What were the major constraints on effective health reform?

Governing Towns Before 1835 many industrial towns did not have a town council, and where they existed they were often inefficient and unaccountable for the ways in which they used the local rates. In towns without councils, power was in the hands of the parish vestry was which was elected by property owners. Local communities in 1830s and 40s had little control over buildings, sewers and piping of water. The improvement commissioners, appointed under a Local Improvement Act, undertook reform of the cleaning and lighting of streets. By 1830 about 350 of these acts in around 200 borough. The problem was each commission dealt with a specific area of health, not the whole package, and they remained separate, leading to lack of co-operation. Rapid growth of urban population outstretched the abilities of this unreformed system. Urban reform began with the Municipal Corporations Act of 1835. It provided the elections of town councils every three years by ratepayers, but contained no specific proposals regarding health. It did allow rates to be levied for street lighting, fresh water supply and sewage disposal, but implementing this required a Local Act of parliament. The chaotic nature of local government made effective reform difficult. Added to this was self-interest: water companies and builders were in search of profit, and exploited demands for cheap housing and paid little attention to drainage, ventilation or water supply. Private landlords were reluctant to pay for improvements or accept responsibility for the health of the working classes. Politicians could not ignore urban living conditions, but there was debate over who was responsible for public health. At local level there were groups whose concern was to improve their own conditions the outbreak of cholera was a significant spur for them to act. The central state was reluctant to become involved laissez-faire attitude. The outbreak of epidemics finally forced the government into action. The cholera in 1831 led to the creation of the Central Board of Health and 1200 local boards. The Cholera Act of 1832 allowed local boards to finance anticholera measures from the poor rates. The Public Health Act of 1848 occurred partly as a result of the return of cholera. There was an increasing amount of statistical and other information on the nature of urban conditions, linking poor living conditions with disease. But, this made little impact on local ratepayers to pay for housing improvements and sanitation for the working class. The impact of cholera in 1832 and 1848 brought home, especially to the middle-classes, the fact that disease could affect all classes. The poor were

blamed for the disease, but it was interests of the middle classes to improve conditions and prevent it from recurring. Intervention was also justified economically; reducing levels of disease would create a more efficient workforce and thereby benefit industrialists and entrepreneurs.

Why reform took so long: There were major technical problems associated with a lack of medical understand of disease and the civil engineering required for large sewers and treatment plants. Knowledge on germs was not widespread until the 1870s and 80s, but people did not have to know why the cesspool caused disease, only that there was a connection. Another problem was related to the building of water and sewerage systems, and there was tension between politicians responsible for finding local solutions to problems but lacked the technical expertise, and between the public health experts who disagreed over the nature of public health problems. This lead to disagreement over how reform was best accomplished locally or nationally. Cost. Sewerage was unpopular and resources were scarce. Controlling spending was important for local government. This cut across party lines and could limit local action. Concern about high cost was linked to who should pay. If social amenities were paid for from the rates, then wealth was being redistributed via local taxation the few funding reform for the benefit of all. Property owners, in particular, objected to paying twice: they spent money on their own sanitary needs and were then asked to pay taxes for others. Councils were often concerned with bringing public health under one administrative body, leading to conflict with existing municipal organisations like water commissioners, commissioners for sewers and improvement commissioners. Ratepayers often objected to rising taxes and commercial organisations were resistant to any change affecting profits. Local councils worried that they would lose control if government took responsibility. These constraints were not resolved until the 1860s and 70s, by which time civil engineering problems had been resolved. There was growing recognition that public health needed a national approach to be established.