Disease and Sanitation in Victorian Britian: Lessons for the Third World

By Gordon Cook

This book highlights the huge advances made in prevention of infectious disease(s) in Victorian Britain. The actual cause of most disease was then unknown, as it was throughout most of the nineteenth century, but it was awareness of their association with poverty, overcrowding, poor ventilation and imperfect sanitation which underlay principal advances. Whilst most texts have concentrated on these crucially important matters, this book brings to light many of the leading pioneers. Late in the Victorian era, the true cause of infectious disease emerged (the ‘germ-theory’ was slowly being accepted) and vague external influences, such as miasmas and other telluric sources no longer dominated the scenario.
Today most disease in developing countries is of an infectious nature, and affected individuals can presently be cured with antimicrobials or anti-parasitic agents. In this author’s opinion this has been associated with a relative neglect of preventive strategies. Developing countries therefore have much to learn from the enormous strides made in preventive medicine during Britain’s Victorian era.

• Language: English
• Publisher: Melrose Books
• Release date: Feb 14, 2017
• ISBN: 9781910792896

Book preview

PART I:

What is public health?

The association between infectious disease and environmental factors (apart from noxious vapours emanating from telluric sources, ie, miasmas) was not widely accepted during much of the nineteenth century; neither was the part played by poverty.

This first section of the book is dominated by contribution(s) made by Thomas Southwood Smith (‘the father of sanitary reform’) and his medical colleagues – Arnott and Kay – which comprehensively demonstrated a close association between ‘the fever’ (epidemic typhus) and living conditions. This was followed by contributions from several non-medical personnel, some lawyers, who aimed to rectify the situation by improving hygiene, sanitation and living standards. Between them they did much to influence various parliamentary bodies and ultimately the legislature.

I have also included ideas on the cause and management of two major scourges of the century – smallpox and tuberculosis (Chapters 6 and 7). The former spared no-one, and the latter caused mortality in many individuals of note – including the composers Chopin and Paganini, and writers Sterne, Shelley, Edgar Allan Poe, O’Neill, Sir Walter Scott, D H Lawrence and John Keats. Although the cause of smallpox (the variola virus) was unknown throughout the nineteenth century, a preventive strategy, ie, vaccination, had come to prominence at the very end of the eighteenth, and clinical trials in the early years of the nineteenth century established this as an effective and safe procedure. The cause of tuberculosis was unknown until late in the nineteenth century, and methods of management were relatively ineffective until well into the twentieth; I have, however, outlined those procedures which in Victorian times were considered beneficial.

CHAPTER 1

Public health in Britain and recognition of importance of environmental factors

This chapter outlines the situation before, during and after the nineteenth century. The Public Health of Britain, as widely accepted today, came into being during a relatively brief period, lasting about thirty years, in the first half of the century (ie, immediately before and during the Victorian era). Although the ‘sanitary idea’ (which obviously took into account environmental factors) had been promulgated in 1824 it took, as this chapter will show, the dynamic input of Edwin Chadwick (1800–90) to bring about the public health dream. This chapter therefore concentrates on public health in Britain in the nineteenth century, but also analyses what went on before and after.

Rational methods to improve peoples’ health, which throughout history has proved a major object of society, are of course dependent upon a background of carefully assembled data – a fact first appreciated by John Graunt FRS (1620–74), son of a City of London haberdasher, and founder of vital statistics. He wrote Natural and Political Observations on the Bills of Mortality (1662), a record of London’s mortality (with causes) dating from 1603, and urged collection – by a Government department – of accurate figures, which in the eighteenth century, had been carried out by others; in 1761, Johann Süssmilch (1707–67) produced a text based upon a vast corpus of accurate statistics – The Divine Ordinance manifested in the Human Race through Birth, Death, and Propagation. The science of vital statistics was later founded by the Belgian astronomer, Lambert Quetelet (1796–1874), who wrote both On Man and the Development of his Faculties, or an Essay on Social Physics (1835) and also Letters on the Theory of Probabilities (1846). The first census in Britain was in fact not undertaken until 1801.

History of Public Health

It is thus advantageous to know of events affecting public health both during and before the Victorian era. Significant contributions by individuals of by-gone ages have significantly shaped the discipline in present-day Britain.

Fraser Brockington (1903–2004) has admirably summarised the history of public health in early civilisations. In the developing world, even today, religious and magical influences frequently dominate views of disease causation, astrology being widely practised. Public health was thus dominated by ideas which lacked a scientific foundation, and this often persists today in many ‘third world’ societies, constructing a serious barrier to public health programmes. Historically, the magician was, however, slowly replaced by the physician. Greece (represented by Hippocrates) took initial steps towards modern medical and clinical practice; however, doctors were unable to discern processes underlying consequent disease. Early physicians were able to recognise symptoms, but were totally ignorant of their cause(s). In Roman Britain (43–409), although the cause remained unknown (dissection of the human body remained forbidden), there were important milestones in the history of public health and origins of many aspects of hygiene can, in fact, be traced to that era. Descriptions of anthrax, leprosy, scabies, measles, smallpox and the ‘pestilential fevers’ had been made in the Arabian Empire, where hospitals with both in-patient and out-patient facilities were established, and the Roman concepts of hygiene were widely adopted.

However, ideas established in Greek, Roman and Arabian culture did not immediately spread to Christianised areas of Europe – where hygiene overall remained abysmal, and endemic disease and epidemics were commonplace. It was not until about 1250, with the founding of medical schools at Bologna, Padua and Pisa, that Europe emerged from intellectual darkness in medicine; human dissection – now incidentally verging on extinction – became acceptable, and clinical medicine achieved university recognition, being no longer practised solely by monks, apothecaries and quacks. Europe was also a major pioneer of one aspect of public health – quarantine (the precursor of a widespread belief in contagion); this applied not only to acute diseases such as plague, but also leprosy. The ‘cordon sanitaire’, by which infected towns were militarily isolated, was in fact put into effect from an early date.

Birth of scientific medicine (1450–1750), and development of a firm structure (1750–1840)

During the European Renaissance (1450–1750), public health involved a revival of Greek teaching, and preventive medicine made significant strides; physicians were first licensed (by bishops) to practise in 1511, and statistical recording of births and deaths took place (demonstrating a higher mortality in towns rather than the country); it also saw the first plausible theory of contagious disease. Galen’s works were ceremoniously burned by Paracelsus (1493–1541), and scientific medicine was established. Study of natural laws by observation and experiment began. As far as public health was concerned, several notable advances took place – inoculation (not vaccination) for smallpox (see Chapter 6), an attempted abolition of prostitution for syphilis (which failed), and quarantine for several diseases – most notably plague (which kept Britain free following the ‘Black Death’ and the Great Plague of 1665). By the mid-eighteenth century, it was widely accepted that both disease and death were established by natural laws, and not by acts of Providence.

In the seventeenth century fevers had been commonplace; scarlatina and measles were separated by Thomas Sydenham (1624–89) in 1676, although typhoid and typhus remained confused until as late as 1849, and diphtheria had not even been described as a specific entity. The discovery of microscopic life in the seventeenth century had given rise to an hypothesis of spontaneous generation, a theory not entirely demolished until Pasteur’s researches (see Chapter 16). Despite recognition that both boiling and sulphur fumigation were of value in dispelling infection, its true nature remained unknown and at that time the miasmatic theory, introduced by the Greeks, remained extant.

It was on this broad canvas that present-day public health came into existence between about 1750 and 1840. Towns, which had remained insanitary since the Middle Ages (see above), began to be ‘cleaned up’; the lessons from ancient Greece, Rome and Arabia were re-learnt and also implemented. Coupled with this were pioneering contributions to health improvement in the Army and Royal Navy (RN) (see below), and seeds were sown for the development of a Welfare Service (particularly with regard to school health and meals, maternity care, sewerage disposal, and pure water supplies – see below); in the field of prevention, widespread introduction of smallpox vaccination (which had replaced inoculation) was paramount. These advances in healthcare were taking place simultaneously with the Industrial Revolution.¹

HEALTH ADVANCES IN THE RN AND ARMY IN THE EIGHTEENTH CENTURY

In the eighteenth century, accurate statistics for disease and health became available in the Army and Navy. Amongst military advances were those of Sir John Pringle FRS (1707–82) (see fig 1.1), a pupil of Hermann Boerhaave (1668–1738), whose book Observations on the Diseases of the Army in Camp and Garrison (1752) went to seven editions; Pringle outlined provision of adequate latrines, proper drainage, and avoidance of marshes. In the USA, Benjamin Rush (1745–1813) followed Pringle’s book with Directions for preserving the Health of Soldiers (1778). Naval medicine also developed a preventive strategy. Much there was based on the evils of a lack of ventilation, which resulted from an increase in numbers of guns with corresponding reduction in space for living accommodation of crews. The RN’s equivalent of Pringle was James Lind (1716–94) (see fig 1.2), also a pupil of Boerhaave, who wrote A Treatise of the Scurvy (1753) which outlined preventive strategies for this important naval disease. Lind was also involved in prevention of typhus, and wrote an Essay on the Most Effectual Means of Preserving the Health of Seamen (1757). His work on scurvy prevention was converted into Admiralty policy by Sir Gilbert Blane (1749–1834) who wrote Observations on the Diseases incident to Seamen (1785). Lind’s and Blane’s works thus led to improvements in both hygiene and ventilation in sailors’ living quarters. Thomas Trotter (1761–1832) concentrated on diet in the RN, and his book Observations on the Scurvy (1786) was also of considerable moment; he also published Medicina Nautica (1797–1803).²

Fig 1.1:Sir John Pringle FRS (1707–82): the ‘father’ of preventive medicine in the British Army. (Reproduced courtesy the Wellcome Library, London).

Fig 1.2:James Lind (1716–94): Pringle’s equivalent in the Royal Navy. (Reproduced courtesy The Wellcome Library, London).

LAND-BASED ADVANCES IN THE EIGHTEENTH CENTURY

Following these major advances in the RN and Army, efforts took place to prevent disease in civilian populations, especially during the Industrial Revolution – in which communities moved en masse from rural to urban conurbations encountering numerous diseases with which they had not previously been in contact. In fact, a higher mortality-rate in towns, which Graunt (see above) had demonstrated in his Bills of Mortality as early as the seventeenth century, was becoming clear. Typhus (see Prologue) was a particular problem – which had been addressed by, for example, Thomas Percival (1740–1804) and John Ferriar (1761–1815) in Manchester. In prisons, improvements in ventilation and sanitation were made by Stephen Hales (1677–1761) and John Howard (1726–90). It was left to Southwood Smith (see Chapter 2) and Edwin Chadwick (1800–1900) (see Chapter 4) however, to introduce the philosophical principles of Jeremy Bentham (1748–1832) to the political arena (see Chapter 4) – factors influencing the health of all the citizens of the country should automatically, he felt, be the concern of the legislature.

In the eighteenth century, Giovanni Lancisi (1654–1720) studied outbreaks of malaria in Rome, and in 1717 he published De noxiis paludum effluvis (‘On the noxious effluvia of marshes’) in which, although also subscribing to the miasmatic theory, he wrote that mosquitoes were probably involved in transmission. Johann Frank (1745–1821) also studied diseases which act collectively on the general population; his book System einer Vollständigen Medicinishen Polizey (‘A complete system of medical policy’) (1779) outlined enforcement of health by state regulations.³

Epidemic and endemic disease

Regarding epidemic disease, quarantine and state regulation were instituted in the eighteenth century, ports being safeguarded against infections, especially plague. Although regarded today as antiquated, expensive and ineffectual, quarantine probably kept plague within bounds, and numerous plague hospitals and lazarettos were founded to keep it at bay. Apart from plague and smallpox (see Chapter 6), other epidemic diseases were also targeted from a preventive viewpoint, albeit without great effect; scarlet fever (scarlatina) is one such which throughout history, has varied significantly in both virulence and prevalence. First accurately described by Thomas Sydenham (1624–89) in 1683, scarlatina was frequently confused with other acute infections possessing an exanthem. Diphtheria was first accurately described by John Huxham (1692–1768), a Devonshire physician in A Dissertation on the malignant ulcerous Sore-throat (1757).

During this time Britain, compared with many other countries, remained relatively free of fevers – primarily as a result of her climate. A rudimentary Board of Health had been formed in Manchester by Thomas Percival in 1793 (see above); due to urbanisation that city was experiencing much infective disease at that time. Three years before the first British census, Thomas Malthus (1766–1834) had maintained in an Essay on the Principles of Population (1798) that, unless checked, population growth would outrun food supply. For a brief period (1805–6), a Central Board of Health, on a national scale, was established by royal proclamation – to advise on how to ward off yellow fever (‘yellow jack’) and in 1808 a National Vaccine Board dominated by the (Royal) College of Physicians of London, was created. There were also local Commissions (most concerned with sanitation) – which had existed since the Middle Ages. However, Britain was at that time, largely for political reasons, lagging behind most other European countries.⁴

The nineteenth century

Apart from these initiatives, very little was happening at the beginning of the nineteenth century as far as public health in Britain was concerned. In 1808 an Act was passed to enable Justices of the Peace (JPs) to establish county asylums; however, the unsatisfactory state of ‘madhouses’ in 1815–16, did much to persuade Anthony Ashley-Cooper (later, seventh Earl of Shaftesbury [1801–85] – see Chapter 4) to devote time and energy to social reform. In the 1830s, four significant events took place which were to exert a significant influence on public health:

•arrival of cholera in Britain for the first time; this particularly affected the slums of expanding urban conurbations; one outbreak was followed by the establishment of >1200 local boards of health. Formation of a General Board of Health (GBH) on the lines of that of 1805, followed,

•breakdown, and subsequent reorganisation of the Elizabethan poor-law system by Chadwick, who became a member of the Royal Commission formed in 1832; Bentham had initiated suggestions for reform,

•beginning of factory legislation (centred on child labour), and

•civil registration of births and deaths, with William Farr (1807–83)⁵ at the helm.

ACCURATE RECORDING OF VITAL STATISTICS

There had been partial registration of deaths, and recording of famines and epidemics since the reign of Elizabeth I. London’s weekly Bills of Mortality were begun in 1593, and were published continuously from 1603 to 1831 (see above). Cholera first appeared in England in 1831, and although 52,547 deaths from this infection were recorded in that epidemic, there was still no formal register of deaths. In 1837, when Queen Victoria ascended the throne, better machinery for the compilation of vital statistics was in operation; Farr (see above) entered the office of the Registrar-General of England in 1839, and initiated the first steps at scientific recording of health statistics. There was, however, still general ignorance of the prevalence of epidemic, endemic, and also contagious disease; between 1 July 1837 and 31 December 1839 a smallpox epidemic killed >30,819 in England and Wales, and in 1838, scarlatina was responsible for the deaths of 5,802, which rose to 19,816 by 1840. In 1840–1 typhus (‘continued fever’) produced heavy mortality, although many cases were probably caused by typhoid. In 1841, an excess of ‘typhus’ deaths in towns compared with the country amounted to 56%. This led to confirmation that mortality in towns exceeded that in the country, which applied especially to tuberculosis.⁶

The sanitary ‘utopia’ – 1840–1900

The General Board of Health (GBH) was established in 1848; the part played by defective sanitation on disease prevalence had been its motivating factor; Chadwick (the ‘father of Public Health’) was its founder, who by then had switched from his major interest(s) of poor-law reform. Prevention rather than cure assumed its major raison d’être, and the main task was provision of adequate facilities for waste disposal in towns. It was also empowered to enquire into localities petitioning for application of the Act, and to initiate enquiries where mortality exceeded 23 per 1000; if inspectors recommended application of the Act, a local Board of Health was created. However, it had the drawback that application of the Act was purely voluntary.

The reports from Arnott, Kay (see Chapter 3) and Southwood Smith (see Chapter 2) prompted the Poor-Law Commissioners to approach the Secretary of State about the unsatisfactory state of Britain’s sanitation. However, the key publication was Chadwick’s The Sanitary Condition of the Working Population of Great Britain (1842), which was compiled from evidence provided by union medical officers throughout Britain. The first part concentrated on the extent and operation of the evils which formed the raison d’être of the inquiry, and the second on means by which sanitary conditions of the labouring classes could be improved. Chadwick, with assistance from his medical colleagues, reached four major conclusions:

•health depended largely upon sanitation;

•sanitation was essentially an engineering and not a medical matter;

•a single local authority should administer all sanitary matters, and

•expert advisers in both engineering and medicine were essential.

Incidentally, Chadwick was at this time also writing his report into widespread abuses resulting from interment in towns, already highlighted by Southwood Smith (see Chapter 2).

The 1842 report (see above) led to the appointment of a Royal Commission ‘to inquire into the state of health in large towns’ (1843). Fifty English towns were studied, and the report on Liverpool by William Duncan (1805–63) (see Chapter 5) is just one example. Following publication, it was clear that legislation by Parliament was required, and after a delay of three years, the Public Health Act of 1848 (see above) was published; it was passed when Britain’s second cholera epidemic was beginning. Chadwick advocated a central body – the GBH (see above) to oversee improvements, and the debate was doubtless influenced by the Health of Towns Association (HTA) (comprising Southwood Smith, Benjamin Disraeli and Shaftesbury, amongst others) founded in 1839. The GBH was thus established – but lasted only five years – with three members (two being Crown appointments – Chadwick paid, and Shaftesbury unpaid); Smith was initially designated Chief Medical Inspector, but later became a fourth member of the Board. The GBH had power to create local Boards of Health in an area where ⅒ of rate-payers were petitioned, and was compulsory in those with a high mortality. Local Boards of Health – suggested in the 1848 Act (see above) – did not exist in 1849; therefore, the GBH had to adjudicate widely, but sadly failed to avert the cholera disaster. Although sanitary improvements lowered mortality significantly, the engineering profession (largely ignored) became antagonistic, leaving over 50% of Britain uncovered. The first Medical Officer of Health (MOH) (see Chapter 5) was appointed under a private Act of Parliament. The 1848 Act had authorised appointment of MOHs to the new Health Boards; however these were not made obligatory as recommended in both Chadwick’s (1842) and the Health of Towns Association (HTA) (1843) reports.

The HTA had been founded in 1844 as a cross-party pressure group, formed to influence Government in introducing legislation to improve ‘quality of life’ in Britain’s towns and cities. Appointment of MOHs had coincided with changing views on the nature of contagion. Possibility of a microbial origin of certain diseases (to replace the ‘miasma theory’, as well as Sydenham’s hypothesis of ‘epidemic constitutions’) had been considered but were still unproven; contributions from Snow (see Chapter 12), Budd (see Chapter 14), Oliver Wendell Holmes (1809–94) and Ignaz Semmelweiss (1881–65) were important in this respect; certain diseases (for example smallpox – see Chapter 6) were already considered contagious. There was thus already strong circumstantial evidence for contagion; the value of quarantine – which had protected Britain from plague since the sixteenth century – had of course been based essentially on this concept.

However, Chadwick (still primarily a miasmatist) had based his thinking merely on elementary principles of sanitary science. He was soon in conflict with numerous organisations, including the College of Physicians, engineers, guardians, vestries, burial boards, parliamentary agents, the Treasury, The Times, local governments and also the water companies. Most hostility resulted from personal differences as well as his ambition to centralise, which in his day was a novelty but would probably be immediately accepted today! Chadwick had a fundamental dislike of doctors. In addition he readily used public monies for his own objectives. Overall, he seems to have possessed significant personality problems!

The GBH (without Chadwick) continued until 1858. Simon (see Chapter 5) meanwhile was appointed medical officer to the central government in 1855, and continued until 1871, when duties of the GBH were transferred to the Privy Council (PC). Unlike Chadwick – essentially a self-educated sanitary engineer – Simon was medically qualified and practised as a surgeon at St Thomas’s Hospital; unlike Chadwick, he was also receptive to the developing ‘germ-theory’.

The Privy Council (PC)

While at the PC, Simon concentrated on attempts at understanding the cause of disease. He changed public health from a simple engineering exercise to a scientific discipline within epidemiology.

Although like several previous Sanitary Acts, that of 1866 (largely a result of Simon’s teaching) failed to achieve a great deal, primarily due to a relative absence of local administrators; however, it gave rise to renewed interest in public health. Compulsory vaccination in 1853 (the ‘conscience’ clause was not added until 1898, ie, 45 years later), introduction of the Medical Act of 1858 (see Chapter 18), a new system of nurse training, and the Education Act were introduced. However, public health in this era was influenced mostly by William Ewart Gladstone (1809–98)’s Royal Commission of 1869, which recommended a uniform system of administration, similar in fact to Chadwick’s recommendations:

•consolidation of sanitary legislation,

•uniform administration under direct supervision from a central authority, presided over by a Government minister,

•this minister to be responsible for both health and the poor-law,

•a central authority with a Chief Medical Officer (CMO) and expert staff – constantly in contact with the local authority, and

•all local authorities to have at least one MOH – qualifications being clearly set out.

In 1871, the Local Government Board (LGB) was created by Act of Parliament, its CMO being Simon; it was to take over the functions of the Poor-Law Board and was in fact to last until 1919. A government supervisory body, it oversaw local administration in England and Wales. In 1872, an Act establishing sanitary areas throughout the entire country was passed, each authority having its own sanitary inspector – working on advice from a medical officer. This work was assisted by official notification of diseases as subsequently set out in the Public Health (1875) (see below) and Notification of Diseases (1889 and 1899 respectively) Acts.

In 1894, the Local Government Act was passed; this meant for example, that 28 metropolitan boroughs in the London area were created by absorbing 38 existant vestries; sanitary administration therefore received a boost, and with creation of county councils, public health services improved dramatically. Regrettably, there was no insistence upon full-time MOHs (which Chadwick had recommended); instead many part-time MOHs (who combined this rôle with private practice) were appointed. The system meant that the sanitary condition of most areas was reported to central government annually, as Chadwick had recommended.

Public Health received a major boost in 1888. Granting of diplomas in that subject (regulated by the General Medical Council) had begun in the 1870s, but became in 1888 a statutory requirement for every MOH in an area with >50,000 population. It was anticipated that the LGB would ratify this, but instead it combined health and poor-law in a central department, thus diminishing the status of the MOH. It was largely due to dominance of the Chadwick poor-law system that Simon resigned from the board in 1876.

The 1875 Act

The great Public Health Act of 1875, designed to combat filthy urban living conditions, and combining a range of Acts covering sewerage, drainage, water supplies, housing and disease, which regulated the relationship between central and local authorities, was a monument to Benjamin Disraeli (1804–81) (‘the health of the people is … the foundation upon which all their happiness and all their powers of state depend’). It was to provide a sanitary code under which MOHs and sanitary inspectors would work effectively. The Act contained 343 sections, was largely consolidatory, and formed the basis of the sanitary law of England which both lasted for the following fifty years, and heralded an era of improvement to environmental sanitation. This was followed by numerous Acts involving occupations and commodities – ranging from ships, canals, river pollution, factories, workshops, cremations, food and drugs, milk supplies, open spaces, coalmines, etc.

HOUSING

Although housing was a major component of the 1875 Act, attention to improvements, and demolition of slum properties was largely ignored. Unfortunately this and subsequent Acts left most responsibility with the property owners, and by 1885 it was clear that legislation regarding housing had failed, slum properties still being present in abundance. A Royal Commission on which both Shaftesbury (who maintained a great interest) and Octavia Hill (1838–1912), as well as numerous MOHs were members, led to the Housing of the Working Classes Acts (1885 and 1890). The rôle of the Sanitary Inspector (many were subsequently appointed) became of paramount importance; Chadwick had meanwhile founded the Royal Sanitary Institute in 1875.

THE LUNACY ACT

This was passed in 1890. Until then, lunatics had been designated paupers, and patients could be admitted and retained in an asylum without intervention of a court or public official. The Act introduced a reception order, and as a result, the risk of improper incarceration had virtually disappeared by the end of the nineteenth century.⁷

The twentieth century

The immediate post-Victorian era was to open with widespread acceptance of the ‘germ-theory’ (see Prologue), with Koch’s demonstration that specific bacteria were causatively related to certain diseases (eg, tuberculosis and cholera) (see Chapter 16). This placed public health in an entirely new perspective; also, wide-ranging immunisation, which had begun with smallpox vaccination (see above), rapidly became possible. The MOH became a practical epidemiologist, and prevention of infectious disease was now a reality. However, overcrowding and inadequate housing remained significant problems.

Most MOHs became full-time public servants. Recognition of the social consequences of both tuberculosis and pregnancy was largely due to Sir Robert Philip (1857–1939) and (John) William Ballantyne (1861–1923), respectively. The era of personal hygiene resulted from changes to local government as had been envisaged in 1888 (see above) and numerous Acts were now passed, much of the work devolving on county and county borough councils.

Much consideration was given to preventive measures by both the Royal Commission on the Poor-Law (1905–9) and also national health insurance. Suggestions that it was better to attempt to prevent pauperism – highlighted by many early nineteenth-century luminaries (including Southwood Smith), and preached by Chadwick (see Chapter 4), were widely instituted. The National Health Insurance (NHI) Act of 1911 both provided public medical-care for 16 million workers, and highlighted the importance of preventive care in public health. However, as Brockington has stressed, ‘it was a considerable disadvantage’ that the organisation of medical services was separated from the LGB – with an essentially poor-law outlook underlying a somewhat apathetic approach. Slowly, the LGB was ‘phased out’, to be replaced by the Ministry of Health (MoH) in 1919.

The Ministry of Health (MoH)

The 1919 Act not only replaced the nineteenth century LGB with the Ministry of Health (with its numerous diverse functions), but also incorporated into the latter the duties of the Registrar General,