Public health by Dr Denise Amos


"King Cholera" as visualised by the Illustrated London News.

"King Cholera" as visualised by the Illustrated London News.

After 1815 the rapid growth in the size of the major towns led to over-crowding, badly-built houses and shortages of pure water and a steep rise in the death-rate amongst town-dwellers. Doctors and public health reformers believed that the miasmic state of the air was responsible for the great number of deaths from cholera, tuberculosis, typhoid and typhus. Following on the heels of the great cholera epidemics 1831-32 and 1838, in which many districts of Great Britain were affected, and the introduction of the New Poor Laws, 1834, Edwin Chadwick, chief Poor law Commissioner began his work into the link between poverty and illness which culminated in the publication of his study Sanitary Conditions of the Labouring Population of Great Britain, 1842. What he and the other Poor law Commissioners; Kay, Arnott and Southwood-Smith concluded was that poverty contributed to disease and disease often turned poverty into pauperism (the crux of the new poor laws). The recommendations of the Poor Law Commission, on the whole met with a favourable response, but because of the political implications including the heavy costs involved in implementing them the Prime Minister, Sir Robert Peel arranged for the whole question to be placed before a Royal Commission. At the end of a very long and thorough investigation two Reports were laid before Parliament, Royal Commission on the State of Large Towns and Populous Districts, First report 1844 and Second report, 1845. The Commission recommended a series of proposals. One of these was the setting up of a new Government Department. A second recommendation was that arrangements for the provision of drains, paving and the provision of clean water supplies should be placed, in each locality, under one administrative body.  The first step was the Health of Towns Association formed in 1844. This was influential in sanitary legislation and administration and had an impressive list of sponsors and supporters. Fours years later, Parliament passed a Public health Act (1848) and a Central Board of Health was set up with the power to set up local boards of health in any area where the death-rate  was 23 per 1000 or higher.

The next piece of legislation dealing with public health was the Public Health Act 1858 which transferred the supervision of public health from the General Board of Health to the Privy Council under the guidance of Sir John Simon. During the period 1858-1871 Simon produced a series of annual reports which are very useful to the study of public health during this period. Unfortunately there were still a  tendency to look at separate issues and legislate individually rather than looking at the fuller picture, for example the prevention of diseases and nuisance removal were dealt with by different legislation.

Finally in 1875 a comprehensive and all-encompassing piece of legislation brought all public health issues under one department, the Local Government Board, which possessed its own status, its own Minister and all the apparatus of a fully formed Government Department. Matters such as sewerage and drainage, nuisances, offensive trades, unsound food, infectious diseases, hospitals, prevention of epidemics, highways, markets and slaughterhouses were all now dealt with by one body. But the most important factor was that each area had to appoint a Medical Officer of Health, who was to be adviser and executive officer of his local authority.

Public health in the borough of Nottingham as such did not become a reality until 1847 when a Sanitary Committee was created to control the nuisances which existed. Nuisances could be anything from decaying housing to keeping pigs to undrained and unpaved alleys to the removal of prives and ashpits. Nottingham had always had a plentiful supply of water; the rivers Trent and Leen had originally been pure streams and there were numerous wells and springs around the town. The (Old) Nottingham Waterworks, 1696, had provided water from the Leen but as the river became contaminated the quality of the water deteriorated. The Zion Hill water (now the area around Canning Circus) was possibly the purest in the town in the early part of the nineteenth century. The long standing improvement in the water supply of Nottingham is acknowledged to Thomas Hawkesley. In 1830, at the age of 23, he undertook the construction of a new pumping station at Trent Bridge for the Trent Company. Water was obtained from the Trent through filtration and pumped to a reservoir on Park Road.In 1845 the three old water companies were amalgamated under Hawkesley. He not only improved the supply but reduced the costs to the consumer and improved conditions when Nottingham had reached an all time low.The 1832 cholera epidemic which claimed its first victims in the densely populated area of Narrow Marsh was the first spur to the Corporation to improve conditions within the town. Unfortunately after the first wave of panic and action little was done until after the Parliamentary report into the State of Large Towns in 1845, revealed the true state of the town. This prompted the Corporation to set up a committee to make a broad survey of the town in 1847, which showed how the town had deteriorated within the last four decades.

The Sanitary Committee faced an uphill task and their first report in 1849  reported on the work thus far achieved. It stated that 34 dwellings situated over privies and ashpits had been gutted or taken down, pig sties had been removed from nearby dwellings and a dozen courts and alleys had been drained and paved. Perhaps not a massive campaign but at least they were making in-roads.

One area which caused a considerable dilemma for the  Health Authority was that of the disposal of corpses. Burial grounds were a serious menace to health because rain falling over graveyards percolated into wells from which the living drew their water. Ancient graveyards had become grossly inadequate for a rapidly expanding population. In 1856 places of internment within the built –up ‘Old Town’ had been closed by the council but despite this they were still being used in 1877. Purpose built cemeteries was the answer and these were constructed on large plots away from housing, eg the Northern Cemetery, Forest Road and the Southern Cemetery on Wilford Hill.

During the next two and a half decades the Committee dealt with a vast array of nuisances but were always hampered by a lack of legislation (apart from the Removal of Nuisances Act 1847) and insufficient manpower and facilities with which to carry out their work. Nottingham failed to take up the opportunity of appointing a Medical Officer of health in 1858, but were forced into appointing one in 1873.

Edward Seaton, the first Medical Officer of Health, began his work with a survey of the town and issuing a fairly damning report on the state of the town. During his period with the town until 1883 he set the foundation stones for later officers to build upon. During his time in office he argued strongly for an isolation hospital to be built within the town – it was subsequently built on the site now occupied by  Nottingham City Hospital. He investigated the relationship between the high infant mortality rate and the number of women who worked within the lace industry. In 1882 he compiled a report on the housing situation and the amount of overcrowding which existed in the town, much of which existed in the 8000 back-to-back housing predominant in the town.

Seaton was succeeded by Sir Arthur Whitelegge who carried on the work of Seaton for the next six years when he was replaced by Phillip Boobbyer. Boobbyer remained as Medical Officer of Health for the next 30 years. During that time he took the public health service to another level, increasing the number of staff as well as their qualificational status. Boobbyer took to task the council over their appalling record over the continued use of pail closets, to the detriment of the whole town’s population. Unfortunately he was unable to achieve his aim in their replacement by flushing water closets, until a public enquiry in 1919, over the extension of the borough forced the council into replacing them. Boobbyer also took on the problem of phthisis in the town and gradually brought about a far greater understanding of the disease as well as improving health care for sufferers. His other main achievement was the introduction of the voluntary Mother and baby welcomes in the city in 1908, which were the beginnings of child health care.

At his retirement in 1929 great improvements had been made in the city of Nottingham in terms of public health. The dreaded pail closets were gradually phased out, tuberculosis sufferers had a greater chance of treatment and mothers and babies had access to some primary care. With an increase of staff, some with a specific detail, improvements were made in the condition of food offered for sale within the borough. This was one area which was increasing and was a potential nightmare for public health officials.

The number of hospitals increased throughout the nineteenth century. The General Hospital had been constructed between 1781-2.  A Fever hospital was built in 1828 and a Children’s hospital in 1869. The first hospital dedicated to women was constructed in 1875 on the place where Radio Trent at present has its offices. Another was built on Raleigh Street in 1887, these two were amalgamated in 1930 on Peel Street and remained there until the construction of the University hospital in the 1970s. A Lunatic Asylum was built in Sneinton in 1812; Mapperley and Saxondale mental hospitals were built in 1880 and 1902 respectively and the Isolation hospital and sanatoria opened at Bagthorpe in 1891. This increase in hospital provision suggests that there was a growing awareness of the need to house certain people within institutions for their own or others safety.

Although this outline is directed mainly at the provision in the City of Nottingham, it can be applied to the county as well and references are made hereafter to documents appertaining to the County of Nottingham.

For an overview of public health, generally, the following books are useful: