Identifying the “Urban Penalty”

Indeed, what Cantlie was really describing, quite accurately, is what geographers and historians now describe as the “urban penalty,” a phenomenon whereby people could reap the benefits of industrialization more readily in cities than in a rural agricultural town, but at the same time were exposed to far more environmental hazards to their health.5There is a robust, if somewhat dated, literature on the “urban penalty,” including Woods and Woodward, Urban Disease and Mortality in Nineteenth Century England; Luckin and Mooney, “Urban History and Historical Epidemiology,” 37–55; and Sheard and Power, Body and City. Historical geographer Gerry Kearns has studied higher rates of infectious diseases in urban spaces and uses this as his metric for measuring the urban penalty.6Kearns, “Biology, Class and the Urban Penalty,” 12–30. He argues that rising cases of respiratory illness were the result of living in increasingly densely populated cities, which tended to lower life expectancy in towns as compared to rural areas.7Kearns, “The Urban Penalty and the Population History of England,” 213–36. Historian Anne Hardy, who has also studied the urban penalty, argues that it was most deleterious to the health of those under the age of five, and especially to weaning Britons (from the age of six months to two years).8Hardy, “Rickets and the Rest,” 389.

Hardy is right to draw our attention to children’s health and the dangerous impacts city life had on healthy development. Some basic demographic data tells us why. From the mid-nineteenth century, life expectancies were gradually rising, and annual mortality rates were falling.9See Woods, The Demography of Victorian England and Wales for a detailed study. In 1841, the average national life expectancy was 40 years for men and 42 for women. By the end of the century, in 1900, life expectancy had risen to 44.1 years for men and 47.8 years for women.10Howe, People, Environment, Disease and Death, 150, 178. By the 1860s, mortality rates in industrial areas of Great Britain began a relatively steady decline from 21–23 deaths per 1,000 living in the 1860s to 14 deaths per 1,000 living by 1914.11Floud and Harris, “Health, Height and Welfare: Britain, 1700–1980,” 96; Hardy, Health and Medicine in Britain since 1860, 12, contrasts urban and rural mortality rates based on William Farr’s data. However, infant mortality rates (the death of children under one year old) remained troublingly high throughout the nineteenth century, as seen in Figure 0.2, not dropping below 100 deaths per 1,000 live births until after the First World War.12Newman, Infant Mortality, 3; Howe, People, Environment, Disease and Death, 177. In short, infant mortality rates lagged behind the other indicators of a demographic transition.13Haines, “Socio-economic Differentials in Infant and Child Mortality during Mortality Decline,” 297. Urban, especially poor, districts were at the center of this problem. During the 1880s and 1890s these areas were particularly responsible for the national increase in infant mortality rates from a five-year average of 145.4 per 1,000 births in 1875–79 to 157.6 per 1,000 births in 1895–99.14Woods, Watterson, and Woodward, “The Causes of Rapid Infant Mortality Decline in England and Wales, 1861–1921 Part I,” 357. On the other hand, Woods et al. also note that the dramatic decline in infant mortality after 1900 was also overwhelmingly the result of urban infant mortality declining. This was a failure of public health that required substantial corrective effort, and which many public health reformers believed necessitated further and greater state financial support.15Marks, Metropolitan Maternity, 3. There is strong historiographical support for this position, including Davin, “Imperialism and the Cult of Motherhood,” 9–65; Dwork, War is Good for Babies and Other Young Children; Steedman, Childhood, Culture and Class in Britain; Marks, “Mothers, Babies and Hospitals”; and Reynolds, Infant Mortality and Working-Class Child Care. I am interested in building on Anne Hardy’s important argument that children were the population most threatened by the urban penalty and exploring how contemporary public health authorities sought to mitigate its effects on the health of English children.

It is my goal to explain how and why children’s health became a special focus of expanding English urban public health programs by the 1880s, and to trace this history through the First World War. Historical geographer Alice Reid describes the “complex interactions of personal and environmental characteristics” that influenced post-neonatal mortality as a “riddle.”16Reid, “Infant Feeding and Post-Neonatal Mortality in Derbyshire,” 152. While I cannot promise to fully solve the riddle, I do hope to center some of the most influential factors in a historical perspective. To this end, I offer an argument that unfolds over three broad stages about how we might reconsider increased attention to children’s health as a major component of expanding late Victorian and early Edwardian public health campaigns. The first element of my argument emphasizes the importance of place in the history of public health; the second turns our attention to the nature of public health programs themselves; and then finally I will examine the changing role of the British state in the administration of public health.

Public health campaigns operate in very specific spatial contexts.17Szreter, “The Importance of Social Intervention in Britain’s Mortality Decline,” 1–38; Szreter, Health and Wealth, 287. Historian Tom Crook argues that an emphasis on “the local and the personal” within a “multi-scalar” history of Victorian public health is critical, because “it was at the local level – in towns, streets, and homes, and in and around human bodies – where policies had to work.”18Crook, Governing Systems, 15–16. Kearns, Laxton, and Campbell, “Duncan and the Cholera Test,” 87, also suggest that we remember the importance of the local in the history of public health. Yet, historian Simon Szreter suggests that a “peculiar invisibility” hid the massive, important work being done by local government to promote public health before 1914.19Szreter, Fertility, Class and Gender in Britain, 1860–1940, 194. It is my goal to render some of this invisible work visible with a particular focus on the locality of public health. The environments in which children lived (or died) were deeply influential on their health, and we need to purposefully link the material and environmental history of urban spaces with the history of public health.20Sellers, “To Place or Not to Place,” 1–45, makes a powerful argument for bridging an environmental-materialist history of “place” and the social history of medicine when studying the history of public health. This argument is extended further, and more recently, in Webster, “Environmental Materialities and the History of Pandemics,” 1–17. While Cantlie was writing about London, the perilous ecological conditions he lamented existed across most large British cities. Rapid urban growth without sufficient sanitary planning resulted in widespread pollution that was a hazard to public health.21Millward and Bell, “Choices for Town Councillors in Nineteenth-Century Britain,” 143. Children were especially at risk from these environmental hazards.

In the early 2000s, Chris Galley argued that we have “few detailed local studies” about the specific measures aimed at reducing infant mortality rates, despite a wealth of source material in the annual reports of the Medical Officers of Health.22Galley, “Social Intervention and the Decline of Infant Mortality,” 29. Indeed, much of the existing literature has still focused on London.23On London, Marks makes a powerful case for studying the local contexts of public health efforts in Metropolitan Maternity, but see also Ross, Love and Toil; Davin, Growing Up Poor; Murdoch, Imagined Orphans; Kerr, Contagion, Isolation, and Biopolitics in Victorian London; and most recently Ferguson, “London and Early Environmentalism.” Welshman, Municipal Medicine is a notable exception. Welshman provides a useful model for studying municipal public health using the city of Leicester, a hub of the anti-vaccination movement in the mid-1880s but an otherwise progressive city in its implementation of public health, as a case study. Pooley, “‘All We Parents Want Is that Our Children’s Health and Lives Should Be Regarded’” also offers a useful model for considering the locality of public health interventions specifically targeting children. In an effort to purposefully consider the importance of place and local government in promoting public health, I have chosen to consider three other large cities where infant mortality rates were among the highest in the nation – Birmingham, Liverpool and Manchester.24Williams and Mooney, “Infant Mortality in an ‘Age of Great Cities,’” 191, quantifies average infant mortality from 1860 to 1899 in twenty-one “Great Cities.” In their study, Manchester ranked third-highest in average infant mortality for the period (194 per 1,000 live births), Liverpool sixth (185), and Birmingham thirteenth (173). Only two cities exceeded Manchester in average annual infant mortality: Preston (209) and Leicester (208). These were three of the twelve most populous cities in the western world by the mid-nineteenth century, and the third (Liverpool), fourth (Manchester), and fifth (Birmingham) largest cities in Great Britain at the opening of Queen Victoria’s reign, behind only London and Glasgow.25Luckin, Death and Survival in Urban Britain, 170; Ward, City-State and Nation, 3. These “urban behemoths,” as historian Christopher Hamlin describes them, “with their own bureaucracies” empowered their respective Medical Officers of Health to take particularly progressive action, which they reported in detail in their annual reports.26Hamlin, “Nuisances and Community in Mid-Victorian England,” 352. Thus, due to a rich source base and their regional influence they serve as useful case studies to understand the ways local ecologies and local politics shaped efforts to lower infant mortality and to improve children’s health and fitness on either side of the turn of the twentieth century.

In each of these three cities, infant mortality rates were on average 16 to 29 percent above the national average (Figure 0.3). This captured the attention of the local Medical Officers of Health, Drs. Alfred Hill and John Robertson (in Birmingham), J. Stopford Taylor and E.W. Hope (in Liverpool), and James Niven and R. Veitch Clark (in Manchester), who led the charge of ongoing public health reforms across British cities from the mid-nineteenth century and who will sit at the center of the story in this book.27In addition to choosing to study these cities as case studies for their unenviable position of those suffering from among the highest rates of infant mortality in Great Britain, the Medical Officers of Health in these cities were also leaders in their profession. E.W. Hope served as president of the Society of Medical Officers of Health from 1912 to 1913, and John Robertson was president of the Society from 1916 to 1917. Frazer, A History of English Public Health, 226. While the Medical Officers of Health rejected the specific language of degeneration and eschewed the nationalist and imperialist concerns espoused by Cantlie, they shared his concerns about environmental conditions and the socio-economics of town life as major contributing factors to the high infant mortality rates and an impediment to healthy physical development.28Pooley, “‘All We Parents Want Is that Our Children’s Health and Lives Should Be Regarded,” 540; Harris, The Health of the Schoolchild, 11. Their concerns mirrored the causes of degeneration that alarmed Cantlie: atmospheric pollution, organic waste, lack of sunlight, crowded streets, and poor housing.29See Newsholme, “Alleged Physical Deterioration in Towns,” 295. Some of these hazards were within their power to control. Victorian public health officials believed that food- and water-borne diseases ranging from cholera to diarrhea to enteric (typhoid) fever could be controlled through effective sewage removal, purity of water supplies, and food inspection.30See, for example, Steere-Williams, The Filth Disease, for an excellent study of the contemporary campaign against typhoid fever in all three of these areas of public health. Combatting diseases of childhood such as measles and scarlet fever, which spread most effectively in crowded living environs, also necessitated reforming crowded housing as a matter of public health.31Wood, The Demography of Victorian England and Wales, 311. See also Mooney, Intrusive Interventions. As I will highlight in Chapter 1, these sorts of public health reforms both emphasize the material influences on public health and laid the groundwork for more personal programs that followed.

I would argue that in addition to knowing where the problem of infant mortality existed, it is also important to understand why children were particularly endangered by urban environments and what could be done about this. In the last two decades of the nineteenth century a rift opened in public health between an emphasis on broad sanitary reforms intended to eliminate the ecological conditions that allowed infectious diseases to thrive and a focus on using laboratory science to identify specific pathogens and treat infection in individuals.32Rogers, “Germs with Legs,” 600. Nash, Inescapable Ecologies, 6–7, makes a compelling argument that “discourse of germ theory obscured as much as it revealed” about the ecological considerations necessary for controlling infectious diseases, as public health experts often “insisted that disease-causing pathogens were situated in human bodies, not environments.” Also see Hardy, “On the Cusp,” 328–46; and more recently, Steere-Williams, “Performing State Medicine During its ‘Frustrating’ Years,” 82–107. Yet, the gradual acceptance of the germ theory of disease altered the responsibilities of the Medical Officers of Health as the practice of disinfection became focused on the destruction of germs through heat or chemical means.33Whyte, “Public Health and Public Safety,” 129. As a result, by the turn of the twentieth century, while infectious diseases remained a serious concern in British public health, increasingly sophisticated understanding of their etiologies allowed for more effective treatments, and that led to a steady drop in disease mortality rates among adults.34Galbraith and McCormick, “Infection in England and Wales,” 2–3. Children’s health was another matter, though.

While the leading cause of infant mortality, which combined premature birth and birth defects into a single category of classification, which was thought to lie outside the responsibility of public health, the second and third most common causes, respiratory infection and infantile diarrhea, respectively, were another matter. As Cantlie observed, atmospheric conditions as well as the poor ventilation of “back-to-back” houses gave rise to the increasing numbers of respiratory illness in town-dwellers. Infants with developing immune systems were particularly susceptible to airborne infection. Infantile diarrhea and gastroenteritis, which remain a threat to infants to this day in parts of the developing world, are in part caused by poor sanitary conditions and nutrition for infants.35Harper, Plagues upon the Earth, 120. Hot, dry summers allowed pathogens to thrive, flies to breed, milk to spoil more easily, and generally weakened the constitution of the infant, contributing to the special danger of summer diarrhea, which we will consider in Chapter 2. I will argue that while environmental and sanitary reforms could mitigate some of these hazards, the classical approach to public health would not be sufficient, alone, to dramatically reduce infant mortality rates. Private, in-home disinfection and sanitation was just as important for the health of infants and young children. But, even more importantly, as historian Linda Bryder argues, the adoption of germ theory “changed the approach to public health,” placing far greater attention on “reforming personal behaviour.” She suggests this shifted the epicenter of health “to the domestic environment” and the responsibilities onto mothers.36Bryder, “Mobilising Mothers,” 5. I concur, and will contend that domestic maternal education became a special emphasis for public health interventions.

Thus, the second stage of my argument extends the importance of place and invites us to think about the nature of public health interventions in the late Victorian and early Edwardian years and where interventions occurred. As Marjaana Niemi notes, public health policy often took one of two forms: sanitary (combatting environmental hazards) or social (changing the social and economic systems that resulted in this stratification of public health).37Niemi, “Public Health Discourses in Birmingham and Gothenburg,” 135. Urban sanitary reforms were the modus operandi of Victorian urban public health campaigns. But we might think of the city as the macro level of the “multi-scalar” nature of public health. Micro-level interventions occurred in individual homes, in individual bodies, and targeting individuals for interventions. I want to suggest that only when both sanitary reforms were coupled together with more personal, targeted interventions emerging in the last decade of the nineteenth century, often occurring inside the household itself, and often directed by non-family members, do we start to see a significant and steady decrease in infant mortality rates and improvement in childhood health. I want to suggest that social interventions were just as important as Victorian sanitary engineering for the promotion of public health and mark an influential, yet historically neglected, component of the British public health enterprise.

By the first decade of the twentieth century, new public health endeavors included expansive maternal and infant welfare campaigns, and later, the growth of a school medical service that continued to care for children’s health through their early adolescence. These programs expanded the scope of public health programs well beyond their modern origins in large-scale sanitary engineering and infectious disease mitigation and into much more personal and domestic areas of English life. At the same time, sanitary reformers continued their ongoing work of condemning and reconstructing ill-ventilated dwellings, the removal of ash pits and midden privies and replacing them with water closets that more effectively removed waste and prevented it from contaminating the home, and sanitary campaigns focused on the removal of “nuisances” that created foul odors and the spread of disease.38Under English law, a “nuisance” could be defined as a “general annoyance” or something that either was or might be “injurious to health” (Crook, “Danger in the Drains,” 116). In short, by the turn of the twentieth century, it had become quite clear to the Medical Officers of Health that improving public health in British cities required both broad sanitary reforms and aid for the individual, as both the “social and biological conditions” that influenced public health were deeply intertwined, especially when trying to reduce infant mortality rates and to promote healthy development through early childhood.39Porter, “Enemies of the Race,” 171.

Finally, extending the brilliant work of historical geographer Graham Mooney in his pathbreaking book Intrusive Interventions, I seek to highlight the emergence of an increasingly interventionist system of public health, deeply invested in a social welfare program intended to improve the health and lives of British children by the turn of the twentieth century.40Mooney, Intrusive Interventions; see also Worboys, “Practice and Science of Medicine in the Nineteenth Century,” 109–15. On the growth of new liberal politics as a driver of an interventionist state more broadly, see Hall and Schwarz, “State and Society, 1880–1930,” 22. Thus, in the final stage of my argument I will contend that the British state (for which the Medical Officers of Health serve as a useful analytical proxy) became more intimately involved in the lives of British children than ever before, intervening in the most private aspects of their lives – in the “domestic ‘micro-environment’” of their homes and even in their very bodies.41Luckin, Death and Survival in Urban Britain, 30. New forms of public health focused on the social aspects of public health as well as the sanitary, and manifested in educational campaigns that encouraged reforming personal habits and private behaviors, such as infant feeding practices.42Bryder, “From Breast to Bottle,” 54; see also Fildes, “Infant Feeding Practices and Infant Mortality,” 251–80. We see this by the turn of the twentieth century, in public health campaigns that sought to improve maternal care and promote infant welfare with in-home lessons in motherhood and hygiene, in efforts to improve children’s diet and nutrition, and in efforts to promote healthy development in schools through physical education during critical early years. These efforts began locally and expanded into national programs. As such, public health campaigns targeting children present an important perspective through which we should consider the changing role of the British state in promoting public health as it gradually became the epicenter of the administration of public health. While public health programs found their roots in Victorian municipalities, by the end of the First World War they were clearly being directed by Westminster and Whitehall.43Unlike the highly planned “High Modernist” state described by Scott, Seeing Like a State, this manifestation of central power was not necessarily problematic. Indeed, the centralization of public health allowed programs to grow in cities that did not have comparable, strong municipal governance to the three case-study cities.