Victorian Public Health

Why a hands-off state laid drains

In 1800 one Briton in five lived in a town; by 1851 it was one in two, and the towns had been built by speculators with no drains, no water supply and no one responsible for either. Families lived in back-to-backs and cellars, a court of twenty houses shared one privy, and water came from a pump or a river into which the privies drained. Governments believed in laissez-faire, leaving things alone, and ratepayers believed in low rates. Nothing changed until a disease arrived that killed the rich as well as the poor. Cholera reached Sunderland from the Baltic in October 1831 and killed around 32,000 people in Britain by the end of 1832; it came back in 1848 to 1849 and killed around 53,000 in England and Wales, again in 1853 to 1854, and in 1866. It killed within a day, by violent diarrhoea and dehydration, and nobody knew why. Edwin Chadwick, a civil servant on the Poor Law, argued in his report of 1842 that disease made paupers and paupers cost rates, and gave the figures: in Manchester a labourer could expect to live to 17, a gentleman to 38. The Public Health Act of 1848 let towns set up boards of health but compelled only those with a death rate above 23 in a thousand, and the Times said in 1854 that England preferred to take its chance of cholera than be bullied into health. That year John Snow mapped the deaths around a pump in Broad Street, Soho, and had the handle removed. What turned permission into compulsion was smell, science and the vote: the Great Stink of 1858, when the Thames stank so badly that Parliament passed a sewer bill in eighteen days; Pasteur in 1861 and Koch in 1883, who explained what Snow had shown; and the Reform Act of 1867, which gave the vote to the men in the courts and cellars. The Public Health Act of 1875 made every town responsible for sewers, water, nuisances and inspection. AQA asks why government acted, and the grade-9 answer is that it acted only when the cost of doing nothing became politically higher than the cost of acting. This module gives you the problem, the reformers, the two Acts and the shapes.

Five terms with their dates

Each definition carries the date and the figure that make it usable as evidence, because a bare definition earns nothing in a significance or factor answer.

The public health story in order

Put these six events in the order they happened.

• Cholera reaches a north-east port from the Baltic
• A Poor Law official publishes a report showing that labourers die young
• Parliament allows, but does not require, towns to set up boards of health
• A doctor has the handle removed from a pump in Soho
• The smell of the Thames drives Parliament to fund new sewers within weeks
• Every town is compelled to provide sewers, water and inspection

Why did government act when it did?

The facts of dirt and death were known from the 1830s, and the state left towns alone until 1875. Which explanation best accounts for the timing?

• Government acted at each stage only when the cost of doing nothing became higher than the cost of acting: cholera in 1831 and 1848 killed the rich and produced the Act of 1848, which was allowed to lapse once the disease did, because ratepayers still paid for drains and nobody could prove they worked; the Great Stink of 1858 threatened Parliament itself and produced money for sewers in eighteen days; Pasteur in 1861 and Koch after him gave the reformers a proof that removed the excuse of doubt; and the Reform Act of 1867 gave the vote to the men in the courts, so that from then on a party that opposed drains lost elections, and Disraeli made compulsion law in 1875. Fear, smell, science and votes each raised the price of inaction until laissez-faire could no longer afford it.
• Politicians became kinder to the poor in the 1870s.
• Chadwick persuaded Parliament in 1842 and it took thirty years to build the drains.
• Nothing could be done until Koch found the cholera germ in 1883.

What each reformer proved, and what moved Parliament

AQA credits the role of reformers and the involvement of government as separate things, and the grade-9 habit is to show that the reformers supplied the case while events supplied the compulsion. The right column is what actually changed the law.

Question 1: how useful is the source?

Source A: a description of a cartoon published in Punch on 3 July 1858, during the Great Stink. A filthy old man rises from the Thames, labelled Father Thames, with rubbish and a dead dog floating around him and factory chimneys behind. He presents three ragged, sickly children to a young woman in a crown who represents the City of London; the children are labelled Diphtheria, Scrofula and Cholera. The caption reads: Father Thames introducing his offspring to the fair City of London. AQA Question 1 asks: How useful is Source A to a historian studying attitudes to public health in the 1850s? Tap the TWO details that make it most useful for that enquiry.

• The diseases are drawn as the children of the river, which shows that by 1858 the link between the polluted Thames and epidemic disease was accepted as obvious by a popular magazine and its middle-class readers
• The City of London is drawn as a young woman in a crown.
• The river presents the diseases to the City as if it were responsible for them, which shows that the public now expected the authorities, not individuals, to act, and was blaming them for not having done so
• There is a dead dog in the water.
• It appeared in Punch.

The two Acts and what lay between

Select the THREE statements that are accurate about government action on public health.

• The Public Health Act of 1848 set up a General Board of Health for five years and allowed towns to create local boards to provide sewers and water, but compelled them only where the death rate exceeded 23 in a thousand, so that by 1854 only about a third of towns had acted and the General Board was abolished.
• After the Great Stink of 1858 Parliament funded the Metropolitan Board of Works to build the London sewers designed by Joseph Bazalgette, some 82 miles of main sewers and 1,100 miles of street sewers with pumping stations and embankments, largely complete by 1875, which removed cholera from London although they were built to remove smell.
• The Public Health Act of 1875 made it compulsory for every local authority to provide sewers, drains and clean water, to remove nuisances and inspect food, and to appoint a medical officer of health, and it came with laws in the same year on slum housing and on the adulteration of food.
• The Act of 1848 compelled every town in Britain to lay sewers.
• The Board of Health accepted the findings of Snow in 1854 and ordered all pumps closed.
• The Act of 1875 was passed because Koch had discovered the cholera germ.

Question 1: the usefulness method

AQA Question 1 on Paper 2 gives one source and asks how useful it is to a historian studying a stated enquiry, for 8 marks. The marks come from three things used together: content, what the source shows about the enquiry; provenance, who made it, when, for whom and why, and what that does to its value; and own knowledge, used to test what the source shows against what else is known. For the Punch cartoon in Source A, the content shows the river as the parent of disease and the City as the party being called to account. The provenance is its strength: Punch was a satirical weekly read by the middle class and by members of Parliament, published on 3 July 1858 in the middle of the Great Stink, so it shows the attitude of the people who elected and sat in the Parliament that voted the sewer money that month, and it shows that attitude at the moment it changed. Its limit is that it is satire drawn for effect: it shows what the readers of Punch found obvious and says nothing about the ratepayers who had voted down boards of health in the 1850s or about the poor who lived beside the river, and the science it assumes, that the smell itself bred the diseases, was wrong. Own knowledge tests it: Parliament did pass the bill within eighteen days, Bazalgette did build on the theory the cartoon shares, and cholera did leave the drained districts. This meant that the source is very useful for the middle-class and parliamentary attitude in the summer of 1858 and less useful for attitudes in the country at large or for what caused disease, and a top-level answer says both and uses the date and audience to explain why the source matters so much for that one moment.

In the council chamber, 1832 to 1875

You sit on the council of a northern industrial town at four moments. Choose what such a council actually did, and notice what changed the sum each time.

• 1832. Cholera has killed 300 in the courts by the river in a month. The vicar wants a day of fasting, a doctor wants the cesspits emptied and the streets limewashed, and the largest ratepayer says the poor bring it on themselves. What do you do?
• 1849. Cholera is back and the Act of 1848 lets you petition for a local board of health with power to lay drains and charge the rates. Your death rate is 22 in a thousand, one below the figure at which the General Board can force you. What do you do?
• 1855. A copy of the Snow map of Broad Street has reached the medical officer, who says the river water supply is the cause and the town should take water from the hills at great cost. The Board of Health in London says Snow is wrong and smell is the cause. What do you do?
• 1876. The Act of 1875 now requires you to provide sewers, water and a medical officer, the working men of the town have had the vote since 1867, and the Local Government Board will lend the money over thirty years. What do you do?

From cause to compulsion

Because the towns of the 1830s had no drains and the privies emptied into the rivers, cholera found its way into the drinking water and killed around 32,000 in its first visit. Because it killed the rich as well as the poor, Parliament passed a Public Health Act in _____, and because the Act was optional and the disease went away, most towns did nothing. Because Snow mapped the deaths around the Broad Street _____ in 1854, the water was shown to be the cause, and because the Board of Health believed in smell, the proof was ignored for years. Because the Thames stank in the summer of _____, Parliament found the money for the sewers of Bazalgette in eighteen days. Because the Reform Act of 1867 gave the _____ to working men in the towns, sanitary reform became a way of winning elections. And because fear, smell, science and votes had raised the price of inaction, the Act of 1875 made drains, water and inspection _____ in every town.

The Chadwick figures

The Chadwick report of 1842 gave the average age at death in Manchester as 38 for the gentry and professional classes and 17 for labourers. By how many years did the gentry outlive the labourers?

Question 3: two similarities, marked

AQA Question 3 asks you to compare across periods, for 8 marks: Explain two ways in which responses to the Black Death in the fourteenth century and to cholera in the nineteenth century were similar. Which answer reaches the top level?

• One similarity is that both were explained by bad air and both produced cleaning orders on that theory: in 1349 Edward III ordered the streets of London cleaned because the filth poisoned the air and worsened the pestilence, and in 1848 Chadwick and the Board of Health believed cholera rose from smell and ordered limewashing, nuisance removal and, after 1858, the London sewers, so that in both periods the right remedy was reached from the wrong cause. A second similarity is that government acted only while the fear lasted: the cleaning orders of 1349 had to be repeated in 1357 and 1361 because they lapsed with the danger, and the Act of 1848 was allowed to run down and its Board abolished in 1854 once the epidemic of 1849 had passed, because in both centuries a state that did not believe in intervening did so only under the pressure of an epidemic and stopped when it stopped.
• Both times people thought bad air caused disease.
• In 1348 nobody knew the cause, but in 1854 Snow proved it was the water.
• Both had prayer, cleaning, quarantine, fear, orders from the king and Parliament, and high death rates.

Question 2: significance, marked

Question 2: Explain the significance of cholera for the development of public health in Britain. At the time, cholera was significant because it was the first disease that forced a laissez-faire state to act. It arrived at Sunderland in October 1831 and killed around 32,000 people within a year, it killed within a day and it killed the rich, which typhus in the slums had never done; this meant that Parliament, which had ignored dirt for a generation, set up temporary boards of health in 1832, commissioned the inquiry that became the Chadwick report of 1842 with its finding that a Manchester labourer died on average at 17, and, when the disease returned in 1848 and killed around 53,000, passed the first Public Health Act within the year. In the longer term its significance was that it produced the proof and the machinery that outlasted it: the Broad Street map of 1854, in which John Snow showed around 500 deaths in ten days clustering around one pump, was the first demonstration that disease could be traced to a source and stopped by an act of government, and the fear of its return kept the sewers of Bazalgette funded through the 1860s, so that when the fourth epidemic came in 1866 it killed mainly in the East End districts the sewers had not yet reached, which proved the case for compulsion in 1875. The limit of the significance is that cholera by itself produced only temporary action: the General Board of Health was abolished in 1854 as soon as the epidemic of 1849 had faded, Snow was disbelieved for seven years, and the compulsory Act of 1875 needed the Great Stink, the germ theory of 1861 and the votes of 1867 as well. Cholera matters most because it set the price of inaction high enough to start the process; the other factors finished it. What earned the marks: significance at the time with dates and figures; significance in the longer term, distinguished from the first and traced through Snow and Bazalgette to 1875; the limit stated plainly with evidence; and a closing judgement on what it matters most for. That three-part shape, at the time, longer term, limit, is what the 8-mark significance question rewards.

Question 4: the factor judgement

Has the role of the individual been the main factor in the improvement of public health in Britain in the nineteenth century? Explain your answer with reference to the role of the individual and other factors.

• Make the case for individuals with evidence: Chadwick in 1842, Snow in 1854, Bazalgette from 1858, and what each proved or built
• Set other factors against it: cholera and fear as the trigger, government in the Acts of 1848 and 1875 and the Reform Act of 1867, science and technology in Pasteur and Koch, communication in the reports, maps and Punch

Question 4: the judgement, tested

A student has argued that the role of the individual was the main factor because Chadwick wrote the report, Snow found the cause and Bazalgette built the sewers. Which is the strongest point to set AGAINST that judgement, in the way the top level of Question 4 requires?

• Each individual was ignored until an event made ignoring him too expensive: Chadwick was sacked in 1854 and his Act allowed to lapse, Snow was rejected by the Board of Health and believed only after Pasteur in 1861, and Bazalgette had designed his sewers years before the Great Stink of 1858 gave Parliament a reason to pay for them in eighteen days; compulsion came in 1875, not when the case was proved but when cholera, smell, science and the votes of 1867 had together raised the political cost of inaction above the cost of drains, so that the individuals supplied the case and government, under pressure of events, supplied the action, and a judgement should rank government and the pressures on it above the individuals whose proofs it had refused for a generation.
• Snow was a genius, so the individual must have been the main factor.
• Nobody improved public health in the nineteenth century because the poor stayed poor.
• Science was the main factor because Koch found the germ.