Politics and Public Health

We can trace the roots of state-sponsored public health at least as early as 1832, when Manchester-born Edwin Chadwick was appointed to the Poor Law Commission and famously began to preach the “gospel of sanitation.” Chadwick believed that sanitary reforms intended to remove filth and odors would reshape the health, mentalities, and behavior of the urban poor.4Hamlin, Public Health and Social Justice, 53. In his 1842 “Report on the Sanitary Conditions of the Labouring Population of Great Britain,” Chadwick argued that improper drainage of fetid water was a problem that the British state could and should remedy, in order to improve economic efficiency by eliminating the cause of fevers.5Chadwick, “Report on the Sanitary Conditions of the Labouring Population of Great Britain,” 25. But, Chadwick also narrowed the focus of public health measures to sanitary systems – particularly hydraulic systems – maintaining the idea of a minimally interventionist state.6Hamlin, Public Health and Social Justice, 15. More importantly still, Chadwick’s vision established a central–local division of responsibilities for managing public health. Chadwick argued that the state should create a central board for the oversight of public health; one which would direct local public health administration in the construction and maintenance of proper drainage and water supply systems. At the local level, Chadwick proposed that individual cities should appoint a Medical Officer of Health to oversee recommended sanitary reforms.7Porter, Health, Civilization and the State, 118. Thus, Chadwick argued there should be a limited central body for oversight but much of the actual work of public health should be left to municipalities – and, by extension, locally appointed public health administrators, the Medical Officers of Health.8Porter, Health, Civilization and the State, 112. For an important overview of the responsibilities of the Medical Officers of Health see Welshman, “The Medical Officer of Health in England and Wales,” 443–50; and Gorsky, “Local Leadership in Public Health,” 468–72.

A few years after Chadwick’s famous Report, Parliament passed the landmark 1848 Public Health Act, which established and empowered a central administrative body, the General Board of Health, to oversee the administration of sanitary conditions across England and Wales (excluding London), as well as the appointment of local sanitary authorities (the Medical Officers of Health), who would be responsible for municipal sanitary and environmental regulation.9Fee and Porter, “Public Health, Preventative Medicine, and Professionalization,” 19. More importantly, though, the 1848 Public Health Act established local boards of health in each English municipality, with the power to improve local sanitation through inspection and improving local water supplies and drainage.10An Act for promoting the Public Health 1848 (UK), cap. LXII, 721–25.

British historian Philip Harling suggests that the Public Health Act was perhaps “the most significant interventionist measure of the mid-Victorian era,” empowering the state to “curb a social ill.”11Harling, The Modern British State, 105–6. However, the permissive nature of the 1848 Public Health Act made its implementation uneven across the nation.12Fee and Porter, “Public Health, Preventative Medicine, and Professionalization,” 19. The Act was “enabling,” not mandatory, and left broad discretionary power in the hands of municipal authorities. Thus, the responsibility for implementing sanitary improvements fell increasingly upon the local Medical Officers of Health, who simultaneously served as expert advisors, reformers, government employees, and local public health administrators, and whose work guiding local efforts to improve children’s health will be central to the story of this book.13See Wohl, Endangered Lives; Brand, Doctors and the State; Hardy, “Public Health and the Expert.” Szreter also discusses the role of the Medical Officer of Health at length in chapter 9 of Health and Wealth. Dorothy Porter provides a wonderful occupational history of the Medical Officers of Health in Porter, “Stratification and Its Discontents.” In turn, the Medical Officers of Health relied on local health inspectors, nurses, school doctors, analysts, and other experts to collect data for them, creating an elaborate yet hierarchical public health bureaucracy.14Writing about the seventeenth-century laboratory of Robert Boyle, Steven Shapin reminds his readers of the importance of the oft-neglected technician, who frequently was the operator responsible for the collection of raw data, in Shapin, “The Invisible Technician,” 554–63. The statisticians, health inspectors, and analysts who were responsible for collection of data for the Medical Officer of Health played an equally critical role in expansion of public health as the technician did in the expansion of laboratory science, but also often do not receive due historical attention, perhaps due to lack of source material.

By 1853, 103 towns had appointed a local Medical Officer of Health in some professional capacity. Yet, while the number of towns appointing Medical Officers of Health grew, the centralized General Board of Health became so unpopular by 1854 that its members were forced to resign in disgrace.15Porter, Health, Civilization and the State, 120. In their place, in 1855, John Simon, who had served as the Medical Officer of Health for London since 1848, was appointed Chief Medical Officer to head a new medical department of the Privy Council. He held this position until 1876. Under Simon’s leadership, the Medical Department monitored for infectious disease outbreaks and managed the administration of the smallpox vaccination.16Steere-Williams, The Filth Disease, 1, 3. Simon’s annual reports “awakened the Government to the urgency of the need for bolder State action.”17Newman, The Building of a Nation’s Health, 20. His vision for “state medicine” would incorporate sanitary regulations on housing, laws prohibiting the sale of adulterated or contaminated food, regulations on the health of industrial laborers, compulsory control of infectious disease through measures such as mandatory vaccination and quarantine, minimizing pollution of atmospheric conditions, as well as ensuring a clean water supply through the construction of more efficient systems of drainage.18Porter, Health, Civilization and the State, 124. The responsibility for doing this work, though, still fell to the local Medical Officers of Health.

Despite Simon’s best efforts, the parliamentary response to public health challenges remained “haphazard and piecemeal,” according to medical historian Dorothy Porter, comprised of legislation that was “too chaotic” to be effectively implemented by local authorities until 1868, when a Royal Commission was established to consolidate public health efforts.19Porter, Health, Civilization and the State, 126. The rationale for sanitary reforms, unsurprisingly, was that “it would save money in the long run” to invest in public health, according to urban historian Asa Briggs.20Briggs, Victorian Cities, 20. A series of new Public Health Acts (1871, 1872, and 1875) were passed, which provided both “the carrot of central subsidy and the stick of inspection” for public health reforms to be enacted locally but empowered by permissive national legislation and funding from the Local Government Board, which was itself established by the 1871 Local Government Act.21Doyle, “The Changing Functions of Urban Government,” 289. Bellamy, Administering Central–Local Relations also provides a broader administrative history of the messiness of this shared power relationship.

The 1875 Public Health Act proved particularly important. It set minimum standards of sanitation and public health nationwide, as well as the establishing local boards of health and a Medical Officer of Health within each borough of England and Wales (except London) to inspect sanitary conditions and implement public health legislation.22An Act for consolidating and amending the Acts relating to Public Health in England 1875, ch. 55. The Act permitted Medical Officers of Health to inspect private property during an epidemic, to mandate disinfection of houses and contents suspected of infection, and to compel the removal or the burial of corpses under penalty of fine or imprisonment. Sanitary inspections combined applied science, politics, and civil discourse. Their purpose was to maintain a “respectable public sphere,” but inspection required access to private residences to conduct “close observation” of any potential nuisances.23Crook, “Sanitary Inspection and the Public Sphere in Late Victorian and Edwardian Britain,” 375. According to Mooney, “such access promised control of the diseased and the nondiseased because it facilitated the swift implementation of existing public health laws.” At the same time, this more reliable data allowed local authorities to “trim the fat” of costly public health programs.24Mooney, Intrusive Interventions, 40.

Although the inspectors carried with them the power of compulsion, the art of diplomacy was a generally more effective means of gaining access to English homes. Being sensitive to the fact that their work necessarily invaded “domestic privacy,” inspectors often had to embrace a certain degree of performative diplomacy, which, according to historian Tom Crook, required being “thorough, but without giving the impression of snooping” while conducting their inspections of the residence.25Crook, “Sanitary Inspection and the Public Sphere,” 385.

By the early twentieth century, the remit of inspection had grown considerably, and the inspection of children became a critical component of a broader system of public health. Midwifery came under inspection and oversight in 1902, and the inspection of school children began in 1907. The most important form of inspection focused on children’s health tied together sanitary inspection and maternal education, and was conducted by municipal health visitors, whom we will study closely in Chapter 3. While earlier historiography considers this growth of an “interventionist state” as “revolution in government,” I agree with Crook that this transformation and expansion of public health was made gradually, intentionally, and primarily occurred in local government.26MacDonagh, “The Nineteenth-Century Revolution in Government,” 57–60; Crook, “Sanitary Inspection and the Public Sphere,” 369. Of course, Patrick Joyce would challenge the idea of a “distant and remote liberal state” by arguing that technologies of governance (like inspection) reflect constant state intervention into the daily lives of Britons, thus challenging the commonly held belief that the aim of a liberal state was to release citizens from government interference. See Joyce, The State of Freedom. Health visitors were an important part of this transformation, as they started their work as charitable volunteers, but beginning in Manchester in 1892 began to shift into a new role as municipal public health employees by the turn of the twentieth century.

When inspection and surveillance were tied together with advances in biomedicine, specifically the emergence of the germ theory of disease after Robert Koch’s discovery of Mycobacterium tuberculosis in 1882, and new innovations in medical technology, including advances in microscopy, staining techniques, and experimental pathology, the ability to control infectious disease increased considerably in the last decade of the nineteenth century.27Note that Worboys, Spreading Germs, argues convincingly that there was not a hard break in the history of medicine and public health in the early 1880s. Worboys notes that the adoption of Koch’s theory occurred gradually over the last two decades of the nineteenth century, as a series of germ theories were debated, contested, and ultimately deployed in British medicine. Greater etiological understanding of diseases allowed public health officials to better understand the “interdependence of those social and biological conditions” that contributed to the outbreak and spread of infectious diseases.28Porter, “Enemies of the Race,” 171. On this intersection between epidemiology and bacteriology see Hardy, “On the Cusp,” 328–46; and more recently, Steere-Williams, “Performing State Medicine during its ‘Frustrating’ Years,” 82–107. In turn, this seemed to broaden the possibilities of public health. Under the local direction of the Medical Officers of Health, paying greater attention to children’s health was a major feature of this broadening. This is the story that I seek to tell.