Public Health During the Industrial Revolution

A Court for King Cholera
Public Domain

One aspect of the industrial revolution (more on coal, iron, steam) was the rapid urbanization, as new and expanding industry caused villages and towns to swell, sometimes into vast cities. The Port of Liverpool rose from a couple of thousand to many tens of thousands in a century. However, 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 stresses the new urban workers were pushed into, and 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 areas—with the everyday laborer— 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 was high density back to back housing which was poor, damp, badly ventilated with few kitchens and many sharing a single tap and privy. In this overcrowding, disease spread easily.

There was also inadequate drainage and sewerage, and what sewers there were tended to be square – so things stuck in the corners – and built of porous brick. Waste was frequently left in the streets and most people shared privies which led to cesspits. What open spaces there were also tended to be filled with rubbish, and the air and water were polluted by factories and slaughterhouses. You can imagine how 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% 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: TB, Typhus, and after 1831, Cholera. Occupational hazards also had an effect, such as lung disease and bone deformities. An 1842 report by Chadwick 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 the worse off to speak, and there was little power in the fields of town planning even when there was such a field. 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 prejudice in the government. Chadwick’s report of 1842 split people into ‘clean’ and ‘dirty’ parties, with the mischievously named ‘dirty party’ claiming 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, where governments didn’t interfere in the lives of adult men, was right, and it was only late that government began to willing 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 the ‘chartered hogsties’. A law with limited effect was passed, as the new councils had 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 in the living conditions in London’s Bethnall 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 an 1842 report which highlighted the problems associated with class and residence. It was damning and sold a huge amount. 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 claimed they preferred Cholera to him.

As a result of Chadwick’s report, the Health of Towns Association was formed in 1844, and branches all over England researched and published on the subject. 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 per cent of all cases proved fatal. Some towns set up quarantine boards, practiced whitewashing with chloride of lime and speedy burials, but they were targeting disease under the miasma theory rather than the real cause. 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 produced in 1848 after a Royal Commission made a set of recommendations. It created a central Board of Health with a five-year mandate, to be reconsidered for renewal at the end. Three commissioners—including Chadwick— and a medical officer were appointed. Where the death rate was worse than 23/1000, or where 10% of rate payers requested, 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, loans could be given and Chadwick pushed his new interest in sewer technology.

The act was very permissive, as while it had the power to appoint boards and inspectors it didn’t have to, 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, and some towns ignored the 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 Dr. John Snow showed how cholera could be spread by a water pump, and in 1865 Louis Pasteur demonstrated his germ theory of disease. The expansion of the vote to the urban working class in 1867 also had an effect, as 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 government 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 Disraeli passed one of several acts aimed at social improvements, such as a new Public Health Act and an Artisan’s Dwellings Act. A Food and Drink act tried to improve diet. This public health act rationalized previous legislation and was all pervasive in influence. 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. This act marked the beginning of genuine public health, with responsibility shared between local and national government, and the death rate began to fall.

Further improvements were boosted by scientific discoveries. Koch discovered micro-organisms and separated out germs, including TB in 1882 and Cholera in 1883. Then vaccines were developed. Public health can still be a problem, but the changes in the role of government, perceived and actual, are mostly engrained in the modern consciousness.