Scope and Aims

Structurally, Children’s Health and Urban Ecology in England examines the various “layers” of public health interventions, in the places where children were at the greatest risk of the “urban penalty,” using the child’s life cycle as an analytical lens as we move through time. Picking up the history of public health in the mid-1880s, after the legal establishment of public health administration and the emergence of germ theory, at a moment when rising infant mortality rates brought closer attention specifically to children’s health, I want to trace the history of public health efforts targeting children through a series of significant inflection points that gradually shifted the epicenter of public health from local administration by the Medical Officers of Health to the national level by the end of the First World War. Two imperial crises, the Second Anglo-Boer War (1899–1902) and the First World War (1914–18), which drew special attention to children’s health, revived Cantlie’s crisis in a way that was more vivid to his contemporaries, and in essence forced greater state investment in public health. These crisis moments serve as the historical pivot points on which my book turns.

Children’s Health and Urban Ecology in England is therefore purposefully divided into two halves. In the first half of the book, we will focus on the local origins of public health campaigns targeting some of the leading causes of infant mortality in the last decades of the Victorian era. We will focus our attention on the three case-study cities that exemplify the growing role of child welfare in the expanding scope of public health. In second half the book, we will gradually move away from these three cities as we consider how lessons from two imperial wars shifted the epicenter of public health away from municipal authorities to the national government, beginning after 1904 and completely by 1918, while also continuing to highlight the importance of children’s welfare.

Chapter 1 establishes an environmental and political context for the important work of the Medical Officers of Health in the three case-study cities of Birmingham, Liverpool, and Manchester. We will consider how each city developed geographically and how this shaped their sanitary conditions, creating their urban penalty. We will note the appointment of the first Medical Officers of Health, and how these doctors implemented Victorian sanitary reforms, which laid the foundation for more intimate approaches to public health that followed. Finally, this chapter will consider how infant mortality came to stand out as a particularly problematic and lingering challenge to the public health of these three cities over the course of the Victorian era and became a special target for expanding state medicine.

Looking specifically at one of the leading causes of infant mortality, summer diarrhea, Chapter 2 extends my argument about the importance of placing the history of public health in particular ecological contexts. The Medical Officers of Health observed that, in part, seasonal climatic conditions could intensify or lessen the severity of this disease state from year to year, and so they monitored the environmental conditions to inform their efforts to mitigate this deadly hazard. However, they also realized that the hygienic conditions (or lack thereof) in the micro-ecologies of individual households also played a major role in the susceptibility of children succumbing to the deadly diarrhea. Chapter 2 will examine how the Medical Officers came to understand summer diarrhea as a function of both climatic and urban ecological conditions, and how they saw this as a particular threat to children’s health that could be specially targeted with more in-home interventions.

Chapter 3 in turn takes up the nature of those in-home interventions themselves, specifically the professionalization of health visiting, as a key tool in the mitigation of the urban penalty. While some mothers found these middle-class women calling on other women to offer in-home lessons in infant care and domestic hygiene after a birth to be an interference, as their ranks grew over the decades, infant mortality declined.3Beier, For Their Own Good, 25. This decline could not be due solely to the work of health visitors (or any single cause). But, as geographer Michael Drake suggests, “surely they made a difference.”4Drake, “Surely They Made a Difference,” 63–69. We begin to see that difference by the turn of the twentieth century, and a continued impact in the decades that followed.

As we approach the turn of the twentieth century, we encounter our first imperial inflection point: the Second Anglo-Boer War (1899–1902), which drew national attention to the importance of public health. Health records from volunteers for military service provided an opportunity to assess national health on a large scale, and the results were shocking. A large minority of Britons deemed medically unfit for military service renewed fears of national “degeneration” and revived Cantlie’s crisis. In the aftermath of the war, Parliament ordered a review of the nation’s health, which was published in the 1904 Report of the Inter-departmental Committee on Physical Deterioration. Part of what historian G.R. Searle has described as a “quest for national efficiency,” the Report of the Inter-departmental Committee on Physical Deterioration offered numerous suggestions about how to improve children’s health so as to improve the health of the “next generation of fighters and workers.”5Searle, The Quest for National Efficiency; Bryder, “Mobilising Mothers,” 5. For this reason, the publication of the report marks an important turning point after which child welfare began to take on a significantly different nature, with central government taking a much greater hand in encouraging (and eventually mandating) public health services that expanded the scope of children’s health beyond infancy and into their early adolescence. In turn, our attention will pivot in the second half of the book as the center of public health administration shifted from the local authority of the Medical Officers of Health into the hands of national government officials at Westminster and Whitehall. At the same time, we will continue to focus on the child’s life cycle in our analytical framework as we move into the twentieth century.

Chapter 4 tells the story of the medical data that emerged from the South African War and the ensuing 1904 Report of the Inter-departmental Committee on Physical Deterioration. In this context Cantlie’s fears about the dangers of urban life reemerged, but with far greater acceptance from his contemporaries. While the 1904 report ultimately rejected the idea of “degeneration,” it offered over fifty suggestions for improving public health, many of which focused on children. Among these recommendations, some of the most consequential suggestions advised that greater attention to children’s health should not be limited to infancy but should be maintained throughout their critical developmental years during early childhood.

Health visiting typically stopped after the children reached one year of age, but occasionally was maintained until the age of five. At five years of age children left home for compulsory elementary school education, where they were that much more accessible to medical surveillance and intervention, which we will explore in Chapter 5. One of the most consequential outcomes of the growing state involvement in public health included the expansion of schools as sites of public health interventions. Medical observation in schools allowed School Medical Officers, who often worked closely with the municipal Medical Officers of Health, to facilitate interventions to prevent malnourishment or physical deformity in children during crucial developmental years as another effort to mitigate the effects of the urban penalty, and to ensure that children were growing up ready to be fighting fit.

The sixth and final chapter considers how the Great War became a second imperial inflection point that influenced the history of children’s health. The devastating loss of life in the First World War made every child’s life more valuable to the future of the nation and the Empire as the “emotional value” of the child continued to rise with the carnage of the war.6Zelizer, Pricing the Priceless Child, 11, while writing about the parallel history of infant and child welfare in the United States, argues that falling birth rates and early deaths had placed an incalculable value on children’s wellbeing from the 1880s. I want to argue that the same was true in England. This alone drove renewed national attention to children’s health, much like the South African War did. But the First World War also tested the results of the efforts that had emerged after 1904: the youngest soldiers conscripted in the last years of the Great War were the first generation to grow up under the surveillance of health visits in their infancy and school medical services monitoring their early adolescence. When they too were often found medically unfit for military service, this further incentivized expanding child health programs. It became clear during the First World War that the state needed to take a firmer hand in guiding the expansion of children’s public health campaigns. Thus, in 1918 as the Great War was coming to an end, we see the culmination of this story with the passage of the landmark 1918 Infant and Maternal Welfare Act, which formalized many of the programs that had been established locally by the Medical Officers of Health in the decades prior and provided national funding to increase programs for infant children and their mothers’ health. As a result, programs that began as municipal and locally administered foundations of public health would finally become the purview of the central state, which asserted its role more completely in 1919 after the establishment of the Ministry of Health, which took over the responsibility for overseeing the health of the nation going forward. Thus, the child welfare movement looked very different by 1919 than it had in 1885. What began locally, in the poorest districts of Great Britain’s “urban behemoths,” had evolved into a national program intended to promote public health for the sake of the nation’s children by the end of the Great War. Our goal is to consider why and how.