Pioneers in Public Health

Lessons from History

Jill Stewart

• Publisher: Routledge
• Year: 2017
• Print ISBN:
  9781138059450
• eBook ISBN:
  9781351671484
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

The public health movement involved numerous individuals who made the case for change and put new practices into place. However despite a growing interest in how we understand history to inform current evidence-based practice, there is no book focusing on our progressive pioneers in public health and environmental health.

This book seeks to fill that gap. It examines carefully selected public and environmental health pioneers who made a real difference to the UK's health, some with international influence. Many of these pioneers were criticised in their life-times, yet they had the strength of character to know what they were doing was fundamentally right and persevered, often against many odds. Including chapters on:

• Thomas Fresh
• John Snow
• Duncan of Liverpool
• Margaret McMillan
• George Cadbury
• Christopher Addison
• Margery Spring Rice and others.

This book will help readers place pioneers in a wider context and to make more sense of their academic and practitioner work today; how evidence (and what was historically understood by it) underpins modern day practice; and how these visionary pioneers developed their ideas into practice, some not fully appreciated until after their own deaths. Pioneers in Public Health sets the tone for a renewed focus on research into evidence-based public and environmental health, which has become subject of growing international interest in recent years.

1 Introduction

Jill Stewart

Chronologies of dates and events in history tell us only limited things of what happened in the past and can have little real meaning in our lives today. But history can be engaging; learning about not just what happened, but why it happened and what motivated people, can make history fascinating, lively and even fun. Bringing history, and its people, back to life makes it enticing and interesting through anecdotes, stories, pictures and film. It can shape what we think today.

This book tells stories of how some people in history, now long gone pioneers in public health, took forward their strong views, ideas and values and in so doing, took sometimes great personal risks which continue to make a difference to all of our lives today. They had little to work from; there is a sense that they had to start from (public health) scratch. Some here are selected as better-known and obvious pioneers whose names and dates will have featured in history books, but others will have not, and may have come under our authors’ radars almost by chance, to now feature in this book.

What is immediately striking in reviewing many of these pioneers is their focus on what we would now call the Social Determinants of Health (Commission on Social Determinants of Health, 2008; Marmot et al., 2010) and these ideas and beliefs about how we could live healthier lives are far from new. In the modern day, we can reflect on what these pioneers archived and provided, and reinvigorate what they did in new forms. The social determinants of health are about conditions into which people are born, how they grow, work, live and age and how wider economic frameworks, politics and policies shape our development (Commission on Social Determinants of Health, 2008).

Others of our pioneers focused on mitigating the worst effects of polluted, contaminated environments and poor housing stock and sought to develop and deliver interventions that reduce risks to health. In fact, what emerges from many of the pioneers featured here is their contribution to the role of the contemporary environmental health practitioner, now one of the key professionals delivering on front line public health practice across a range of fronts with a focus in the social determinants of health as well as interventions to mitigate negative environmental health stressors (Burke et al., 2002).

What we can see from this is the ongoing relevance of and standing of the contemporary Environmental Health Practitioner (EHP), previously known as Public Health Inspectors, Sanitary Inspectors or earlier still as Inspector of Nuisance. Some notable researchers of environmental health who have focused on early EHPs (Inspector of Nuisance, later Sanitary Inspectors) and statutory nuisance continue to provide remedy conditions prejudicial to health.

Hamlin (2013) consolidates Victorian notions of nuisances into neighbours’ complaints; early development of what should not be acceptable by community standards (rotten meat, leaky cesspools, noxious trades, overcrowded housing); inspection of public services; and finally, infected persons whose liberty of movement was seen to threaten everyone. Nuisance legislation was seen to help relieve a range of environmental threats and at a very local level. What seemed to be important was character rather than technical ability. It was not until later on that Inspectors of Nuisance were able to develop their own professional organisation. They remained subordinate to Medical Officers of Health; but were very busy with very explicit local bye-laws and statutes in creating local government to help “shape views of local government as competent and responsive” (Hamlin, 2013, p. 379).

Crook also comments on this gradual change to local government functions and the development of the accountable, interventionist and surveillance state by the end of the Edwardian period and for our purposes here, the role of the by then Sanitary Inspector. Derived from Chadwick-initiated reforms, roles still varied from place to place, but continued to develop and evolve as scientific understanding grew, most notably with germ theory, possibly – it is argued – at the “expense of traditional sanitary concerns” (Crook, 2007, p. 377), or even simply applying common sense; but the culture remained more reactive than proactive within a liberal culture of governance allowing for public rights and freedoms, alongside social order and health. Crook argues that this led to tensions between political or ethical tasks for the Sanitary Inspector and for him, the role is more flexible, nuanced and informed by a range of issues. In summary, Crook (2007, p. 393), reflecting on the interventionist and surveillance roles of Sanitary Inspectors, asks:

Was it freedom from the tyranny of disease and discomfort, or freedom from the tyranny of government? Inspectors, naturally enough, were convinced it was the former.

Why bother with history?

What happened in the past and how can we understand and interpret events and developments in public health today? Different organisations take different perspectives in using history in contemporary policy drawing from heritage and tradition. Understanding what happened in history, and why, can help inform and enlighten current debate – and perhaps one key thing that is often forgotten, can make things far more interesting today. Historical events and interpretations can help us challenge our own viewpoints, our morals, ethics and beliefs, attitudes and inform more sensitive and effective interventions into the future. Policy would surely be weaker if we fail to understand where it has come from and why it shifted as it did.

History, heritage and the built environment provides a major contribution to contemporary public health (Berridge, 2008). History is also about power, ideology, attitude and value and many of our public health pioneers were born into positions of power; they had the right and perhaps felt an obligation, to use that power and make change.

The era, values and attitudes into which we were born can have a profound effect on what we believe, even if it is not founded in evidence or is outright wrong. Accepted beliefs around causation of disease and illness shape how we deal with it and our solutions are frequently founded in ideologies rather than evidence of what works. If for example we believe – without a shadow of doubt – that it is miasma, or foul air, that causes illness, it follows that what we need to do about it is related to that belief. It is therefore ironic that Edwin Chadwick, the father of the modern environmental health profession, was a miasmist, along with many others of his time. John Snow, conversely, was not; as a result he faced ridicule and it was not until after his death that those in a position of power accepted his evidence-based ‘germ theory’.

Chadwick: miasma and environmental health

Those interested in public health will already be familiar with the life and times of Edwin Chadwick (1800–1890), who has been widely written about (for example Lewis, 1952), so we have not devoted a chapter to him in this book. Chadwick wanted people to understand that health was an issue for everyone with prevention being better than cure. He had been influential around matters of juvenile labour, factory inspectors and compensation for industrial employees. His long and wider-ranging career included appointment by the Royal Commission to examine Poor Laws and his reforms included Poor Law Unions, each with a workhouse and he later favoured new approaches to local administration. He enrolled at Law School in 1823, and became a barrister in 1830, when he made friends with philosophers including John Stuart Mill and Jeremy Bentham¹ and doctors including Thomas Southwood Smith. His combination of circumstance and friendships led him to become increasingly interested in sanitary and health conditions reform and in 1842 he published ‘The Sanitary Condition of the Labouring Population’, researched and funded at his own expense (see Figure 1.1).

Chadwick of course pioneered the first Public Health Act of 1848, and believed that without compulsory legislation, there would be little progress. He called for reform to overcome the multiple complexities around the range of organisations and administrations involved in public health implementation. As Meneces (1972, p. 177) states: “slowly but with gathering momentum the new values which the ‘Sanitary Idea’ set before society were permeating the minds of law-makers and administrators.”

The new legislation, related organisational and administrative reforms and the development of inter-professional relationships in the sphere of public health were to provide immense impetus for change. Chadwick had firmly established a relationship between the environment and health, although he clung doggedly to his belief in miasma. By 1884 Chadwick was appointed as the first President of the Association of Public Sanitary Inspectors, now the Chartered Institute of Environmental Health. The head offices are named Chadwick Court.

Figure 1.1 Edwin Chadwick

Despite everything Chadwick achieved, he seems not to have made many friends, but perhaps that was the price of his progress and he has been described as obstinate and a “pest wherever he went” (Finer, 1951, p. 442). Meneces (1972, p. 352) reports: “that he was so hated was a distasteful fact which he faced unflinchingly, but, conscious of his own high purpose he was honestly bewildered that it was so.”

Names of other pioneers crop up in reading about Chadwick, including the engineers Bazalgette (with whom he also had disagreements – Finer, 1951) and Rawlinson, concerning mainly sewers but also controls around common lodging houses and the Medical Officers of Health.

Beyond miasma: the unsung heroes

During the writing of this book, it became clear that there was a body of environmental health people interested in the history of their profession and in particular some of the pioneers who drove developments. These were people they considered their own local ‘unsung heroes’ and indeed there seems little – if anything – published on some of these pioneering souls. It also emerged that there are history societies and archives nationally with substantial untapped resources with a wealth of material about the history of environmental health and public health.

Bryan Boulter, a retired EHP from Portsmouth, forwarded details about a speech he was giving to a local history society about Sir Robert Rawlinson. Not surprisingly as a garrison town, Portsmouth faced huge public health challenges as the Public Health Act 1848 came into being. Mr Rawlinson was amongst the first inspectors to be appointed under the General Board of Health created by the new Act, a role that developed from his earlier position as borough surveyor and engineer. Public health problems facing him were overcrowding, unsatisfactory drainage and sanitation. Proposals were put in place to provide drainage, cheap pure water, by substituting water closets and soil pan apparatus for privies and cesspools and by maintaining good roads, courts, passages and footpaths. There were arguments about who should pay for what; particularly the contribution of the military. As a result, little progress was made in drainage until the 1860s. It was Robert Rawlinson who gained credit for using tact and skill to facilitate progress amongst the different factions.

Rawlinson also has national significance and headed a Sanitary Commission to remedy ill health and mortality during the Crimean War, travelling widely. He was then sent by Lord Palmerstone to Lancashire in 1863 following the collapse of the cotton industry to help support poverty-stricken communities; he provided for better water and drainage. He is said to have visited some 100 towns. In the 1860s he chaired a Royal Commission on the Pollution of Rivers and became Chief Engineer to the Local Government Board and sits alongside Bazalgette for his contribution to innovative sewerage systems. He was knighted in 1883 and was elected President of the Institution of Civil Engineers in 1894.

A further little known pioneer was Dr Thomas Shapter, brought to our attention by David Sexton, EHP, also of Exeter. Thomas Shapter graduated from Edinburgh and moved to Exeter in 1832, coincidentally as Asiatic cholera also arrived. He published his book The History of the Cholera in Exeter 1832 (Shapter, 1849) and describes the arrival of cholera in the city, the residents’ and authorities’ reaction to it. The book sets the scene for environmental health conditions in the city and outlines symptoms, treatments, deaths and burial grounds as well as presenting detailed statistical data about cholera with comparisons across ages, duration, gender and relationship to other data; all basic epidemiological methods to find the casus and influences of cholera. His data indicated a population mortality rate of 1.42% and his data suggested a 1 in 3 chance of death once contracted, and that it affected the entire population similarly. His work was well received and cited by John Snow and whilst he did not link it to contaminated water, he had tried to understand its cause and observed that the intensity of cases, by drawing a map of the outbreak, were situated in crowded and ill-drained areas, which he referred to as ‘social errors’ and that he felt it was a preventable disease.

Back to the future

Compiling public health histories can be tricky; not all documents are available to us and archives may be few and far between and due to costs, non-digitised. This can lead to hours and days trawling through dusty papers before finding gems of information. It is there that our authors shine. Some have trawled through archives and in their chapters, acknowledged those individuals and organisations who have particularly helped them. Such localised, historical data varies from place to place, is hard to compare (if this is possible at all – see even Shapter and Snow) and there are also variations in geographical, social and economic contexts and we may use history in a very ad-hoc manner, but hopefully this book provides a useful starting point.

Each of our authors had been inspired to write about their pioneers from a different standpoint. For some, there was an obvious geographical connection, to their place of childhood or employment and a snowballing interest in the local significance of what an individual had achieved, be in a beautiful architectural contribution to the built environment, or a shift in policy and organisational thinking that was to have significant national – if not international – ramifications. For some of our authors, theirs was also an organic, personal journey of discovery and ongoing learning.

Research for other chapters also included searches using Google and Google Scholar, leading to wider identified reading, appraised literature from relevant academic journals, scrutiny of specific websites as well as reviews of ...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• List of figures
• List of tables
• List of contributors
• Series preface
• Preface
• Acknowledgements
• 1 Introduction
• 2 Thomas Fresh: the first environmental health practitioner
• 3 Sir John Simon: a role model for public health practice?
• 4 John Snow: a pioneer in epidemiology
• 5 Sir Joseph Bazalgette: a man of persistence and vision
• 6 George Smith of Coalville (‘the Children’s Friend’): campaigner for factory and canal boats legislation
• 7 Duncan of Liverpool: the first Medical Officer of Health
• 8 Margaret McMillan: advocate and practitioner of improvements in children’s health
• 9 George Cadbury and corporate social responsibility: working conditions, housing, education and food policy
• 10 Charles Booth’s inquiry: poverty, poor housing and legacies for environmental health
• 11 Christopher Addison: health visionary, man of war, Parliamentarian and practical pioneer
• 12 Margery Spring Rice: throwing light on hidden misery
• 13 Berthold Lubetkin: ‘nothing is too good for ordinary people’
• 14 Conclusions
• Index