Pioneers of Public Health 7 May 1948

Speech by Aneurin Bevan to mark the centenary of the 1848 Public Health Act 7 May 1948

In paying tribute to the Pioneers of Public Health it is not my task to stretch back to the earliest pioneers, to the forgotten Roman engineers whose pipes and paving made Londinium a healthier city than it was to be for another 1,500 years, nor to look at the work of the reformers of the Renaissance, Sir Thomas More and Sir T. Elyot, not even to the edicts of the Lord Mayor and the city council for maintaining the health of the city in times of plague and pestilence.

Our gaze to-day is fixed on the first Public Health Act of 1848, on the men who formed the opinion which made it possible, and men who carried it through and the men whose administration of its provisions laid the foundation of the century-long struggle to provide a comprehensive service for the health of the people.

I do not even need to remind you of the appalling task which the reformers of 1848 faced.

Their labours were two-fold. One lay in the immensity of the practical problems themselves. The unpaved streets, the ordure-ridden water supply, the non-existent sewers, the hovels which served the people as homes, paralleled by the writers of the day only to the negro huts of the West Indies. These conditions led to an infantile mortality of 200 per 1,000; to a maternal mortality of 6 per 1,000. They led from time to time to the cholera epidemics of Asiatic violence which claimed their deaths not in hundreds as in the outbreak of poliomyelitis in 1947, not even in thousands as the influenza epidemics in living memory, but in tens and scores of thousands mounting, as in 1832, to national disasters only exceeded by the Black Plague of the Middle Ages and the Great Plague of 1666.

The second problem lay in the bitter opposition of many vested interests to reform. The Parish Officers,” wrote Chadwick, “frequently oppose improved modes of paving and efficient cleansing, as they generally opposed the new police on the ground that it diminished the means of sustenance of decrepit old men as watchmen, for the avowed reason that it is expedient to keep up the means of employing indigent persons as street-sweepers and sweepers of crossings in removing it.”

Property and bumbledom fought together to deny the child the right to live; ignorance and indifference presented his father with a choice between quick death by foul water and slow death by foul spirits.

To blatant opposition add bored indifference.

No one thought public health a good investment. “The Great Plague of London will be revived and naturalised,” said The Times, for the sake of saving half as many pounds as are found readily forthcoming for a German mine or a French railway.”

Even the leading Radicals of the day ignored the cause of public health. It is recorded that John Bright in twenty years of political life only spoke once on the subject and then to oppose a measure of smoke abatement.

The task of rallying public opinion and getting anything done was, therefore, enormous. “Stench and smoke,” wrote The Times, “could not have preserved that which corn and sugar lost if they had been attacked with half the same determination.” It was from the pioneers – Edwin Chadwick, John Simon and William Farr – that the determination came.

JL. and Barbara Hammond in their Life of Lord Shaftesbury describe Chadwick as a man “chiefly known for his success in making enemies.” Chadwick, the Poor Law Commissioner, was one of the most heartily hated men in our history. He worked unhesitatingly to his object, listening neither to opposition nor advice. The newspapers detested him for his fierce unyielding spirit. The Government disliked him just as much. His fearless energy meant unanswerable reports which it was embarrassing to shelve. It was never a part of Chadwick’s work to cure disease in the medical sense of the word. He was for prevention. He stated that men could live longer if they took the trouble to clear away the evils which shortened human life. (His career was a good example of this as he died at the age of 90, and Simon lived to be 88, Farr to be 76.)

His seminal work was the great report of his Royal Commission on the Sanitary Condition of the Labouring Population of Great Britain published in 1842.

For six years the cause of public health fought an apparently losing battle with the Corn Laws for public attention. Then at last in 1848, the first Public Health Act went through. The General Board of Health was finally set up but only lasted six years.

When, in 1854, it came to an end, one of the main reasons for this was personal antipathy to Chadwick. In Parliament, they saw him as a man fighting against private property and private interests. He was a danger to their comfort and prosperity. He was deposed.

Unfortunately, the disfavour which Chadwick had aroused attached itself to the whole movement of public health. In fact, the post of chief medical officer, first filled in 1855 by Sir John Simon, would have been abolished had not the Prince Consort intervened.

John Simon had been London’s first medical officer of health since 1848. The conception of a medical officer in an administrative post was then quite new. It had not been realised that the appalling conditions brought to light mainly through Chadwick could be put right in any way by the medical profession.

John Simon’s annual reports for the years 1848-55, when he held the office of medical officer of health for the city, have become classics in the history of English sanitation.

In these reports, Simon exposed all the degradation under which the masses were obliged to live. He showed the risks that arose from bad drainage in the spread of cholera and other diseases. He got in touch with the Registrar-General and made an arrangement with him by which punctually every Monday morning, the nine city registrars provided the Registrar-General with returns of deaths registered during the previous week and the causes of such deaths, and these papers were placed at Simon’s disposal. Gradually through his influence a weekly inspection in all the poorer parts of the city took place.

Yet when in 1855 Simon accepted the post of medical officer in the new Board of Health, he said: “None but the vaguest notions had been formed as to the work which the officer ought to do.” The general view was that a medical officer’s functions should be confined to fighting the dangers of the diseases when they occurred. This was not Simon’s idea. But he was up against great difficulties because, as he wrote: The legislature recognises no medical authority. Occasionally this fact stands out in painful conspicuousness and brings most injurious results.”

His report on the Sanitary State of the People of England presented an unanswerable case for the establishment of a medical department of Government; and in 1859, after the passing of the Public Health Act of 1858, when the functions of the Board of Health were absorbed by the Privy Council, Simon was permanently appointed medical officer to that council.

In 1858 he published a Paper on the Constitution of the Medical Profession, and this was followed by the passing of the Medical Act by which the General Medical Council was established with a system of registration to enable persons requiring medical aid to distinguish qualified or unqualified practitioners.” Before this Act, Simon said: “The legal titles of medical practitioners were as various as the names of snuffs and sauces.”

It was at Simon’s instigation that the Royal Sanitary Commission was set up in 1868 to inquire into the administration of sanitary laws and the formation of local sanitary areas. In 1871, as an outcome of this, the Local Government Board was set up. Simon accepted the post of chief medical officer of the new Board. But he found that the medical department was placed in a subordinate position, and in 1876 he retired. Had his statesmanlike conception of a Ministry of Health prevailed over local board methods, the progress of sanitary science would have been unquestionably more rapid.

So much for the work of Simon and Chadwick. But the administrator of today cannot write his bluebooks nor the medical officer of health his reports unless both can draw upon the bullion of statistically analysed experience.

Soon after civil registration of births, etc., began in 1837, there was appointed to the post of Compiler of Abstracts in the newly created General Register Office a “gentleman of the medical profession,” a young general practitioner whose medical qualification was the Society of Apothecaries. William Farr, son of a farm labourer, first became known through his free-lance journalism in The Lancet and elsewhere on matters medical and economic. A notable article on Vital Statistics in 1837 put him at once in the front rank, and for the rest of his life this self-taught mathematician gave himself without stint to the development of his chosen science, medical statistics.

Farr was a true pioneer; he was original and courageous; in his field he was a genius. His Annual Letters to the Registrar-General on the causes of death in England, and the reports to which they are appended, covering a period of forty years, provide a statistical record of disease of the time such as is possessed by no other country in the world.

The answers to the questions in the 1851 Census of Great Britain provided a wealth of information which he used in his enquiry into the mortality of the English working man; the tool-grinder inhaling sharp particles of metal dust, the clerk poring over his ledgers in a stuffy office, the miner hewing at the coal-face, all these and many more became the objects of study and concern. And he was not content only with study. He was one of the first – far ahead of his time – to point out the advantages of a government system of health insurance.

Farr was no collector of facts for facts’ sake; it was not ink he had in his veins but good red blood. Throughout his life his aim was the use of medical statistics to reveal the causes of disease, to compare the value of various forms of treatment and to compel social and sanitary reforms. To him “prevention is better than cure” was not merely a truism – to him it was a constant challenge. Medical men, the guardians of public health,” he wrote, “never have their attention called to the prevention of sickness; it forms no part of their education. To promote health is apparently contrary to their interests.” In his unceasing efforts to change this attitude Farr was a great force in his day and he has been a source of inspiration to generations of our health workers right down to our own times.

I have spoken so far of Chadwick, Simon and Farr. Many others might be mentioned, particularly Delane, the great editor of The Times, and Dickens. But I should like to save my concluding words for a fourth figure – Lord Morpeth.

It is not enough for the social reformers to smell out abuses and bring them to light. It is not enough even for the administrator to have the knowledge and the ability to deal with the abuses once he is given power. In our method of government, no social reform can come to fruition and no new system of administration can be inaugurated until public opinion accepts, or is induced to tolerate, the reform. It is here that the politician becomes essential to give form to the idea; to modify it, if necessary, in such a way as to make it acceptable to the many interests affected; to keep intact the kernel of the matter and to place the new principle upon the statute book.

Morpeth is not remembered as a man of great ideas or sweeping principles but to him and not to Chadwick goes the final credit of steering the first Public Health Act through Parliament after one initial failure. His popularity and his gift for compromise succeeded where the unyielding Chadwick would have failed. That, as I see it, is the essential function of the despised politician. He is the accoucheur of the public conscience. Not in himself the pioneer but yet in the final stages the catalyst by which the pioneers’ reforms are transformed into practical realities. And so tonight, we remember Lord Morpeth as one who not only got the Act through, but who kept its principles alive during the first six vital and challenging years and, in so doing, paved the way to the development of the most effective Public Health Service in the world.

I give you the toast of Edwin Chadwick, John Simon, William Farr, coupled with the name of Lord Morpeth.

Source: The Medical Officer, 15 May 1948, pp. 207