Health Visits in Manchester, Liverpool, and Birmingham
Like Alice Reid, I contend that the expansion and professionalization of health visiting around the turn of the twentieth century played a significant role in the decline in the infant mortality rate in cities where health visitors attended to most births.
1Reid, “Health Visitors and Child Health,” 122. Historians disagree about the degree to which health visits had a direct rather than coincidental impact on the decline in British infant mortality in the early twentieth century. For example, see the debate in Local Population Studies between Drake, “Surely They Made a Difference?” and Galley, “Health Visitors: How Much Difference Did They Make?” Indeed health visiting very much remained a locally administered effort in the decades preceding the First World War.
2While, “The Early History of Health Visiting,” 129–30. Our three case-study cities reflect the importance of health visiting as the Medical Officers of Health in all three cities expanded their staff of health visitors in the early Edwardian years, growing their ranks from just a handful of municipal employees to an average staff of nearly thirty health visitors in each city by the outbreak of the First World War.
3National funding for Health Visitors began in 1907, well after they were paid by local authorities. See Ross, “Mothers and the State in Britain, 1904–1914,” 55. As their ranks grew, their work proved instrumental in combating the urban penalty.
Recall that the original duties of health visitors focused on improving the unsanitary conditions that contributed to the spread of infectious diseases like measles and whooping cough, and arranging for the cleansing of unsanitary or infected houses.
4Niven, Report on the Health of Greater Manchester, 1894, 31. Health visitors extended the reach of the sanitary authority, as they typically lived in the districts they observed and were “at the constant call of the people for help and advice in cases of emergency.”
5Niven, Report on the Health of the City of Manchester, 1897, 127. Health visitors supplied lime and carbolic soap for washing bedrooms, cellars, yards, and closets, and provided instruction on its use. They explained the importance of fresh air and sold blocks of wood to prop windows open in living rooms and bedrooms. In addition, health visitors in Manchester called attention to “bad clothing” and “neglected conditions” surrounding children.
6Niven, Report on the Health of the City of Manchester, 1897, 127–28.When Manchester became the first of the three cities to employ health visitors as municipal employees, professionalization changed the main responsibilities of health visiting.
7Niven, Report on the Health of the City of Manchester, 1897, 128. The Medical Officers of Health insisted that
health visitors’ work should focus first and foremost on systematic visits to births and, in turn, on education on infant health and childcare for mothers, while their other responsibilities as observers for infection and distributors of hygienic materials would be secondary.
8Heggie, “Health Visitors and District Nursing,” 409–10. This is not terribly surprising, given the concerns of the Medical Officers of Health about the danger of summer diarrhea and its impact on infant mortality. When Niven became Manchester’s Medical Officer of Health in 1894, he almost immediately emphasized the importance of infant feeding in reducing infant mortality. Within a few years, it became clear to Niven that while educational materials were having a positive effect, public service announcements were insufficient to substantially reduce diarrheal deaths in Manchester. Greater intervention would be necessary, and he believed that the Ladies’ Health Society was well positioned to do “very good work precisely in this subject.”
9Niven, Report on the Health of the City of Manchester, 1896, 127. He regularly praised the important work of the health visitors in Manchester, who often reported alarming discoveries after their visits. Health visitors often reported that “through ignorance alone of the mother the baby is suffering.”
10Forty-second Annual Report of the Ladies’ Public Health Society, 5. For example, one health visitor found that parents falsely believed that “the addition of raw milk to bread boiled in water was the equivalent of boiling the milk.” Another found that mothers in poorer districts tended to cease breastfeeding their children at an earlier age than the city-wide average, though they did this most often so as to go back to work (often to pay for food).
11Niven, Report on the Health of the City of Manchester, 1896, 126–28.To prevent diarrhea, in addition to lessons in proper feeding practices, health visitors advised parents to not allow their children to remain in dirty clothes nor to place their children on the floor unless it “is scrupulously clean and free from draughts,” or else “all the benefits of [healthy] feeding may be destroyed.”
12Niven, Report on the Health of City of Manchester, 1902, 129–30. For many mothers, like one who, for example, had not once washed her baby in its first seven weeks of life and lived in a “sadly dirty condition,” the health visitor’s attendance reportedly resulted in considerable improvement in domestic hygiene and the child’s health. In this unusual case, on a subsequent visit the baby was cleansed, and household sanitation was considerably improved. Thus, revisits were often necessary, visitors claimed. Visitors asserted that revisits not only saved lives, but also helped to ensure that children would grow up in living conditions that would allow them to be “helpful to the community at large, not just a drag upon it.”
13Forty-second Annual Report of the Ladies’ Public Health Society, 5–6.As Manchester’s health visitors continued their work during the first decade of the twentieth century, expanding their networks and frequency of visits per year, they self-reported being greeted with great pleasure by the new mothers they visited.
14Forty-fifth Annual Report of the Ladies’ Public Health Society, 5. Mrs. Mather, the health visitor for St. George’s, offered one explanation as to why: “The Visitor is always in touch with the people among whom she lives . . . knows their lives and their needs, and in this way many opportunities of usefulness are found.”
15Forty-fifth Annual Report of the Ladies’ Public Health Society, 29. Mrs. W.B. Worthington, a member of the Ladies’ Public Health Society, reported that her mission to promote a “higher standard of domesticity . . . continually” saw “small results.”
16Report of the Inter-departmental Committee on Physical Deterioration, 2:283. She reported that “almost invariably” mothers “accept with gladness . . . the advice” of the visitor.
17Report of the Inter-departmental Committee on Physical Deterioration, 2:283. The validity of this claim is hard to determine, due to the obvious bias of visitors promoting the importance of their own work and the lack of available sources from the visited mothers. Perhaps this was because health visitors in Manchester took great pains not to be condescending to the mothers they visited, but without good records of voices of the mothers they visited, we can only speculate.
By 1902 health visitors in Manchester routinely conducted visits in twenty-three districts of the city. Infant mortality remained the highest in the districts of Manchester Township, in Clayton and Bradford in north Manchester, and in Openshaw, West Gorton, and Ardwick in south Manchester. Performing health visits in these poor central districts was often complicated. Mrs. Bostock, a health visitor attending about 1,500 homes in South Ancoats with fourteen years of experience, reported in 1904 that the people of Lancashire were “rather suspicious” of her work, and that she had to form a relationship with them first. Bostock recalled that mothers she visited were often “anxious” but “not willfully” neglectful, but rather ignorant of best practices.
18Report of the Inter-departmental Committee on Physical Deterioration, 2:287. But they were “very ready to learn, most of them.”
19Report of the Inter-departmental Committee on Physical Deterioration, 2:288.Niven also faced problems in extending the work of the health visitors into these districts. Not all health visitors were municipal employees in 1904.
20Niven, Report on the Health of City of Manchester, 1904, 234. It took several years, but by 1908 his office had assumed all oversight over the work of the health visitors in Manchester.
21Greenwood, “The Evolution of the Health Visitor,” 174. Eleanor Greg, who reported directly to Niven and held a certificate from the Sanitary
Institute, was appointed Superintendent of the health visitors. Under Greg’s supervision, the work of the health visitors became more “systematized” and became “steadily more satisfactory.”
22Niven, Report on the Health of City of Manchester, 1907, 188.In Greg’s first annual report, in 1908, she noted several important changes in the work of the health visitors as the position increasingly became a professional opportunity for young women. First, as salaried municipal employees rather than friendly charitable volunteers, they received more specialized training on how to provide instructions in the “delicate task of instructing mothers in rearing infants, in household management, etc.” Their promotions were made based on merit, to promote “best development of their work,” and health visitors who received certification from the Royal Sanitary Institute were rewarded with a higher salary.
23Niven, Report on the Health of City of Manchester, 1908, 142. By 1910, the city of Manchester employed sixteen health visitors, at least half of whom were certified by the Royal Sanitary Institute for Health Visitors and School Nurses.
24Greenwood, “The Evolution of the Health Visitor,” 174.The duties of the health visitors were clearly codified under Greg’s supervision:
1. the visiting of infants under 12 months of age and providing mothers instructions on child welfare;
2. maintaining a record and relationship with the Ladies’ Public Health Society meetings and Health Lectures where important educational work continued;
3. visiting phthisis (tuberculosis) patients and providing instructions on cleaning of the effects and households of consumptives; and
4. house-to-house inspections for sanitary defects.
Greg made clear, though, that during diarrhea season, house-to-house inspections would often need to be suspended in favor of preventing the conditions that contributed to deadly diarrheal cases. This was especially the case in years when diarrheal deaths surged, such as 1911, when diarrhea claimed the lives of 1,080 infants.
25Niven, Report on the Health of City of Manchester, 1908, 143–45; Niven, Report on the Health of City of Manchester, 1911, 154. Unsurprisingly, the lessons from health visitors about proper feeding were impactful. Historians suggest that
during this 1911 surge, babies who were entirely breastfed rarely died from diarrhea.
26Fildes, “Infant Feeding Practices and Infant Mortality in England,” 270.The history of health visits in Liverpool followed a similar path and shared a similar goal: reducing infant mortality through maternal education. The city began employing its first health visitors in 1897.
27Notes on Health Visiting, October 17, 1917. Their duties included monitoring household and personal cleanliness and giving advice on child rearing, but their primary purpose was “educational” to “induce compliance with the requests which they make” without having to resort to compulsion under the Sanitary Acts. However, the credentials required of health visitors in Liverpool were more specific than in the other two cities: the candidate for the position of a health visitor had to be no older than thirty-five, to have experience “dealing with the lower classes,” and was required to show proof of training in “sanitary requirements.”
28“Female Sanitary Staff.”As in Manchester, during their visits female sanitary staff in Liverpool provided “instruction to parents who appeared to be ignorant of the methods in which young infants should be fed.”
29Hope, Report on the Health of the City of Liverpool during 1899, 95. The results were effective. Fildes, “Breast-Feeding in London,” 58, estimates that upwards of 71 percent of Liverpool’s infants were breast-fed at least during their first month of life by the second decade of the twentieth century. As the data increasingly indicated that infants who were partially or wholly artificially fed were at fifteen times greater risk of contracting fatal diarrhea than those who were breastfed, house-to-house visitation became an increasingly important public health tool.
30Hope, Report on the Health of the City of Liverpool during 1907, 42. In their lessons, Liverpudlian health visitors warned that the use of a long-tube bottle was much more susceptible to contamination and placed the infant at a higher risk of deadly diarrhea.
31Hope, Report on the Health of the City of Liverpool during 1903, 116. When infants could not be reasonably breastfed, health visitors encouraged the use of milk prepared at the Milk Depot for infants, which was carefully monitored for contamination.
32Hope, Report on the Health of the City of Liverpool during 1909, 118. In addition, based on recommendations from the Medical Officer of Health, they gave instructions about which foodstuffs were unsuitable for infants, including bread, tea, and meat.
33Hope, Report on the Health of the City of Liverpool during 1904, 98. Finally, when a mother was unable to bathe the baby, a health visitor would do so, while reminding mothers to keep “the eyes, mouth and head of the infant clean.”
34Lovegrove, “The Babies’ Welcome,” 518.Liverpool’s Medical Officer of Health, E.W. Hope, was particularly heartened that “no difficulty [was] experienced in carrying out this work.” He reported by 1905 that “inspectors [were] welcomed by the parents,” who took the advice of the health visitors seriously, especially with regards to bottle feeding.
35Hope, Report on the Health of the City of Liverpool during 1905, 91. J.E.W. Lovegrove, who served as the Superintendent of the Ladies’ Sanitary Association in Liverpool, agreed. She believed that a health visit was “an essential part” of “the babies’ welcome” into the world. She acknowledged that the work of health visiting was occasionally difficult, but felt that most “mothers are pleased to be visited, and seem to appreciate what is being done for the benefit of themselves and their little ones.”
36Lovegrove, “The Babies’ Welcome,” 518. With each passing year, the Female Sanitary Staff in Liverpool reported “less difficulty . . . in overcoming the prejudices of women with regard to infant feeding” and greater understanding of the risks of “giving anything but the breast to very young infants.”
37Hope, Report on the Health of the City of Liverpool during 1906, 101. By 1907, health visitors reported marked improvements in the sanitary habits of Liverpool’s poor, which coincided with a notable reduction in infant mortality. Hope believed that the anticipation of a visit from a member of the Female Sanitary Staff incentivized “extra precaution against dirt and neglect,” which contributed to this improvement in public health.
38Hope, Report on the Health of the City of Liverpool during 1907, 98.By way of further comparison, Birmingham was the slowest of the three cities to employ health visitors professionally. The city first employed four health visitors in April 1899.
39Eve, Manual for Health Visitors and Infant Welfare Workers, 1. When these women were hired, Medical Officer of Health Alfred Hill very purposefully objected to their title being “inspectors.” He insisted that they should be specifically classified as “health visitors.” According to Florence Greenwood, a Sanitary Inspector in Finsbury, because this title “was originally used by a class of women of inferior education and standing . . . it was felt by many that it lowered the standard of the Public Health Service.”
40Greenwood, “The Evolution of the Health Visitor,” 175. Nevertheless, Hill reported in his annual report that he believed that their work was “a striking success” which “resulted in a very marked and in many cases a permanent improvement in the homes of the poor.” He encouraged the city health department to appoint more health visitors.
41Hill, Report on the Health of the City of Birmingham for the Year 1899, 3. It did so. A year later the city of Birmingham
employed eight health visitors; by 1902 there were twelve; and by 1914 the city of Birmingham was employing nineteen health visitors.
42Gardiner, “The Varied Nature of the Work of Women Public Health Officials,” 511.The early responsibilities of the health visitors fit into Hill’s campaign to improve the sanitary conditions of dwellings of the urban poor; they visited almost exclusively the wards considered most unsanitary.
43Niemi, “Public Health Discourses in Birmingham and Gothenburg,” 129. In 1899, health visitors visited approximately 11,700 houses in the poorest parts of the city and gave notice to landlords of 1,800 (nearly one sixth of all their inspections) that sanitary improvements were necessary. They advised tenants on the unhealthy conditions of their homes. Health visitors warned tenants that foul odors, a lack of fresh air, and other “dirty conditions of all kinds” resulted from their “general mode of living.”
44Hill, Report on the Health of the City of Birmingham for the Year 1899, 9, 34. Health visitors in Birmingham also distributed handbills related to household management and cleanliness, which included recommendations such as the following:
1. Floors should be scrubbed very often, as dirt may cause disease.
2. Walls should be dusted, not swept (tie duster on broom head and dust the walls all over, to keep cobwebs and dirt away).
3. Bedroom windows must be opened first thing in the morning, and all slops emptied and articles thoroughly washed out with clean water early in the day.
4. Beds must be stripped, shaken, and turned every morning, and the bed clothes thrown back and left to air till afternoon.
5. As few people as possible – not more than two or three, as a rule – should sleep in the same bedroom.
6. No rubbish is to be put in the bedroom grates, and all chimneys must be kept clear.
7. No pieces of carpet, bagging or old clothes are to be hung across the windows. These keep the bad air from getting out and the fresh air from coming in.
45Hill, Report on the Health of the City of Birmingham for the Year 1899, 37.It alarmed Hill that the poorest classes lived in ignorance of the dangers of unsanitary housing. But, unlike the Inspector of Nuisances, who was responsible for regulating and condemning unsanitary conditions, health visitors only made note of sanitary defects for their reports. They were not
expressly evaluating houses for their sanitary conditions. In fact, Hill warned that the health visitor must not be seen as “an inspector,” as “inspectors were looked upon with something like distain.”
46Evans, “The Essential Qualifications of a Lady Health Visitor,” 311. Rather, health visitors were advised to “show people how to make the best of the existing conditions in their homes, how to bring up their children, and how to nurse their sick.”
47Hill, Report on the Health of the City of Birmingham for the Year 1900, 30. Most likely to assuage cross-class tensions as middle-class guests in working-class homes, health visitors in Birmingham tried to present themselves as “anxious to help rather than to find fault,” and they were “generally well received” as a result.
48Hill, Report on the Health of the City of Birmingham for the Year 1899, 35.In addition to recommending sanitary improvements, health visitors in Birmingham undertook two other important public health tasks: providing advice on the prevention of infectious diseases like measles, summer diarrhea, and consumption, and, like their colleagues in Manchester, teaching lessons on infant feeding. These lessons proved crucial in the reduction of infant mortality. During an 1899 surge in diarrheal deaths, Hill “directed the health visitors to relinquish for a time their ordinary house-to-house visitation, in order that they might find out how many cases of diarrhea as soon as possible, and give advice as to nursing and diet.”
49Hill, Report on the Health of the City of Birmingham for the Year 1899, 28. Health visitors offered advice on “the great advantage of cleanliness” in preventing diarrheal mortality as well as other diseases of filth.
50Hill, Report on the Health of the City of Birmingham for the Year 1901, 20.Health visitors also collected important epidemiological data, which they reported back to the Medical Officer of Health. They often found that cases of summer diarrhea occurred in smaller houses occupied by the artisan classes, and that fatalities often followed the onset of symptoms very quickly (less than one to four days).
51Robertson, Report on the Health of the City of Birmingham for the Year 1904, 37–38, 40. During another surge in diarrheal deaths in 1904, data collected by health visitors revealed that as few as 7.8 babies per 1,000 live births who were breastfed died from summer diarrhea, while as many as 252.3 babies per 1,000 live births among those who were not breastfed at all died from the disease. This reinforced the increasingly obvious point that milk was a critical vector for the deadly pathogen. In turn, this made the health visitors’ work of encouraging breastfeeding even more
important in Birmingham, where only some 57 percent of mothers breastfed their infants under six months of age.
52Robertson, Report on the Health of the City of Birmingham for the Year 1904, 42–43.In the years that followed, the Medical Officer of Health supplied the health visitors with a list of addresses of all weekly registered births and tasked them to visit “all of them where there is a possibility of ignorance or carelessness occurring in the rearing of infants, with a view to giving mothers the necessary instructions.”
53Robertson, Report on the Health of the City of Birmingham for the Year 1905, 57. The adoption of the 1907 Notification of Births Act in Birmingham on March 1, 1908, which required reporting of all births to the Medical Officer of Health within thirty-six hours, increased the efficiency of this process. In turn “the most skilled and most frequent visiting” of births occurred the districts with the highest infant mortality rates: St. Stephen’s and St. George’s wards.
54Robertson, Report on the Health of the City of Birmingham for the Year 1908, 23. As in Manchester and Liverpool, health visitors in Birmingham self-reported that they were nearly always “welcomed as friendly advisors of the people” and their work produced “cleaner homes and getting the children better looked after.”
55Robertson, Report on the Health of the City of Birmingham for the Year 1910, 110. By 1914, Blanche Gardiner, who served as the Superintendent of health visitors in Birmingham, reported that each of the nineteen health visitors employed in the city regularly received these lists of births in their district, and after the first fortnight after a birth paid a visit to “see that all is done that is needful for the welfare of the infant.”
56Gardiner, “The Varied Nature of the Work of Women Public Health Officials,” 512.In all three cities, what we can start to see clearly is that the work of health visiting followed a similar pattern of gradually expanding duties. Health visitors were initially employed by private charity to advise on the sanitary condition inside the English home, but their work shifted towards providing maternal education and infant care as the position of the health visitor became professionalized. Evidence from the annual reports of the Medical Officers of Health and their superintendents suggests that the work of the health visitor was central in the campaign to curb infant mortality, deaths from summer diarrhea, and the deleterious effects of the urban penalty. Emilia Kanthack wrote about this explicitly in her 1907 lectures, in which she argued that the work of health visitors was essential to combat the urban ecological and social conditions that contributed to “race-deterioration and
race-degeneration” and that resulted in babies being kept alive but not kept healthy.
57Kanthack, The Preservation of Infant Life, 8.While Alice Reid is correct that it is difficult to precisely quantify the impact of health visits on infant mortality, it is reasonable to conclude, over the long term, as Arthur Newsholme did in 1935, that education on health and hygiene played a vital role in improving public health and in the gradual reduction of infant mortality after 1901.
58Reid, “Health Visitors and Child Health,” 119–120; Newsholme, Fifty Years in Public Health, 374. The reasons are quite clear. Health visitors facilitated, through their lessons, the types of social interventions that improved infant survival: improvements in feeding and household hygiene. In wealthy families their services were less critical, but for poorer families, living in the epicenter of the urban penalty, health visits were literally lifesaving, especially as professional health visiting was in full swing by the outset of the First World War.
59Drake, “Surely They Made a Difference,” 66.