Origins: Inspection for Infection

Building a public health partnership with schools required an extremely complex and coordinated system that required teachers and school authorities to act as mediators between domestic space and organized public health campaigns, providing an “additional line of defense” against an infectious disease outbreak, and reporting absent or suspected diseased students to the authorities.3Mooney, Intrusive Interventions, 96. In his testimony before the Inter-departmental Committee, Niven thought that teachers could play a powerful role in promoting public health simply due to the regularity of their contact with their pupils.4Report of the Inter-departmental Committee on Physical Deterioration, 2:253. Yet, building a system in which teachers became a part of the process of promoting public health was difficult. Even though the 1875 Public Health Act obligated teachers to notify the local health department of any suspected cases of diseases among their students, cases often went unnoticed, especially as class sizes grew. Even worse, medically untrained teachers often made “diagnostic” mistakes when reported suspected cases. Niven acknowledged that teachers would need “special training . . . in the detection of conditions of illness” for their partnership to have maximal value.5Report of the Inter-departmental Committee on Physical Deterioration, 2:253. In some cases, School Boards simply prevented teachers from corresponding with and reporting cases directly to the Medical Officer of Health, instead issuing their own regulations on health matters. Nevertheless, as Graham Mooney notes, the Medical Officers of Health “were relentless in the quest for access to schools and information about pupils.”6Mooney, Intrusive Interventions, 102. The faster schools reported a case, the faster the Medical Officer of Health could send a Sanitary Inspector to visit their home, where the inspector could order isolation and disinfection, with the goal of containing a wider outbreak.

It took over a decade following the 1875 Public Health Act for a clear partnership between schools and municipal health authorities to begin to coalesce. Setting a model for other cities to follow, in 1890 the London School Board appointed W.R. Smith to serve as a part-time medical officer for the elementary schools. His mandate was to serve as a watchdog for signs of infection. Other towns then followed suit. Bradford was the first town to appoint a full-time School Medical Officer (James Kerr), in 1893; Salford and Halifax followed suit in the years after.7Newman, The Building of a Nation’s Health, 187. As more towns appointed School Medical Officers, it became increasingly clear that School Medical Officers needed to work closely with the local Medical Officer of Health to take case histories, to register the absence and presence of diseased children, and to coordinate between school authorities and parents to prevent disease outbreaks in schools.

Once a system was established to identify cases of infection in the 1890s, medical authorities began to strategize on policies for effective mitigations. Under Local Government Board policy, a student could be barred from school until cleared by medical examination if they posed a risk of spreading an infectious disease. This was a highly contentious practice because it was nearly impossible to segregate “the sick from the healthy,” especially in working-class homes. As a result, if one child contracted a disease, often the entire family was barred from attendance in schools until they had recovered.8Mooney, Intrusive Interventions, 96. In the event of a larger outbreak, a common but similarly controversial practice was to close an entire classroom or even the whole school. This had serious financial consequences because the school budgets under the Board of Education’s Code of Regulations were assessed based on attendance and examination results.9Mooney, Intrusive Interventions, 99. Medical Officers of Health were aware of the problems associated with school closures as a public health strategy, but many still supported the practice. For example, in Manchester, James Niven controversially insisted in 1896 that if 10 percent or more of a school became afflicted with measles, then the entire school should be closed for three weeks of disinfection.10Niven, Report on the Health of the City of Manchester, 1896, 97. School authorities strongly disagreed.

A series of measles outbreaks beginning in 1897 tested Niven’s relationship with school medical staff as he continued to advocate for school closures. As teachers were becoming more attentive to absences due to illness, they usually reported absences to the School Board. School Board Attendance Officers served as the first line of defense against a wider outbreak, serving notice to the homes of the infected along with leaflets on precautions. The Clerk of the School Board sent a weekly report of measles cases to Medical Officer of Health James Niven, who, in turn, deployed Sanitary Inspectors to visit the homes of the infected to assess the patients’ isolation and sanitary conditions, and to provide further instructions to the members of the household on precautions they should take to avoid further spreading the disease. Sanitary Inspectors would then attempt to contact-trace around the neighborhood for other possible cases of measles.11Niven, Report on the Health of the City of Manchester, 1897, 112. Because measles was not officially a notifiable disease, though, school officials were only voluntarily collecting this important epidemiological data and supplying it to Niven, making his response to the outbreak effective but not comprehensive.

The following year, in 1898, when measles cases subsided in Manchester after three bad years, Niven took the time to reflect on his partnership with schools. He praised the School Board for providing him with a daily list of cases, which allowed for “prompter action” to isolate measles patients and better trace the spread of the outbreak. At the same time, he was aware of his “heavy responsibility” to occasionally order school closures. Niven believed that if “the disease spreads outside the school in a manner comparable with what occurs in schools,” then closure of schools would not have been an effective tool in preventing the spread. Yet, he wrote, “this, it seems to me, has not been the case.” Closing schools delayed the course of an outbreak, and he believed this was sufficient justification for the practice, much to the chagrin of school officials.12Niven, Report on the Health of the City of Manchester, 1898 Report of the Inter-departmental Committee on Physical Deterioration, 88–89.

A massive resurgence of measles in 1899 (killing 699 children) appeared to vindicate Niven’s approach to disease prevention through school closures.13Niven, Report on the Health of the City of Manchester, 1899, 78, 81–83. This outbreak, which Niven described as “more violent than ever,” forced him to order the closure of many infant services as well as schools. Teachers were asked to report measles cases directly to the health authorities, but in practice reports often came in too slowly to be useful, because measles is most infectious in its primary (and often pre-symptomatic) stages. Niven reported that in spaces where 10 percent of the infant department of a school was infected with measles, after a three-week closure a resurgence of measles was rare.14Niven, Report on the Health of the City of Manchester, 1899, 80. Thus, Niven believed that the benefits of school closures outweighed the harms to education authorities’ budgets, and he would continue to exercise his authority to enact school closures to prevent measles as late as 1899.

Still, the School Board most strenuously objected to the closing of schools during the 1899 measles outbreak.15Niven, Report on the Health of the City of Manchester, 1899, 81. This tension between school authorities and Niven’s office continued so long as he continued to rely on school closures in response to measles outbreaks. Salvaging this relationship, though, Niven decreasingly felt the need to rely on school closures by the first decade of the twentieth century. By 1916, James Kerr declared school closures “as obsolete as quarantine.”16Kerr, Newsholme’s School Hygiene, 248. Instead, over time, health officials began to use more targeted practices that removed only the individual ill child and their close contacts from schools, to minimize the impact of a disease outbreak on the general education of the entire school population.17Mooney, Intrusive Interventions, 111–12.

Despite the tensions surrounding school closures, infection control brought the Medical Officer of Health into closer contact with school medical authorities, and this cooperation laid an important foundation for the expansion of public health services in the decades to follow. According to W. Leslie Mackenzie, the Medical Inspector for the Local Government Board of Scotland, and Edwin Matthew, a Clinical Tutor at the Edinburgh Royal Infirmary, who co-authored an important early textbook on The Medical Inspection of School Children, infection control “played an enormous, perhaps an exaggerated part” in shaping medical examination in schools.18Mackenzie and Matthew, The Medical Inspection of School Children, 2. But infection control was only one aspect of the cooperation between the Medical Officers of Health and school medical authorities. Forming a partnership to prevent infectious disease outbreaks created an important opportunity for Medical Officers of Health to work closely with School Medical Officers. As a result, over time they were able to collaboratively expand medical services in schools to monitor children not only for cases of infectious diseases but for other forms of ill-health as well. Mackenzie and Matthew certainly saw this as a good thing, based on how they opened the 1904 edition of their textbook:

Two further programs are particularly illustrative of the benefits that medical supervision and inspection in schools had on English children’s health and very much represented the types of intervention recommended by the Inter-departmental Committee. The first was the provision of free or reduced-cost school meals to prevent even the possibility of degeneration from malnutrition. The second was the expansion of the physical education curriculum to improve the health and military preparedness of the next generation of young Britons. These two programs complemented the ongoing efforts to combat infant mortality, while continuing to place children’s health at the center of the nation’s health. For the rest of this chapter, let us trace the history of proactive public health campaigns in schools as a point of comparison to programs of proactive public health in the homes of English infants.