John Leech's cartoon in Punch, 23 (25 September 1852): 139, showing the association of cholera with squalor. [Click on all images to enlarge them.]

When Florence Nightingale came home from the Crimean War in 1856 the slums in England's cities were probably worse than any before or since, anywhere. Half of city children died of epidemic disease before their fifth birthday. Average life expectancy was 40 years. The industrial revolution had brought vast numbers of workers to the towns, and they were surrounded by one inescapable feature: the ordure seen in the cartoon above, created not only by humans but also by horses — the only transport vehicles available. Germ theory would not even be a theory for another decade.

Most of us have heard of Joseph Bazalgette and his metropolitan sewer system, started after the 1858 "great stink". This stopped sewage from clogging the Thames in central London, the smell of which had even forced Parliament to move out of town. It didn't do much for the capital's housing which still used streets and open ditches for dumping effluent, which if they were lucky connected to one of Bazalgette's sewers. Only a few houses had their own cess-pools.

[Left: Sir Edwin Chadwick, from the frontispiece of Vol. 1 of The Health of Nations. Right: Sir John Simon, from a lithograph by C. Baugniet, 1848. Courtesy of the Wellcome Library, London.]

The government had appointed two national public health 'Czars' — Edwin Chadwick and then John Simon. Chadwick was sacked in 1854 because he was too dictatorial and unscientific, and his replacement John Simon was the opposite, concentrating on researching cures or inoculations for the most lethal epidemic diseases. Neither of them made any progress in persuading towns to connect houses to main drainage. Sanitary legislation and the power to enforce it were fragmented and overlapping and the few people allowed to vote were mostly property owners who were not convinced that sanitation would save lives. There was therefore not much motivation in Parliament to strengthen the sanitary legislation.

In 1858 Florence Nightingale fell out with Simon when he claimed that only medical research could prevent death from epidemic disease. As part of her argument she produced her famous diagram (above) to show that deaths in the army had been reduced by non-medical means.

She claimed that this proved that millions of lives could be saved by putting the lessons of the Crimean War to good use:

Let us now ask, how it was that our noble army all but perished in the East? And we shall at the same time learn how it has happened that so many hundreds of millions of the human race have by pestilence perished before their time.

Their argument spilled over into a magazine called The Builder, for which Nightingale wrote anonymous editorials proposing what seemed like a utopian solution: slum clearance by Act of Parliament.

Not surprisingly the landlords could see this as a get-rich-quick scheme for builders. True, poor people were dying more than rich from epidemic disease, but they were dissolute and played games on Sundays instead of spending the day in church. Intensive prayer was considered a protection against disease in those days.

But despite these prejudices slum clearance did happen. Before looking at Nightingale's involvement, let's look at a summary timeline of it (above). In 1867 the second reform act doubled the number of people allowed to vote, and the power of the landlords was reduced in Parliament because working men voted for middle class candidates. Gladstone's new liberal government set up a Sanitary Commission which in 1869 recommended consolidation of all the existing legislation into a single Public Health Bill. This Bill proposed that all NEW dwellings should be connected to, and be made to pay for, main drainage where available. Two years later a Local Government Board Act gave local authorities full responsibilities for implementing these regulations, using higher local taxes and utility charges if the citizens would pay. Then Parliament decided to debate a much stronger Public Health Bill, which not only compelled NEW houses but also EXISTING ones to be connected to main drainage. This retrospective clause, if it could be enforced, would make slum landlords rebuild their properties. The legislation went through several changes but was enacted to become the Public Health Act of 1874.

Why did Parliament go along with this huge escalation in the legislation proposed by the sanitary commission? It occurs to me that for some opponents of reform the devolution of responsibility for public health to local authorities may have appeared to be kicking the whole sanitation issue into the long grass. Most local authorities had successfully resisted compulsory sanitation for a quarter of a century. Surely they were the best defence against what its opponents saw as a soak-the-rich scam?

[Two views of Joseph Chamberlain. Click on the picures for more information about the images and Chamberlain himself.]

Then Joseph Chamberlain, Mayor of Birmingham, helped to push through the Artisans' Dwellings Act of 1875 which made it legal for towns to condemn buildings on health grounds under the Public Health Act, and then compulsorily purchase them. This enabled wholesale slum clearance to begin in Birmingham. Chamberlain was a Unitarian like Nightingale, and campaigned on the slogan "high taxes for a healthy city." The results for life expectancy could not be ignored and the rest of the country followed so that by the 1930s much of the inner cities had been rebuilt.

What did this have to do with Nightingale?

First she won over the retired former sanitary Czar Edwin Chadwick, who had been convinced that his successor John Simon was a true believer in sanitary improvements. Nightingale's arguments made Chadwick change his mind, and they persuaded the new President of the Local Government Board to dispense with Simon's services and devolve his powers to local government bureaucrats. The President was cabinet member James Stansfeld who was a believer in women's rights and a Unitarian like Nightingale and Joe Chamberlain. Nightingale rarely left her home, and his was one of the few requests to visit here there that she granted. All this is known because the standard 1963 biography of John Simon describes Nightingale as causing the downfall of the great medical hero John Simon by using her "subtle attentions" on the Cabinet Minister, presumably batting her eyelashes at him. But there were good reasons for transferring Simon's powers to local councils, notably those of Nightingale's friend John Stuart Mill, the leading political theorist of the day, who had presented the case for more devolution of power. In 2012 Lord Heseltine put these arguments forcibly in his report to the present cabinet, and in 2013 public health responsibilities were transferred from the NHS to local councils.

Nightingale's next recorded intervention was to write to her helpful brother in law the MP Sir Harry Verney telling him to ask Stansfeld to introduce a new clause in the Public Health Bill that required mains drainage to be fitted to EXISTING buildings; this was the huge expansion of the Sanitary Commission's recommendations that I've already described, and now we know that she initiated it. A few months later she announced that her request had been granted and widely praised. This is new information from a study of her recently published and still unpublished letters and from a detailed analysis of the various Public Health Bills which are now accessible on the computers of the British Library. The evidence that she influenced this legislation is recorded in detail for the first time in the new 2013 edition of Florence Nightingale, Avenging Angel.

When the Artisans' Dwellings Act was used to compulsory purchase condemned properties, it was Nightingale's clause in the Public Health Act that was used to condemn houses that landlords could not afford to connect to mains drainage.

And what was the result? This data from the Office of National Statistics shows that life expectancy remained flat until the very year of the passing of responsibility for Public Health to local government, and then it took off like a rocket right up until the mid-thirties, before which there were no inoculations or treatments against the killer epidemic diseases. Simon Szreter, in a classic 1988 paper, attributed most of the increase in life expectancy to mains drainage and slum clearance – the developments which Nightingale and other ‘sanitarians’ championed.

It would be a mistake to give Nightingale too much credit for one of most profound social reforms in history. She is a messenger, whose incomparable archive sheds light on an organic process which incorporated many different cultural trends. Her correspondence — preserved in the British Library — naturally places her at the centre of events but she also documented her mistakes showing that her intention was not to convince posterity of her greatness. She was an eyewitness historian, and her sometimes harrowing narrative is spoken with a single voice; this gives it unique human interest as well as showing how the meaning of words such as 'sanitary' and 'prevention' evolved as knowledge was created. The part of her archive that deals with public health has not been much exploited, in part because she was portrayed as a handicapped eccentric by the historians of a technocratic medical approach which is now badly dated. The Oxford Dictionary of National Biography describes her only as a "Reformer of Army medical services and nursing organization." Truly, Nightingale's afterlife in every sense of the word has been forgotten.

Victorian Web Public Health

Last modified 15 January 2014