Education and Debate

Education and debate Revolutions in public health: 1848, and 1998? Christopher Hamlin, Sally Sheard This autumn marks the 150th anniversary of the Pub- Editorials by lic Health Act for England and Wales, the beginning of Alderslade, Palmer Summary points Recent advances a commitment to proactive, rather than a reactive, pub- p 584 lic health. The act began a series of legislative measures Education and debate 150 years ago the Public Health Act for England pp 592, 596 extending through the Victorian era and into this cen- and Wales marked the start of a commitment to Department of tury in which the state became guarantor of standards proactive, rather than a reactive, public health in History, University of health and environmental quality and provided which the state became guarantor of standards of of Notre Dame, 219 O’Shaughnessy means for local units of government to make the struc- health and environmental quality and provided Hall, Notre Dame, tural changes to meet those standards. means for local government to meet those IN 46556-0368, That public action can substantially improve the standards USA Christopher health of the general population now seems obvious, Hamlin, and it also seems obvious that public authorities owe The driving force bechind the act, Edwin professor and head their citizens that improvement. Both were controver- Chadwick, began inquiries into public health as a Department of sial in the 1830s and 1840s. For centuries European means of reducing the costs of public relief Public Health, University of governments had reacted to epidemics with decrees. Liverpool, With medical boards to advise them, they set their The act that finally emerged was a stripped down Liverpool L69 3BX version of the original proposal and concentrated military forces to protecting borders and ports, white- Sally Sheard, on provision of a constant water supply and lecturer in history of washed towns, fumigated dwellings, and burnt efficient removal of sewage public health bedding. The threat of unusual disease prompted Correspondence to: these reactions, and they were relaxed when the Although riddled with compromise one is now Professor Hamlin epidemics passed.1 Normal disease—infant mortality Christopher. struck by the practical wisdom and revolutionary S.Hamlin.1@nd.edu of more than 50% in inner city wards, annual mortality implications of the legislation of over 30/1000 in some towns—prompted no such BMJ 1998;317:587–91 reactions. The recent green paper on public health, Our Unless we are familiar with some of the cities of the Healthier Nation, reflects the heritage of this developing world, most of us are probably unable to legislation in seeing health improvement as a fathom the enormity of the unplanned urbanisation of process involving central government, local the 19th century: roughly 3 million people (slightly communities, and individuals over 30%) were urban in 1801 in England and Wales, compared with 28.5 million (almost 80%) in 1901. Growth rates in some textile boom towns, like Bradford from 1811 to 1831, exceeded 60% per Acknowledging a need for public health: decade; this despite the fact that towns were acting as the great sanitary inquiries a sink for human life. In Liverpool average life expect- Among the hardest of a historian’s jobs is to ancy by class ranged from 15 years for the unemployed understand how people move from hope for a or poor to 35 years for the well to do.2–6 different future to practical actions that secure it. In Yet that growth was accompanied, if belatedly, by an public health, fear had a large part. So too did ambition urban sanitary revolution. Many of us are its and perseverance. beneficiaries. To facilitate the building of sanitary Edwin Chadwick was the widely hated architect and systems, especially water supplies and sewerage, was enforcer of the new poor law of 1834. Its principle was the main purpose of the 1848 act, but it also to make the conditions under which public relief could established local and central units of government that be given so unpleasant that most would refuse to would take responsibility for health, at least for those request it.7 Ever under pressure to cut costs, Chadwick aspects affected by the built environment. It repre- began to focus on the causes of indigence: prevention sented a commitment to the long term, to be made not was cheaper than relief. By 1838 he was looking mainly by sanitarian boffins in Whitehall but by more or less at one cause: acute infectious diseases that were fatal to ordinary (though usually upper middle class) towns- male breadwinners, leaving families dependent on men who were suddenly to be given powers to obtain relief. These diseases, Chadwick insisted, had physical 30 year mortgages for these networks of pipes. causes in poor urban drainage, which left towns BMJ VOLUME 317 29 AUGUST 1998 www.bmj.com 587 Education and debate covered in a residue of filth that contaminated the air 8 in some ill defined way and caused disease. Public Health Debates, 1847-8 The focus on physical causes and acute disease was defensible but was also politically adroit, for it diverted On the background of legislation “In consequences of these vast changes in the social attention from the claim of an increasingly vociferous condition of the country, large masses of the group of medical men, many of them local poor law population were suffering irreparable injury from the medical officers, that the harsh policies of the poor law want of proper sanitary precautions.” were themselves the cause of much illness. The other R A Slaney. Hansard’s Parliamentary Debates 3rd series, 96 half of the vicious circle—that deprivation might itself 1848 Feb 10, 412. cause the disease that left so many dependent— On the epidemiology of sanitation Chadwick suppressed: if hardship produced illness, a “‘If you trace down the fever districts on a map, and poor law founded on disincentives to seek relief was then compare that map with the map of the counterproductive and morally indefensible.910 commissioners of sewers, you will find that wherever In autumn 1839, as a result of a request made in the the commissioners of sewers have not been, there House of Lords by the cooperative Bishop of London, fever is prevalent; and, on the contrary, wherever they have been, there fever is comparatively absent.’” Chadwick was charged with documenting the extent of Lord Morpeth, quoting Thomas Southwood Smith. those insanitary conditions and of the disease they Hansard’s Parliamentary Debates 3rd series, 91 presumably caused, and to explore remedies in policy 1847 Mar 30, 621. and technology, initially in England and Wales and then in Scotland. Chadwick’s superiors were happy to On the results of sanitation let him get on with the report; they found him impos- “By such measures they would be able to change . the condition of large bodies of the population of sibly inflexible as a policy administrator. great towns, and to make them contented and The grand report finally appeared in summer cheerful. “By a measure of this nature they would do 1842.3 10–13 It digested the returns of the vast staff of much to increase the security of property.” poor law officials and “eminent” urban medical men R A Slaney. Hansard’s Parliamentary Debates 3rd series, 98 who had been persuaded to report on conditions in 1848 May 8, 770. their towns. Its focus had broadened. It seemed that insanitary conditions caused social as well as biological disease, a psychological degradation that led desperate revolution daily. And it was a route to stability that people to invest their hope in alcohol or, worse, in seemed to interfere with none of the grand structures revolution. A public gift of good sanitation might be of incentives that political economists insisted must the key to a happy, healthy, and docile proletariat—a order society.10 welcome prospect to a government that expected Among the disease and degradation detailed in the report were sketches of a comprehensive solution. It would involve new technologies, particularly sewers Sir Edwin Chadwick (with egg shaped cross section to encourage self scour- The man who revolutionised public ing), and new legal and administrative structures that health, Edwin Chadwick (1800-90), had would bring communities the expertise and authority no training in medicine or sanitary needed to build these works. In spring 1843, at engineering or public administration. He Chadwick’s request and with Chadwick as a behind the trained as a barrister and solicitor, worked as journalist, and absorbed principles of scenes adviser, Sir Robert Peel’s government issued a public administration as a disciple of Royal Commission on the Health of Towns. Its tasks Jeremy Bentham. were to document the sanitary situation of 50 of the As (initially) a junior member of the largest towns in England and Wales (London, 1832 royal commission on the poor law, recognised as a unique case, was left out) and to work Chadwick transformed policy analysis: he out technical details. Dividing the territory into documented conditions far more districts, the commissioners themselves visited towns to comprehensively than had his predecessors and, equally, was creative in interview councillors and improvement commission- discovering acceptable solutions to ers and to administer the lengthy questionnaires that longstanding conflicts. He was the main Chadwick supplied. They became convinced that much architect of the new poor law of 1834 more could be done and that many towns were far too and, as its administrator, was said to be sanguine about the conditions they tolerated. the most hated man in England. Issues of poor law administration led him into education and law enforcement as well as From inquiry to legislation public health.

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