilled workers could marry as soon as they had a job or even if they didn’t have one.
    • Earlier marriages, in the days before contraception, meant more babies.
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Housing

  • Bad housing was widespread and had dense overcrowding. ‘vacant’ space and then living new dwellings.
  • Cellars and attics filled up with working people and their families and were also used as work places.
  • Prior to the Industrial Revolution, rich, poor and those in-between lived in close proximity.
  • In Industrialised Britain, the absence of affordable public transport meant that industrial workers had to be housed close to the mills and factories they worked at.
  • The houses that were new built varied widely in style: cottages , back-to-back houses, enclosed courtyards and vast tenements. Many were poor built, with floor being just bare boards over beaten earth.
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Sanitation

  • Most houses in the 19th Century lacked of drainage, sewerage and regular water supply.
  • Lavatories were usually outside and emptied into cesspits.Some houses had ash privies.
  • ‘night-soil-men’ 
  • Water needed for cooking, washing and drinking. Water was expensive. The supply was controlled by vested interests. They normally took water from local rivers. Middle class had pipes at home but water was irregular and uncertain so they had them in the cisterns. Poor people had to queue  to get water from the stand pipes. The poorest people didn’t bother at all or got it from local wells and streams.
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Impact of epidemics on the health of the nation

  • Connection between dirt and disease had been appreciated for hundreds of years. Louis Pasteur 1867 developed his germ theory of disease.
  • Overcrowding and lack of sanitation and clean water meant that disease was rampant and life expectancy of the working classes was low for the following reasons:
  • People living overcrowded, unsanitary conditions and without easy access to a supply f clean water housed by body lice, which spread typhus fever. Typhus epidemics in 1837 and 1839 and in 1847 that the last one killed over 10,000 in north-west England alone.
  • Influenza, scarlet fever, tuberculosis and measles were endemic and were often killers.
  • Typhoid and diarrhoea were common
  • Cholera hit Britain in four massive epidemics: 1831-32(31,000 killed), 1848-49, 1853-54 and 1866(62,000)
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Miasma theory of disease

  • Diseases were caused by the presence , in the air, of miasma.
  • Miasma was a poisonous gas that was suspended minute particles of decaying matter that couldn’t be seen by the naked eye. It had a foul smell.
  • Theory was: if you breathed miasma you were going to get ill because it carried disease. Diseases were spread person to person and place to place on the air. 
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Germ theory

  • Scientists became really interested in decaying matter and in the maggots and flies that lived on and in it. The development of microscopes enabled them to observe micro-organisms in rotting material.
  • There were two ideas:
    • Decaying material created the micro-organisms
    • Micro-organisms in the air were attracted to the decaying material.
  • In 1860, Louis Pasteur conducted a series of experiments proving that microorganisms existed in the air and were not created by the decaying material. It was the beginning of his germ theory. Germs could and did cause diseases in humans.
  • Not everyone believed in it and people were slow to let go the miasma theory- German doctor, Robert Koch had to prove that once and for all in the 1880s and 1890s when they discovered most of the germs that caused the diseases.
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Cholera Epidemic 1832- phobia riots

  • There were recorded 30 cholera-phobia riots:
  • Cholera-phobia riots Exeter
  • Authorities had instituted regulations for the disposal of cholera-infected corpses and their clothing and bedding.
  • Those riots arose because of specific fears that medical students were stealing bodies for their anatomy classes, doctors were murdering cholera victims( without religious ceremony and alive)
  • The rioting seen as political and social unrest.
  • Cholera-phobia riots Liverpool
  • The worst ones.
  • Between May 29 and 8 June 1832 eight major riot occurred. They were rioting against the medical men. Believed that Cholera victims were taken to the hospital where they died, doubtless murdered by doctors to provide bodies for dissection.
  • In 1826, 33 bodies had been found on the Liverpool docks ready to be shipped to Scotland for dissection. William Gil was founded guilty or running a grave-robbing system in order to provide bodies for dissection.
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How did the government react ot the cholera outbre

  • Central government did nothing about the endemic fevers and ‘dirty’ diseases that were common amongst all classes in all large towns. The government had to take action.
  • 1831 two doctors sent to St Petersburg in Russia for an outbreak there and that created the Board of Health.
  • Central government for the first time recognised that cleanliness, adequate clothing and food are necessary factors in public health.
  • Some areas set up cholera hospitals and institute quarantine regimes but any measures were rather hit or miss affairs.
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The Board of Health

  • It consisted of the president and four fellows of the royal college o Physicians, the general of quarantine, the director-general of the Army Medical Department , the medical commissioner of the Victualling Office and two civil servants.
  • London- based organisation set up in 1831 as a temporary measure to collate information and disseminate advice in relation to the cholera epidemic. It was made permanent by the Public Health Act 1848 and merged into the Local government Board in 1871.
  • It appointed district inspectors to report on the food, clothing and bedding o the poor, ventilation of their dwellings , number of people per room and the ways they kept clean and their behaviour.
  • Houses were to be whitewashed and limed and all infected furniture and clothing was to be fumigated.
  • People with cholera  were to be put in strict quarantine.
  • Food and flannel clothing were to be distributed to the poor.
  • Temporary fever hospitals were to be set up.
  • It suggested some remedies  such as rubs of castor oil and laudanum, plasters of mustard, peppermint and hot turpentine, bleeding by leeches and warm baths.
  • Legality was a problem. In 1832, temporary Cholera Acts were passed to enforce some measures and to finance them from the poor rates. Once the epidemics were done, the boards were disbanded.
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Cure for cholera?

  • Cholera was silent, deadly and had no known or cause.
  • 1.       The contagionist theory suggested that Cholera was spread by contact with cholera victims. Eminently sensible, it met with considerable opposition. If true, it meant that houses, streets or even whole cities had to be put into quarantine. Agued that not everyone in the same household fell ill with cholera and so the theory could not be true.
  • 2.       The miasmic theory suggested that Cholera was spread by a miasma of filth that was breathed in from infected air. At least actions base on this theory were steps in the right direction. The connection of sewers to rivers and other water courses, was not.
  • 3.       1831 The Lancet, a journal written by doctors for doctors, reported a community of Jews hat kept their selves free from Cholera with an oilment made from wine, vinegar, camphor, mustard, pepper, garlic and the crushed bodies of beetles.
  • 4.       Patent medicines grew and multiplied in number, as did their claims. Moxon’s Effervescent  Universal Mixture , Daffey’s Elixir and Morrison the Hygienist’s Genuine Vegetable Universal Mixture. All claimed to cure Cholera and because many took them and survived they had great following of those who believed in those curative properties.
  • 5.       Prayer was recommended by all the main Christian Churches. Cholera was God’s punishment for lax and immoral behaviour. Repent and all would be good. Many of those who prayed for themselves survived, as did those for whom they prayed.
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Reports on the state of towns

  • 19th Century was a time of investigating and reporting, of collecting and collating information. Many reports were local and went no further than the local town hall. Other found their way to local organisations such as the Board of Health. Some reports were the result of the enquiries of select commissions, set up for specific enquiries by parliament, others generated by bodies such as the Poor Law Commission.

  • Moral and physical condition of the working classes of Manchester 1832

  • Sanitary condition of the Labouring Population of Great Britain, 1842

  • Bradford Woolcombers Sanatory Committee, 1845

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Flushing toilets

  • 1775 with the invention of the S-trap by Alexander  Cummings.- Sealed the toilet bowl, preventing any foul air coming up from the sewer.
  • Joseph Bramah afterwards combined it with a float valve system for a cistern to build the first practical, workable, flush toilet.
  • George Jennings and Thomas Twyford
  • George Jennings established a business manufacturing toilets(water closets). He employed 97men and 18 boys. Jennings was granted a patent in 1852 of his invention of a water closet where the pan and the water trap were constructed together so that a small amount of water was retained in the pan.
  • By the end of 1850s new buildings required to be equipped with a water closet.
  • William Twyford in 1875 developed and sold the first ‘wash out’ trap water closet. 1880s he improved his inventions of the flushing rim and the outlet. He applied a new pattern in 1888 that gave him the power to refill the water pan with a small quantity of clean water.
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Sewerage

  • Human and industrial waste piled up on land and rivers as it was an easy and cheap solution to the problem of the disposal.
  • Rough walls, inadequate connections between sewers of different sizes, intermittent volumes of water and inadequate slopes meant solids accumulated and on a heavy storm would flush the sewers clean.
  • There was a system of flushing gates invented by John Roe in 1842. This was not combined with the hydraulic pumps to ensure a constant water flow of water through the sewers and make them self flushing until the 1870s , 1880s.
  • Discharging untreated sewage into the natural water syste became a problem as more was understood about the transmission of disease and Chadwick’s idea of spraying it on the fields as a fertiliser was not well received.
  • Manchester University developed the sewage treatment system of activated sludge where the  sewage was biologically treated to make it safe.
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Watter supply

  • Companies invested in modernising, using the latest  equipment  and taking up-to-date advice. Examples in London:
  • 1802, the Lambeth Waterworks expanded to supply Kennington and replaced its wooden pipes with cast iron pipes. Six years later the West Middlesex Waterworks company did the same.
  • 1822-Southwark Water Company extracted water from the river Thames using steam engines to pump it to a cistern.
  • 1829- Chelsea Waterworks Company installed a sand filtration system to purify the water taken from the Thames.
  • 1838- Grand Junction Waterworks company- pumping station at Kew Bridge at Brentford on the Thames to house three steams pumps.
  • London and other cities problems: extracted drinking water from rivers that were polluted. Change had to wait for the knowledge of water-born diseases to remove impurities and the will of people and the government that this should be done.
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Raising social cocnerns 1

  • Housing conditions were reported by writers and journalists. Charles Dickens and Elizabeth Gaskell.Dickens focused on London. Albert Bennett, series of novels that had housing and poverty in Staffordshire towns. George Orwell, documented the bleak living conditions of many working-class people in Yorkshire and Lancashire.
  • National and newspapers reported public health matters and commented on them, normally favourable. Occasionally, connections between poor living conditions and disease. They had the greatest impact on changing attitudes of those who were in power.- The Times held a campaign for effective sewerage of London as a result of the Great Stink of 1858.
  • Artists created paintings and engravings of the rural and poor. Attracted the attention of those writing novels about the urban poor and destitute.
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Raising concerns 2

  • Doctors, parishes and country councils improved their record-keeping facilities. Enabled the production of statistical evidence to illustrate the connection between population density and overcrowding on the one hand and death and disease on the other.
  • Increasing scientific knowledge and understanding of diseases- Increased public awareness about the need for clean water, sewerage and drainage and encouraged the emergence of Health and Sanitation Committees to take action.. 1844, Health of Towns and Association was established.
  • Governments set up Royal Commissions to investigate the living conditions of the poor and authorised a range of investigations during the period. 1843 set up the Royal Commission for Enquiry into the State of Large Towns and Populous Districts and reported in 1844.
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Economic imperatives

  • The cost of public health reforms could be calculated against the cost of losing a productive worker to one of the so-called ‘dirty’ diseases.
  • The cost to the nation of the Poor Law was escalating. Local officials set this against the cost of public health reform. Many could see a reduction in the poor rate occurring as a result of providing good drains and clean water. Any reduction in rates and taxes would resonate well with voters.
  • Initial costs of connecting a house to a water supply and sewerage fell upon the householder. The landlords of the tenements and lodgings, should be persuaded to link the properties they were letting out to the new drains and water supplies.- that would increase rents to cover costs and the poor could not pay it. Throw more poor into pauperism. Local authorities had to step in and take over responsibility for public health. This happened slowly as economic and political imperatives altered the minds and attitudes  of those that had to bring change.
  • Second Boer War(1899-1902) had a specific impact as army recruitment showed up the poor physical condition of working men in industrial towns. This impacted on the role of central government.
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Government's growth in 19th and 20th century

  • 1780 Government involvement in social policy was minimal. Taxes raised to finance foreign wars and to keeps the borders secure. Social policy and public health, business of the parishes that was supported by the strongly ideology of laissez-faire. Whig government won in elections 1830 involved a move away from the laissez-faire:
  • The Representation of the People Act 1832. Important adjustments and distribution of seats, allowing for greater representation from the growing industrial towns of the Midlands and the North. Middle-class representation wanted to keep rates low meant that sanitary reform was low on MP’s and general feeling that public health reforms were the business of local authorities, not parliament.
  • The Municipal Corporations Act 1835 ended the system of ‘closed’ corporations. Borough councils were to be elected by male ratepayers for a three-year term of office. Councillors elected a mayor and chose aldermen.  The Act stated that councils would assume control of paving, sewerage, street cleaning and drainage in their areas. Still needed a Private Act of Parliament to enable to do so. Central government showed little interest in public health.
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Central government begins to get involved.

  • 1844 Report of the Royal Commission into the Sanitary Condition of Large Towns and Populous Districts marked a mid-century appraisal of the sanitary condition of Britain. Followed by some minor legislation to hold the situation until a main Public Health Act could be prepared.
  • 1846. Nuisance Removal Act. To enable justices in petty session courts to prosecute those responsible for ‘nuisances’.
  • 1846. The baths and Washhouses Act. enabled local authorities to provide baths and washhouses out of public money.
  • 1847. Towns Improvement Clauses Act. defined the right of towns to lay water supplies and drainage schemes and to control nuisances. Legalised the discharge of sewage into rivers and the sea, and allowed its sale for agricultural purposes.
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The Public Health Act 1848-1

  • General Board of Health was set up. Based in London. Lord Morpeth, Lord Shaftesbury and Edwin Chadwick.
  • Local authorities were empowered to set up local boards of health. Could be set up where:
    • 10% of the ratepayers asked for one
    • The death rate was greater than 23 per 1,000.
  • Local Boards of health were permitted to appoint medical officer of health and pay his wages out of the rates.
  • Local boards of health were to manage sewers and drains, wells, slaughterhouses, refuse  and sewerage systems, burial grounds and public baths, recreation areas and public  parks.
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The Public Health Act 1848-2

  • The Acts were permissive and did not apply everywhere. There was little or no opposition and implementation would be relatively smooth. People were desperate for any remedy. But it had lack of universality-  no apply to London or City of London as they had their own Acts. Nor did apply to Scotland . Only applied where the death rate was more than 23 deaths per each 1,000 and only the General Boar of Health could force a local authority to set up a local board of health that were not required to take on wider public health consideration that included such things as parks and baths.
  • Public Health Act failing- meant that the government was prepared to do something. Prepared to provide a solution for towns and cities to fight their way through the morass of private and local legislation to achieve standard public health. Prepared to intervene on behalf of the most vulnerable members of society. This Act generated both pressure from the public for further reform and confidence in the legislators that they could deliver it.
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Continued opposition to public health in the 1850s

  • Improvement schemes for any kind cost money. Property owners paid to have clean water piped to large cisterns and for sewers and cesspits to hold waste from their inside lavatories.
  • Many people felt that government was encroaching on their individual liberties by requiring them to, remove dung heaps from their properties or whitewash a slaughterhouse.
  • Vested interests- directors of local water companies- were usually represented in local government and often on local boards of health. They were unlikely to vote for measures that would reduce their company profits.
  • The civil engineering problems posed by sewerage and water supply schemes were barely understood by lay people on local boards of health; this caused delay, and the implementation of inappropriate systems.
  • Chadwick himself- one of the three commissioners on the General Board of Health set up by the Public Health Act 1848- irritated, annoyed and angered many because of his bullying tactics.
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The Local Government Act 1858 and the Public Healt

  • Brought the following changes:
  • General Board of Health was abolished.
  • The powers of the General Board of Health were given to a new Local Government Act office.
  • A medical department of the Privy Council was set up.
  • Local Boards of health were given powers to take preventative action and appoint officials.
  • The solution to this act and Edwin’s Chadwick bullying was to split the powers between the privy council and the local government act office was the solution. The permission of the Local Government Act office was needed for all loans that local authorities  wanted to raise in order to carry out public works. The central government for the first time became involved in the administration of public health in the localities. In ten years up to 1868, 568 towns set up boards of health and began implementing public health reforms.
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The Sanitary Act 1866

  • John Simon was the key mover of this Act. He was London’s first medical of officer of health in 1848 and medical officer to the general board of health in 1855. He became first medical officer to the medical department of the Privy Council.
  • As a direct consequence of the sort of advice he gave in his annual report in 1865 in 1866 the government pass a sanitary act which brought some changes:
  • Sanitary powers that had been granted to individual local boards of health under the 1848 Act were made available to all local boards.
  • Local authorities were made responsible for the removal of ‘nuisances’ to public health. If local authorities failed to act, central government could do the work of improvement and charge local authorities.
  • ‘Nuisances’ was extended to domestic properties and included overcrowding.
  • Local authorities were given the power to improve or demolish slum dwellings.
  • Compulsion was a significant element of an Act of Parliament dealing with public health. The state direct and advise local authorities AND it could now compel them to act. The state was from this point, directing public health.
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Pressure for further changes?

  • 1867, the Parliamentary Act effectively gave the voto to working men in towns. Politicians had to pay attention to their problems, which included public health issues.
  • There was a third cholera epidemic in 1865, Loui s Pasteur proved conclusively that germs caused disease and were not caused by it.
  • 1869 A Royal Commission on public health was set up, which revealed that conditions in towns were little better than when Chadwick had been masterminding investigations some 30 years earlier
  • 1871 a Local Government Board was set up. This consolidated the functions of the Local Government Act Office, the Registrar-General’s Office, the medical department of the Privy Council  and the Poor Law Board. The president was usually a member of the Cabinet.
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The Public Health Act 1875

  • Was the most comprehensive legislation to date, codifying and consolidating previous laws.
  • It was to remain the foundation of all publiv health work until 1936. Established the following:
  • Every part of the country had to have public health authority.
  • Every public health authority had to have at least one medical officer and one sanitary inspector to ensure that the laws on food adulteration, housing, water supplies and cleansing were enforced.
  • Local authorities were given wide powers to al sewers and drains, build reservoirs, parks, public baths and public conveniences.
  • Government was completely committed to the provision of public health for the people it governed. The Act was a turning point in the regulation of house building. By permitting sanitary authorities to make by-laws that controlled building standards and plans, they were able to lay down such things as street widths and the provision of open space.
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The Public Health Act 1936

  • Consolidated a range of previous legislation, addressed such as matters as sanitation, nuisances and offensive trades, baths and washhouses and the prevention and notification of diseases which local authorities had immediate responsibility. Extended the Food and Drugs Act 1938, control over slaughterhouses and food adulteration was added into their responsibilities.
  • The years 1919-39 saw the virtual completion of the process whereby local authorities took over control of water supplies with all the complex systems of reservoirs, pipelines and treatment centres that this involved. By 1935, 80% of the population was supplied with water by the local authorities. This water was generally safe, although there were some typhoid epidemics in Bournemouth, Poole and Christchurch in Dorset in 1936 and Croydon in 1937 cause by sewage contamination. The provision of clean water supply with the combination of an efficient sewerage system represented a major, unspectacular, advance in public health.
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amreecesekhon

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amazing for revision goes through everything I need to know for chapter 1!!

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