A sanitary revolution
The struggle for health in 19th-century Hereford – by Jane Wise
“I witnessed such scenes of filth and uncleanliness in the city as I did not before believe could exist in a civilized community.” So wrote Hereford’s first municipal engineer, Timothy Curley, in the 19th century – doubtless in awe of the challenges before him. He was dismayed by the spectacle of cesspools and open sewers, sources of foul ‘miasmas’ believed to cause infections, for in those days noxious stench generally brought with it life-threatening diseases.
The task facing Curley and others was formidable. In a series of annual public health reports submitted to central and local government between 1875 and 1900, Hereford’s Medical Officer of Health wrote about his indefatigable efforts to implement a formidable succession of new laws. Then, as now, statistics were used extensively to identify public health problems and to monitor improvements, with an important emphasis on the early reporting of fatal infectious diseases.
Hereford’s population doubled during the 19th century but it was still a relatively small city, with 12 000 inhabitants in 1851. And its population density was (in 1881) only 7.9 per acre, compared with 106 per acre for a major city like Liverpool. Hereford’s annual mortality from all causes, between 1846 and 1852, was 27 per 1000 – above the threshold of 23 set by the 1848 Public Health Act, making it eligible to seek advice from the General Board of Health.
Following much debate, a movement energised by the eminent local physician Dr Henry Graves Bull led to the Hereford Improvement Act of 1854. This stimulated a wide range of civic improvements, focusing particularly on clean water supplies and better waste drainage. A pumping station to deliver purified water from the river Wye was constructed in 1856 but the project’s vision was slow to materialise: there were deliberations and delays, internal disputes and funding crises, probably typical of all local government in transition (then as now). By the 1880s, every household in the city had access to wholesome water. In contrast, work on a sewage treatment plant began only in 1885, after threat of prosecution under the Rivers Pollution Act of 1876. Progress here was faster: by 1890, an efficient sewer system had been completed to replace inefficient drains suitable only for storm water.
Alongside these structural changes, in 1874 an important decision was taken by Hereford City Council, in response to the Public Health Act of 1872, to appoint a Medical Officer of Health to supervise local sanitary reform. By all accounts, the city was fortunate to secure the dedicated services of Dr Horace Vavasour Sandford, who worked tirelessly in the best Victorian tradition of public service. Towards the end of his tenure, he observed that the overall mortality rate in Hereford had fallen substantially over 50 years – from the mid-century annual average of 27 people per 1000 to 19.5 per 1000 in 1895. By 1900, one-quarter of all deaths in Hereford were due to infections, down from one-third in 1875. These trends attest to the hard work and commitment of those leading the local public health campaign, such as Curley and Sandford.
Reducing deaths from infection was a daily challenge but one that was tackled head-on in the city environs. Deaths from infection (described in reports as “zymotic” diseases, supposedly associated with inhaled miasmas from putrifying matter) fell significantly during the second half of the 19th century, from 4.3 per 1000 people in 1851 to 1.25 per 1000 in 1900. Deaths caused by tuberculosis, for instance, fell from 3.5 per 1000 people in 1851 to 1.2 per 1000 in 1878, mirroring national trends (although at a lower level). Most infectious deaths, other than tuberculosis, were in children under five years of age.
Mortality from non-specific diarrhoeal diseases was a serious problem, especially for young children, whose feeds were often prepared using contaminated water. Diarrhoea accounted for 12 per cent of deaths in children aged under five in 1878, but just 1.3 per cent in people over five. It was second only to lower respiratory infections as a cause of death in children. But deaths from diarrhoea became much less common during the last quarter of the century, falling from 4.4 per cent of all deaths to 1 per cent between 1878 and 1900. The Medical Officer of Health played a prominent role here, in promoting the public understanding of hygiene. Improved health education – along with water quality – meant that parents were more likely to ensure that their children continued to drink, protecting them from death by dehydration during diarrhoeal illness.
However, infant death rates from infection overall showed little change, as there were outbreaks of infections such as whooping cough, scarlet fever and measles – and, sporadically, diphtheria and smallpox.
The fall in Hereford’s overall annual mortality rate during the last quarter of the century – from 22 per 1000 in 1875 to 18.2 per 1000 in 1900 – was relatively modest, though much in line with the rest of England and Wales. Sanitary reforms had done little to reduce the incidence of potentially fatal childhood infections such as scarlet fever, which were difficult to control in overcrowded communities. Quarantine was enforced following the 1889 Public Health Act and this, along with school closures during outbreaks, seems to have interrupted transmission of infection. Following the 1893 Isolation Hospitals Act and soon after a smallpox outbreak, Hereford opened a small prefabricated infectious diseases unit to prevent contagion in the community.
Despite its foundation in the widely held but mistaken idea of miasmas, public health reform in the second half of the 19th century made environments much safer and more pleasant. Edwin Chadwick, pioneer of the vast project in his seminal 1842 Report on the Sanitary Condition of the Labouring Population of Great Britain, was proved right in one key respect: that legislation was essential to promote change. Sanitary reform produced dramatic results, notably in heavily populated industrial towns, by reducing water-borne outbreaks of cholera, typhoid and other diarrhoeal diseases. Hereford’s mortality rates fell in parallel with trends for England and Wales; notably there were no large-scale outbreaks of water-borne diseases. The reduction in mortality from tuberculosis may have been related to improved nutrition and better living conditions, but there is no evidence of this in local documents, and slum clearance was delayed until the end of the 19th century. Health improvements overall seem to be the result of a multi-level effort following numerous practical interventions driven by determined efforts and increasingly reinforced by scientific understanding. Recognition of the microbial basis of infection thus replaced belief in miasmas by the close of the 19th century.
Today, 40 per cent of the world’s population still lack access to sanitation and some 1.5 million children die each year from potentially preventable diarrhoeal diseases. These communities sorely need the resources and formidable dedication that revolutionised sanitation throughout Victorian Britain.
Jane Wise is a retired Clinical Microbiologist from Hereford. The new research in this article features in a long dissertation submitted as part of a BA in Humanities at the University of Birmingham. She welcomes enquiries from those researching the development of public health in less well-known areas of Britain (firstname.lastname@example.org).