Lessons from Urban Environmental History
This brief overview of Victorian public health in Manchester, Liverpool, and Birmingham is far from exhaustive. Rather, it gives a sense of how overcrowding, poor air and water quality, and excess waste created an urban ecology that threatened the public health and required large-scale sanitary and civil engineering to remedy. These were the conditions that made cities ripe for the spread of disease, and so, mitigation of these hazards was the primary focus of Victorian public health. By the end of the nineteenth century, across all three cities, ongoing sanitary reforms including the paving of streets, the improvement of household privies, and the reduction of overcrowded dwellings began to mitigate some of the effects of the urban penalty.
Public health was shaped by competing political and economic interests, especially those of municipal elites who feared imposing the costs of housing and sanitary reforms onto landlords and factory owners. Despite this, Liverpool set a standard for the rest of the country to follow, appointing the first Medical Officer of Health in the entire country, William Duncan, in 1847, ahead of the landmark 1848 Public Health Act. Victorian municipal public health reforms also happened at different speeds. Among the three cities, despite its “more middling sort” less divided along class lines, Birmingham was the slowest to employ a full-time Medical Officer of Health. It took the election of a radical, nonconformist mayor to press for a full time Medical Officer of Health, after the weight of the 1872 Public Health Act standardized the position. It is possible that the reason why Birmingham lagged behind was because it did not suffer as severely from the pollutants of industrialization as the other two cities, and so perhaps it took the force of personality of Joseph Chamberlain to drive forward urban sanitary reforms rather than an obvious ecological nightmare.
Still, having a sense of the environmental conditions in Victorian cities helps us understand the need for public health reforms and the spatial contexts in which they were implemented. For much of the Victorian era, public health campaigns focused on reforms at the level of towns, streets, and buildings. This was public health at a macro scale, and macro-scale problems remained serious threats to public health through the remainder of the nineteenth century, as Cantlie argued. By the 1890s, however, the epicenter of public health began to shift from the macro scale of the built environment into the micro-scale environment of the individual household, as the problem of infant and early childhood mortality began to stand out as a persistent threat to public health. This shift built upon the foundations laid by concerns about sanitation at the municipal level. The emergence of germ theory in the 1880s was also particularly important for this shift as the origins of diseases were reconceptualized. With an understanding of disease etiology being tied to specific pathogens rather that miasmas in the environment, reforming the ecological conditions that allowed diseases to spread remained important, but so too were interventions at the more intimate, individualized level, including personal preventative measures. Troublingly high infant mortality rates and early childhood deaths into the last decades of the nineteenth century were a major driver of this shift.
Beginning in the 1880s, we start to see a marked increase in state-sponsored “medical and social welfare.”
1Ashton and Ubido, “The Healthy City and the Ecological Idea,” 176. While directives often continued to result from Acts of Parliament, the responsibility for the implementation for social welfare and promoting the public’s health still fell on municipal authorities. For example, in 1889, Parliament passed the Infectious Diseases (Notification) Act (1889), which made the reporting of cases of infectious diseases such as cholera, diphtheria, scarlet fever, smallpox, typhoid fever, and typhus mandatory in London and permissive in the rest of the country (until the Infectious Disease (Notification) Extension Act (1899) made notification mandatory nationwide). Under these two Acts, general practitioners were required to report cases of infectious diseases to the local Medical
Officer of Health, who would then call for further inspection and, as necessary, intervention, which might include hospitalization and isolation for the patient, disinfection of property, or school closures.
2Mooney, Intrusive Interventions, 19. While the Medical Officers of Health had been paying close attention to infectious diseases as a public health hazard since their appointment, the implementation of the Infectious Diseases (Notification) Acts streamlined the process of data collection. The adoption of a simple form saved the Sanitary Inspectors the time required to visit the homes of the infected, allowing them greater time to devote to their other responsibilities.
3Taylor, Report on the Health of Liverpool during the Year 1890, 7–9. Within a year, Liverpool’s Medical Officer of Health, J. Stopford Taylor, praised “the smoothness with which [notification] works” and found it “gratifying to record . . . a considerable reduction in the mortality of the specified diseases,” often as a result of the removal of notified cases to city hospitals for treatment.
4Taylor, Report on the Health of Liverpool during the Year 1891, 4. After removal, Taylor noted in his 1891 annual report, “the house and clothing are disinfected by the Corporation, free of charge; the sanitary arrangements of the premises are carefully inspected, and notices are sent to the schools of children from infected homes, who are found attending them.”
5Taylor, Report on the Health of Liverpool during the Year 1891, 5. More significantly still, notification opened “individuals to the intrusive scrutiny of public health.” As historical geographer Graham Mooney argues, and as I will emphasize in the following chapters, this new approach to public health opened up “domestic space” as “a specific focus of intervention,” and “the school came to be seen as a place of pathogenic exchange” worthy of closer scrutiny.
6Mooney, Intrusive Interventions, 7.More purposeful monitoring for disease outbreaks proved particularly impactful for children’s health because children were often the population most endangered by infectious diseases. The impacts of more careful monitoring and containment of infectious diseases are clear in the general decline in annual mortality rates by the end of the nineteenth century. But there was also a clear disparity between the decline in the overall annual mortality rates and continued high infantile mortality rates in last decade of the nineteenth century, which made it increasingly clear that the health of the youngest Britons required greater attention. Children were the future of the nation and the Empire – a future in peril if James Cantlie was to be believed. Whether they agreed with Cantlie’s rhetoric or not, though, the Medical Officers of Health in Manchester, Liverpool, and Birmingham began to pay special attention to children’s health by the last decade of the nineteenth century and began to establish additional programs to purposefully protect the health of English children.
First and foremost, this required protecting children from infectious diseases. While measles and whooping cough certainly afflicted children in schools during early childhood and were unquestionably a serious cause for concern, another disease proved to be a far greater threat to British children during infancy. Summer diarrhea and gastroenteritis claimed far more lives of British infants than any other notifiable disease by a considerable margin, and so it received special attention from the Medical Officers of Health and their staff.