History of public health in the United Kingdom

History of public health in the United Kingdom covers public health in the United Kingdom since about 1700.

18th century

With the onset of the Industrial Revolution, living standards amongst the working population began to worsen, with cramped and unsanitary urban conditions. A severe long-term shortage of cheap housing led to the rapid growth of slums, the death rate began to rise alarmingly, almost doubling in Birmingham and Liverpool. Thomas Malthus warned of the dangers of overpopulation in 1798. His ideas, as well as those of Jeremy Bentham, became very influential in government circles in the early years of the 19th century. The latter part of the century brought the establishment of the basic pattern of improvements in public health over the next two centuries: a social evil was identified, private philanthropists brought attention to it, and changing public opinion led to government action.

The practice of medicine grew rapidly in the 18th century, as seen in the rapid growth in voluntary hospitals in England. The acceptance of vaccination quickly followed the pioneering work of Edward Jenner in treating smallpox. James Lind's discovery of the causes of scurvy amongst sailors and its mitigation via the introduction of fruit on lengthy voyages was published in 1754 and led to the adoption of this idea by the Royal Navy.

Efforts were also made to promulgate health matters to the broader public; in 1752 the British physician Sir John Pringle published Observations on the Diseases of the Army in Camp and Garrison, in which he advocated for the importance of adequate ventilation in the barracks and the provision of latrines for the soldiers.

Infant mortality

Further information: Infant mortality

Infant mortality in the United Kingdom underwent a dramatic decline from 1700 to 2025. Good national statistics begin in 1837; before then historians use local studies.

In the early 18th century, infant mortality rates were extremely high:

• 1700-1749: The infant mortality rate in London was 342 deaths per 1,000 live births.
• 1700-1740: Nationally, infant mortality reached about 20% of all live-born infants.

19th century

Infant mortality

Historians have developed estimates before 1837 for localities. Finally in that year the introduction of civil registration of births and deaths enabled the tracking of infant mortality by date, location and cause.

The 19th century saw substantial improvements in infant survival:

• 1800-1824: Infant mortality for Quakers in London fell to 151 deaths per 1,000 live births.
• 1837-1844: The national infant mortality rate was around 148 deaths per 1,000 live births.
• 1839-1844: There was a steady increase in the proportion of neonatal to infant deaths, possibly indicating improved registration practices.
• 1870s: The Registrar General's office finally began regularly reporting infant mortality rates.

Legislation

A series of laws passed by Parliament and affecting England and Wales marked a shift towards proactive public health measures. They concerned sanitation, disease prevention, and living conditions in urban areas, as well as national and local rules of oversight. "Sanitary reform," was a common refrain of Conservative politicians in their landslide victory in 1874. Liberal politicians tended to ridicule it, but Disraeli had a broader vision of 'sanitary' stating: "that phrase so little understood [included] most of the civilizing influences of humanity." What the voters really wanted, in Disraeli's opinion, was healthier conditions at home and at work, and across their towns.

• Public Health Act 1848 established the General Board of Health and allowed local authorities to set up local boards of health. It empowered them to appoint a Medical Officer of Health (MOH) to take charge of local issues, especially sanitation. The law marked the beginning of active state involvement in public health matters.
• Vaccination Act 1853 made vaccination against smallpox compulsory for all infants under three months old, while the Vaccination Act of 1867 extended compulsory vaccination to all children under the age of 14.
• Public Health Act 1875: Consolidated the previous public health legislation.

Child labour

Main article: Child labour

Evangelical religious forces reflected Victorian morality by taking the lead in identifying the evils of child labour, and legislating against them. Their anger at the contradiction between the conditions on the ground for children of the poor and the middle-class notion of childhood as a time of innocence led to the first campaigns for the imposition of legal protection for children. Reformers attacked child labor from the 1830s onward. The campaign that led to the Factory Acts was spearheaded by rich philanthropists of the era, especially Anthony Ashley-Cooper, 7th Earl of Shaftesbury, who introduced bills in Parliament to mitigate the exploitation of children at the workplace. In 1833, he introduced the Ten Hours Act 1833, which provided that children working in the cotton and woollen mills must be aged nine or above; no person under the age of eighteen was to work more than ten hours a day or eight hours on a Saturday; and no one under twenty-five was to work nights. The Factories Act 1844 said children 9–13 years could work for at most 9 hours a day with a lunch break. Additional legal interventions throughout the century increased the level of childhood protection, despite the resistance from the laissez-faire attitudes against government interference by factory owners. Parliament respected laissez-faire in the case of adult men, and there was minimal interference in the Victorian era.

Unemployed street children suffered too, as novelist Charles Dickens revealed to a large middle class audience the horrors of London street life.

Urban crisis

In the first four decades of the 19th century alone, London's population doubled and even greater growth rates were recorded in the new industrial towns, such as Leeds and Manchester. From 1801 to 1851, the proportion of Englanders living in cities over 20,000 more than doubled from 17% to 38%.

This rapid urbanization exacerbated the spread of disease in the large conurbations that built up around the workhouses and factories. These settlements were cramped and primitive with no organized sanitation. Disease was inevitable and its incubation in these areas was encouraged by the poor lifestyle of the inhabitants. Not enough new housing was built, and people squeezed into small, dirty apartments, and drank dirty water. One result was high rates of tuberculosis, which became leading cause of death.

Liverpool.

Further information: History of Liverpool and History of housing in Liverpool

19th Century Court Housing Liverpool

Very rapid population growth from rural England, and especially from Ireland firing the famine years 1847-1852, led to severe overcrowding and very poor sanitation. The city faced several cholera outbreaks. Housing in Liverpool was dark, poorly ventilated, damp and overcrowded, with no provision for human or horse waste. Liverpool had not only the worst type of cellar dwelling, but also a larger proportion of its inhabitants living in cellars than any other city in the UK. The people living in court housing made use of privies and it was common practice to dispose of the contents by spreading them over the courts. As a result., many of the cellar dwellers were routinely knee deep in sewage.

These hardships galvanized public health reforms and philanthropic efforts. Reformers led by William Rathbone worked tirelessly to improve healthcare and education. In 1822 a commission of sewers was established and over the next 20 years built 30 miles of sewers, but these were for surface water drainage only, houses did not connect to their drains.

William Henry Duncan (1805–1863) was Medical Officer of Health (1847-1863). He was the first Medical Officer anywhere in the UK. He worked energetically to upgrade the city's sanitation, especially in the face of overwhelming migration from Ireland during the great famine of 1845 to 1852.

Chadwick and sanitation solutions

Edwin Chadwick (1800–1890) identified bad sanitation as a major threat to public health in crowded cities. He promoted major construction programs in urban sewers and water supplies . He pioneered the use of systematic surveys to identify all phases of a complex social problem, and pioneered the use of systematic long-term inspection programmes to make sure the reforms operated as planned. Similar sanitation programs were developed by most major cities in Europe and North America.

Following a serious outbreak of typhus in 1838, Chadwick convinced the Poor Law Board that an enquiry was urgently required. Chadwick sent questionnaires to every Poor Law Union, and talked to surveyors, builders, prison governors, police officers and factory inspectors to obtain additional data about the lives of the poor. He edited the information himself, and prepared it for publication in 1842 at his own expense. It became a best-seller. His Report on The Sanitary Condition of the Labouring Population of Great Britain caught the public imagination and was soon incorporated into English law.

Chadwick argued eight main points, emphasizing the absolute necessity of better water supplies and of a drainage system to remove waste, as ways to lower the death rate. He saw that every house needed a permanent water supply, rather than the intermittent supplies from standpipes that were often provided. He proposed each house would have a constant water supply, and privies would ensure that soil was discharged into egg-shaped sewers, to be carried away and spread on the land as manure, preventing rivers from becoming polluted. Chadwick understood that both water supply and drainage were important, since there had to be enough sewers to carry the waste away. Chadwick later helped to ensure that the Waterworks Clauses Act 1847 limited profits, and required them to provide a constant supply of wholesome water for houses, and a supply for cleansing sewers and watering streets.

Dirt causes miasma that cause cholera

Main articles: 1854 Broad Street cholera outbreak, History of cholera, and 1846–1860 cholera pandemic

Cholera was the main concern. Officials knew that the disease had hit India hard in 1818 and was steadily progressing westward. There was no known cure, and about a third of he patients died. Doctors assumed it was caused by breathing "miasma"—mysterious air particles produced by rotting waste. Sanitation using sewers to move out all the waste was seen as the solution. Early on no one realized it was caused by a germ that passed through the water supply from person to person. The first case appeared in England in 1833. A quarantine was imposed on shipping in the seaports, much to the dismay of merchants and sailors. By 1832 there were 52,000 deaths, including 10,000 in Edinburgh and Glasgow alone. It focused on cities but not on social status; the victims represented every class of society. Local governments ordered whitewashing houses with chloride of lime or burning barrels of tar in the streets in order to dissipate the supposed miasma causing. the disease. The epidemics petered out, then reappeared every few years. Major cholera epidemics struck Britain in 1848–1849 with 70,000 deaths; 1853–1854 with 30,000 deaths; and 1866 with 18,000 deaths.

John Snow discovers the cause: drinking bad water

A replica of the famous London pump in SoHo--after John Snow closed it down there were no more new cases of cholera.

Chadwick was working on removing the waste and dirt as the solution but exactly what was causing the disease was not known until the work of John Snow in 1854. That year there was a severe outbreak of cholera in the upper class Soho district of western London. It was part of the 1846–1860 cholera pandemic happening worldwide. It prompted Snow to map the homes of people who got sick in Soho and show they had all been drinking water that came from one neighborhood pump in Broad Street. Everyone breathed the same air but only some people used that particular pump and only its users got sick. He then deduced germ-contaminated water was the source of all the cholera cases. Snow's maps were a powerful confirmation of the Germ theory of disease, and explained how the germs spread. Doctors could now discard the old airborne "Miasma theory".

Snow's great discovery decisively influenced public health policies and quickly led to the construction of improved sanitation facilities. The term "focus of infection" started to be used to describe sites, such as one particular water pump in Broad Street that spread the cholera germs.

London sewers

Further information: Water supply and sanitation in the United Kingdom § History

Sir Joseph Bazalgette was the Chief Engineer of London's Metropolitan Board of Works, 1856–1889. His major achievement was the creation of a sewerage system for central London, in response to the Great Stink of 1858. His solution in 1864–1875 was to construct a network of 82 miles (132 km) of enclosed underground brick main sewers to intercept sewage outflows, and 1,100 miles (1,800 km) of street sewers, to divert the raw sewage which flowed freely through the streets and thoroughfares of London to the river. His system proved instrumental in relieving the city of cholera epidemics, while beginning to clean the River Thames.

Impact of sanitation

Historians have been using quantitative models to estimate the impact of investment in sanitation and pure water supplies on health indicators. One study of 16 cities outside London indicates that for 1845–1884, the first round of sanitation investments were associated with sharp declines in infant and child mortality, and a 13% decline in overall mortality. However subsequent rounds of spending in the same cities gave a much smaller decline.

Housing and public health in the Victorian era

Further information: Demographics of the Victorian era

19th-century Britain saw a huge population increase accompanied by rapid urbanisation stimulated by the Industrial Revolution. In the 1901 census, more than three out of every four people were classified as living in an urban area, compared to one in five a century earlier. Historian Richard A. Soloway wrote that "Great Britain had become the most urbanized country in the West." The rapid growth in the urban population included the new industrial and manufacturing cities, as well as service centres such as Edinburgh and London. Private renting from housing landlords was the dominant tenure. P. Kemp says this was usually of advantage to tenants. Overcrowding was a major problem with seven or eight people frequently sleeping in a single room. Until at least the 1880s, sanitation was inadequate in areas such as water supply and disposal of sewage. This all had a negative effect on health, especially that of the impoverished young. For instance, of the babies born in Liverpool in 1851, only 45 per cent survived to age 20. Conditions were particularly bad in London, where the population rose sharply and poorly maintained, overcrowded dwellings became slum housing. Kellow Chesney wrote of the situation:

Hideous slums, some of them acres wide, some no more than crannies of obscure misery, make up a substantial part of the metropolis... In big, once handsome houses, thirty or more people of all ages may inhabit a single room

Hunger and poor diet was a common aspect of life across the UK in the Victorian period, especially in the 1840s, but the mass starvation seen in the Great Famine in Ireland was unique. Levels of poverty fell significantly during the 19th century from as much as two thirds of the population in 1800 to less than a third by 1901. However, 1890s studies suggested that almost 10% of the urban population lived in a state of desperation lacking the food necessary to maintain basic physical functions. Attitudes towards the poor were often unsympathetic and they were frequently blamed for their situation. In that spirit, the Poor Law Amendment Act 1834 had been deliberately designed to punish them and would remain the basis for welfare provision into the 20th century. While many people were prone to vices, not least alcoholism, historian Bernard A. Cook argues that the main reason for 19th century poverty was that typical wages for much of the population were simply too low. Barely enough to provide a subsistence living in good times, let alone save up for bad.

Improvements were made over time to housing along with the management of sewage and water eventually giving the UK the most advanced system of public health protection anywhere in the world. The quality and safety of household lighting improved over the period with oil lamps becoming the norm in the early 1860s, gas lighting in the 1890s and electric lights beginning to appear in the homes of the richest by the end of the period. Medicine advanced rapidly during the 19th century and germ theory was developed for the first time. Doctors became more specialised and the number of hospitals grew. The overall number of deaths fell by about 20%. The life expectancy of women increased from around 42 to 55 and 40 to 56 for men. In spite of this, the mortality rate fell only marginally, from 20.8 per thousand in 1850 to 18.2 by the end of the century. Urbanisation aided the spread of diseases and squalid living conditions in many places exacerbated the problem. The population of England, Scotland and Wales grew rapidly during the 19th century. Various factors are considered contributary to this, including a rising fertility rate (though it was falling by the end of the period), the lack of a catastrophic pandemic or famine in the island of Great Britain during the 19th century for the first time in history, improved nutrition, and a lower overall mortality rate. Ireland's population shrank significantly, mostly due to emigration and the Great Famine.

• 
  Slum area in Glasgow (1871)
• 
  Buildings originally built as Llanfyllin workhouse, a state-funded home for the destitute which operated from 1838 to 1930.
• 
  Photograph of a mother and baby by Alfred Capel-Cure (c. 1850s or 60s)

1890s-1918

Further information: Edwardian era

By the late-1880s, the Industrial Revolution had created new technologies and new industrial cities that changed the way people lived. The growth of industry shifts in manufacturing factories, special-purpose machinery and technological innovations, which led to increased productivity. Gender roles shifted as women made use of the new technology to upgrade their lifestyle and their career opportunities.

Mortality declined steadily in urban England and Wales 1870–1917. Robert Millward and Frances N. Bell looked statistically at those factors in the physical environment (especially population density and overcrowding) that raised death rates directly, as well as indirect factors such as price and income movements that affected expenditures on sewers, water supplies, food, and medical staff. The statistical data show that increases in the incomes of households and increases in town tax revenues helped cause the decline of mortality.

The new money permitted higher spending on food, and also on a wide range of health-enhancing goods and services such as medical care. The major improvement in the physical environment was the quality of the housing stock, which rose faster than the population; its quality was increasingly regulated by central and local government. Infant mortality fell faster in England and Wales than in Scotland. Clive Lee argues that one factor was the continued overcrowding in Scotland's housing. During the First World War, infant mortality fell sharply across the country. J. M. Winter attributes this to the full employment and higher wages paid to war workers. In 1901-1910, infant mortality became a focus of public health concerns, with more detailed reporting and analysis. The Midwives Act of 1902 regulated midwifery, in order to ensure safer childbirth practices.

Since 1919

Nursing

The number of nurses rose rapidly in the 20th century. According to the 1901 United Kingdom census, there were 64,000 women nurses, along with 5,000 men. Of the total, 12,500 were trained or registered. By 1921 there were 110,000 women and 12,000 men in nursing, 25,000 were trained or registered. By 1939 there were 160,000 nurses in all, of whom 60,000 were trained and registered.

Infant mortality

The 20th century witnessed further declines in infant mortality:

• 1993: The infant mortality rate in England was 6.3 deaths per 1,000 live births.
• The current infant mortality rate for U.K. in 2025 is 3.2 deaths per 1000 live births, and the rate is declining at about 2% a year.

Factors in decline

Multiple factors contributed to the overall decline in infant mortality: Historians emphasize that progress was not always linear. For example, there were periods of stagnation and even slight increases in infant mortality rates, particularly in urban areas during rapid industrialization

• * Advancements in citywide sanitation and public health measures. Improvements in infant care, particularly in antenatal and neonatal care.
• Changes in breastfeeding practices and infant feeding methods.
• Reduction in specific diseases, especially smallpox and yellow fever after 1750.

Role of philanthropy

In the 1920s government public health funding concentrated on upgrading public infrastructure and helping wounded war veterans. Meanwhile, a number of private philanthropies took roles in public health. They were not funded by the government and ranged from major international operations such as the Rockefeller Foundation, to membership groups like the Order of Saint John, to small local charities. Rockefeller sponsored training programs for visiting nurses. The others focused on individual needs at the neighborhood level, such as helping poor families with childbirth and child welfare and dealing with tuberculosis, or providing ambulance services to hospitals for victims of traffic accidents.

See also

• Health in the United Kingdom
  • Health in England
  • Health in Wales
  • Health in Scotland
  • Health in Northern Ireland
• UK Health Security Agency
• Healthcare in the United Kingdom
• History of the National Health Service, since 1948
• History of nursing in the United Kingdom
• Water supply and sanitation in the United Kingdom
• Leaders
  • Edward Jenner 1749-1823 , first vaccine
  • Edwin Chadwick, 1800–1890
  • William Henry Duncan (1805–1863), activist in Liverpool; the first Medical Officer of Health
  • John Snow, 1813–1858
  • John Simon (pathologist), 1816–1904
  • Joseph Bazalgette, 1819–1891, built the sewerage system for London
  • Florence Nightingale, 1820–1910, founded modern nursing
  • Arthur Newsholme 1857–1943, local projects
  • Brian Abel-Smith,1926–1996, developed the economics of public health

Further reading

• Abel-Smith, B. The Hospitals 1800–1948: A Study in Social Administration in England and Wales (1964) online
• Abel-Smith, B. A History of the Nursing Profession (1960) online
• Allan, P. and Jolley, M. Nursing, Midwifery and Health Visiting since 1900 (1982)
• Bell, Frances, and Robert Millward. "Public health expenditures and mortality in England and Wales, 1870–1914." Continuity and Change 13.2 (1998): 221-249.
• Berridge, Virginia. " Health and medicine" in The Cambridge Social History of Britain. 1750–1950: Volume 3 Social Agencies and Institutions, edited by F.M.L. Thomson, (Cambridge University Press. 1990) pp. 171–242.
• Berridge, Virginia. Health and Society in Britain since 1939 (1999)
• Borsay, Anne, and Peter Shapely (eds). Medicine, Charity and Mutual Aid: The Consumption of Health and Welfare in Britain, c.1550–1950 (2007)
• Brand. Jeanne L. Doctors and the state: the British medical profession and government action in public health, 1870-1912 (Johns Hopkins UP, 1965).
• Briggs, Asa. Cholera and Society in the Nineteenth Century Past & Present, No. 19 (1961), pp. 76–96 online
• Carpenter, Mary Wilson. Health, Medicine, and Society in Victorian England (Bloomsbury, 2009)
• Davenport, Romola J. "Urbanization and mortality in Britain, c. 1800–50." Economic History Review 73.2 (2020): 455-485. online
• Donaldson, L. "The UK public health system: Change and constancy" Public Health (2008) 122, 1032e1034 doi:10.1016/j.puhe.2008.05.001
• Frazer. W.M. A history of English public health, 1834–1939 (1950). online copy of the book; see also review of this book
• Hamlin, Christopher. Public health and social justice in the age of Chadwick: Britain, 1800–1854 (1998) online
• Hamlin, Christopher. "Muddling in bumbledom: On the enormity of large sanitary improvements in four British towns, 1855–1885." Victorian Studies 32.1 (1988): 55-83. online
• Hardy, Anne. Health and medicine in Britain since 1860 (2001)
• Harris, James Jeffrey. "Body Politics: A History of Public Health and Politics in Britain, 1885–1922" (PhD dissertation, The Ohio State University, 2017) online.
• Heggie, Vanessa. “Women Doctors and Lady Nurses: Class, Education, and the Professional Victorian Woman.” Bulletin of the History of Medicine 39#2 (2015), pp. 267–92. online
• Longmate, Norman. King Cholera: The biography of a disease (1966), focus on UK epidemics
• McLean, David. Public Health and Politics in the Age of Reform: Cholera, the State and the Royal Navy in Victorian Britain (2006).
• Mosley, Stephen. The Chimney of the World: A History of Smoke Pollution in Victorian and Edwardian Manchester (2001).
• Niemi, Marjaana. Public Health and Municipal Policy Making: Britain and Sweden, 1900–1940 (Ashgate, 2007)
• Porter, Roy. The Greatest Benefit to Mankind: A Medical History of Humanity (W.W. Norton, 1997) pp. 397–427.
• Porter, Roy, and Dorothy Porter. In sickness and in health: the British experience,1650–1850 (1988) online review of this book how educated patients talked about personal health issues.
• Porter, Dorothy. Health, Civilization and the State: A History of Public Health from Ancient to Modern Times (1998), good coverage of the British record in ch. 8-9.
• Rosen, George A History of Public Health (1958). online, a standard scholarly history.
• Sheppard, Francis. London 1808-1870: The infernal wen (1971, reprint 2022) online, see pp 247–296..
• Siena, Kevin. "Moral Economy, Mixed Economy, and the Biohazardous Shaping of Health Infrastructure in Eighteenth-Century London." Eighteenth-Century Studies 58.1 (2024): 25-32.
• Sigsworth, Michael, and Michael Worboys. "The public's view of public health in mid-Victorian Britain." Urban History 21.2 (1994): 237–250. online
• Skelton, Leona J. Sanitation in Urban Britain, 1560-1700 (Routledge, 2016)
• Smith, F. B. The People's health. 1830-1910 (1979).
• Szreter, Simon (1988). "The importance of social intervention in Britain's mortality decline c.1850–1914: A re-interpretation of the role of public health". Social History of Medicine. 1: 1–37. doi:10.1093/shm/1.1.1. S2CID 34704101.
• Warren, Michael D. A chronology of state medicine, public health, welfare and related services in Britain 1066–1999 (2000) online
• Webster, Charles. The National Health Service : a political history (2002) [1]
• Wohl, Anthony S. Endangered lives: public health in Victorian Britain (1983) online.
• Woods, Robert, and John Woodward. Urban Disease and Mortality in Nineteenth Century England (1984)

Biographical

Further information: Dictionary of National Biography

• • The Dictionary of National Biography is online for Wikipedia editors only at The Wikipedia Library
• Baly, M. (1986) Florence Nightingale and the Nursing Legacy, (1986)
• Bostridge, Mark. Florence Nightingale: The Making of an Icon (2008), a standard scholarly biography.
• Cohen, I. Bernard. "Florence Nightingale." Scientific American 250.3 (1984): 128-137. On her statistical methods. online
• Eyler, John M. Sir Arthur Newsholme and State Medicine, 1885-1935 (Cambridge University Press, 1997).
• Finer, S.E. The life and times of Sir Edwin Chadwick (1952).
• Lewis, R.A. Edwin Chadwick and the Public Health Movement 1832 – 1854 (1952) online
• Royston, Lambert. Sir John Simon and English social administration (1963).

Historiography

• Cherry, Steven. "Medicine and Public Health, 1900-1939" in A Companion to Early Twentieth-Century Britain ed. by Chris Wrigley, (Blackwell, 2003) pp. 405– 423.
• Gorsky, Martin "The British National Health Service 1948–2008: A Review of the Historiography" Social History of Medicine 21#3 (2008), pp. 437–460. online
• Sweet, Helen. "Establishing Connections, Restoring Relationships: Exploring the Historiography of Nursing in Britain," Gender and History, (2007) 19#3 pp. 565–580

Primary sources

• National Statistics: The health of adult Britain, 1841–1994 (1997) online
• Schneider, Dona, and David E. Lilienfeld, eds. Public health: the development of a discipline. Vol. 1. (Rutgers University Press, 2008), long excerpts from key primary sources before 1920, UK and United States. excerpts
  • Public health: the development of a discipline. Vol. 2 Twentieth century challenges (2011), covers 1920 to 2010.

• Simon, John. English sanitary institutions, reviewed in their course of development, and in some of their political and social relations (1890) online
• Statistical Abstract of the United Kingdom annual 1871–1908, online
• Young G. M., and W. D. Handcock, eds. English Historical Documents: Volume XII(1) 1833–1874. (Oxford University Press 1970), pp. 751–828.

External links.

• History of Public Health Timeline