Public Health During the Industrial Revolution

A Court for King Cholera
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One important impact of the industrial revolution (more on coal, iron, steam) was rapid urbanization, as new and expanding industry caused villages and towns to swell, sometimes into vast cities. The Port of Liverpool, for example, rose from a population of a couple of thousand to many tens of thousands in the space of a century. As a result, these towns became hotbeds of disease and depredation, prompting a debate in Britain about public health. It's important to remember that science wasn't as advanced as today, so people didn't know exactly what was going wrong, and the speed of changes was pushing government and charities structures in new and strange ways. But there was always a group of people who looked at the new stresses on the new urban workers and were willing to campaign to solve them.

The Problems of Town Life in the Nineteenth Century

Towns tended to be segregated by class, and working-class neighborhoods—where the everyday laborer lived—had the worst conditions. As the governing classes lived in different areas they never saw these conditions, and protests from the workers were ignored. Housing was generally bad and made worse by the numbers of people constantly arriving in cities. The most common housing pattern was high-density back-to-back structures which were poor, damp, badly ventilated with few kitchens and many sharing a single tap and privy. In this overcrowding, disease spread easily.

'London going out of Town - or The March of Bricks and Mortar', 1829. Artist: George Cruikshank
1829 George Cruikshank editorial cartoon illustrating the explosive growth of London. Print Collector/Getty Images / Getty Images

There was also inadequate drainage and sewerage, and what sewers there were tended to be square, stuck in the corners, and built of porous brick. Waste was frequently left in the streets and most people shared privies which emptied into cesspits. What open spaces there were also tended to be filled with rubbish, and the air and water were polluted by factories and slaughterhouses. The satirical cartoonists of the day didn't have to imagine a hell to illustrate in these cramped, poorly designed cities.

Consequently, there was much illness, and in 1832 one doctor said only 10 percent of Leeds was actually in full health. In fact, despite technological developments, the death rate rose, and infant mortality was very high. There was also a range of common diseases: tuberculosis, typhus, and after 1831, cholera. The terrible working environments created new occupational hazards, such as lung disease and bone deformities. The 1842 report by the British social reformer Edwin Chadwick called "Report on the Sanitary Condition of the Labouring Population of Great Britain" showed that the life expectancy of an urban dweller was less than that of a rural one, and this was also affected by class.

Why Public Health Was Slow to Be Dealt With

Before 1835, town administration was weak, poor and too impotent to meet the demands of new urban life. There were few representative elections to produce forums for people who were worse off to speak, and there was little power in the hands of town planners, even after such a job was created by necessity. Revenues tended to be spent on large, new civic buildings. Some regions had chartered boroughs with rights, and others found themselves governed by a lord of the manor, but all these arrangements were too out-of-date to deal with the speed of urbanization. Scientific ignorance also played a role, as people simply didn’t know what caused the diseases that afflicted them.

There was self-interest too, as builders wanted profits, not better quality housing, and the government held a deep prejudice about the poor's worthiness of efforts. Chadwick’s influential sanitary report of 1842 divided people into ‘clean’ and ‘dirty’ parties and some people believed Chadwick wanted the poor to be made clean against their will Government attitudes also played a role. It was commonly thought that the laissez-faire system, in which governments didn’t interfere in the lives of adult men, was the only reasonable system, and it was only late in the process that government became willing to undertake reform and humanitarian action. The prime motivation then was cholera, not ideology.

The Municipal Corporations Act of 1835

In 1835 a commission was appointed to look into municipal government. It was badly organized, but the report published was deeply critical of what it called ‘chartered hogsties.’ A law with limited effect was passed, but newly created councils were given few powers and were expensive to form. Nevertheless, this wasn't a failure, as it set the pattern for English government and made possible the later public health acts.

Beginnings of the Sanitary Reform Movement

A group of doctors wrote two reports in 1838 on the living conditions in London’s Bethnal Green. They drew attention to the connection between unsanitary conditions, disease, and pauperism. The Bishop of London then called for a national survey. Chadwick, a force in all things public service in the mid-eighteenth century, mobilized the medical officers provided by the Poor Law and created his 1842 report which highlighted the problems associated with class and residence. It was damning and sold a huge number of copies. Amongst its recommendations were an arterial system for clean water and the replacement of improvement commissions by a single body with power. Many objected to Chadwick and some wags in the government claimed they preferred cholera to him.

As a result of Chadwick’s report, though, the Health of Towns Association was formed in 1844, and branches all over England researched and published on their local conditions. Meanwhile, the government was recommended to introduce public health reforms by other sources in 1847. By this stage, some municipal governments had acted on their own initiative and passed private acts of Parliament to force through changes.

Cholera Highlights the Need

A cholera epidemic left India in 1817 and reached Sunderland in late 1831; London was affected by February 1832. Fifty percent of all cases proved fatal. Some towns set up quarantine boards, and they promoted whitewashing—cleaning clothing with chloride of lime—and speedy burials, but they were targeting disease under the miasma theory that disease was caused by floating vapors rather than the unrecognized infectious bacterium. Several leading surgeons recognized that cholera prevailed where sanitation and drainage were poor, but their ideas for improvement were temporarily ignored. In 1848 cholera returned to Britain, and the government resolved that something had to be done.

The Public Health Act of 1848

The first Public Health act was passed in 1848 based on the recommendations of a Royal Commission. The act created a central Board of Health with a five-year mandate, to be considered for renewal at the end of that period. Three commissioners, including Chadwick, and a medical officer were appointed to the board. Wherever the death rate was worse than 23/1000, or where 10 percent of ratepayers requested assistance, the board would send an inspector to authorize the town council to carry out duties and form a local board. These authorities would have powers over drainage, building regulations, water supplies, paving, and rubbish. Inspections were to be carried out, and loans could be given. Chadwick took the opportunity to push his new interest in sewer technology to the local authorities.

The act did not have much potency, because while it had the power to appoint boards and inspectors, that wasn't required, and local works were frequently held up by legal and financial obstacles. It was, however, much cheaper to set up a board than previously, with a local one costing just £100. Some towns ignored the national board and set up their own private committees to avoid central interference. The central board worked hard, and between 1840 and 1855 they posted a hundred thousand letters, although it lost much of its teeth when Chadwick was forced from office and a switch to annual renewal was made. Overall, the act is considered to have failed as the death rate remained the same, and the problems remained, but it did establish a precedent for government intervention.

Public Health after 1854

The central board was disbanded in 1854. By the mid-1860s, the government had come to a more positive and interventionist approach, spurred on by the 1866 cholera epidemic that clearly revealed the flaws in the earlier act. A set of innovations aided the progress, as in 1854 English physician John Snow showed how cholera could be spread by a water pump, and in 1865 Louis Pasteur demonstrated his germ theory of disease. The ability to vote was expanded to the urban working class in 1867, and politicians now had to make promises regarding public health to gain votes. Local authorities also began to take more of a lead. The 1866 Sanitary Act forced towns to appoint inspectors to check that water supplies and drainage were adequate. The 1871 Local Government Board Act placed public health and the poor law in the hands of empowered local governmental bodies and came about because of an 1869 Royal Sanitary Commission which recommended strong local government.

1875 Public Health Act

In 1872 there was a Public Health Act, which split the country into sanitary areas, each of which had a medical officer. In 1875 Prime Minister Benjamin Disraeli saw that several acts aimed at social improvements were passed, such as a new Public Health Act and an Artisan’s Dwellings Act. A Food and Drink Act was passed to attempt to improve diet. This set of public health acts rationalized previous legislation and was extremely influential. Local authorities were made responsible for a range of public health issues and given the powers to enforce decisions, including sewage, water, drains, waste disposal, public works, and lighting. These acts marked the beginning of a genuine, workable public health strategy, with responsibility shared between local and national government, and the death rate finally began to fall.

Further improvements were boosted by scientific discoveries. Koch discovered micro-organisms and separated out germs, including tuberculosis in 1882 and cholera in 1883. Vaccines were developed. Public health can still be a problem, but the changes in the role of government established in this period, both perceived and actual, are mostly ingrained into the modern consciousness and provide a working strategy to ameliorate problems as they arise.