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Who is responsible for the health of the people? Is it up to the individual to ensure that they remain in good health, or is it the job of government?

By the late 19th century, after a deadly disease outbreak and the threat of war, this question of public health became serious enough to lead to ground-breaking reforms.

During the 19th century, the idea that the individual was responsible for their own health was widely accepted.

Often many governments operated under a laissez-faire approach to health.

Under this approach, politicians believed that the state only had limited responsibilities:

• It was the state's duty to provide security for the country against foreign aggressors.
• It was up to the people to look after and provide for themselves – the state should not intervene.

As time progressed, the ideals of laissez-faire were slowly abandoned and the government passed a series of laws to help improve the lives of the British people.

There were various reasons why the majority of people in Britain experienced poor health at this time. Often it was as a result of not having access to things we take for granted today:

• the inability to access fresh, clean water
• the lack of good, affordable housing
• no access to affordable healthcare

The Industrial Revolution had made Britain into a major world power but in many ways, whilst the status of the country progressed, the majority of the population had been left behind.

There was no such thing as a minimum wage – many workers worked for low wages, preventing them from accessing better housing and healthcare.

Sick pay did not exist, so many workers would go to work whilst they were ill, rather than take the time off to recover properly. This only made their health worse.

The industrial cities such as Glasgow, Manchester, and London all experienced a growth in their populations when the Industrial Revolution took hold.

New housing was built quickly and cheaply to cope with this, but conditions were poor. Workers and their families were housed in crowded flats or back-to-back houses.

These buildings were often of poor quality and were built close together. Conditions were often dark, damp and dirty. Dampness, lack of sanitation and rat infestations lead to disease.

In the 1800s, poorer houses did not have running water. They certainly didn't have flushing toilets, which were so expensive that only the rich could afford them.

As a result, many people still got rid of human body waste by throwing it into streams and rivers. This practice led to water supplies becoming polluted and when individuals drank this water, they became sick.

The lack of sewers and sanitation also led to bad smells in crowded areas of towns and cities. This led to the false idea that bad smells actually caused illnesses.

To make things worse, up until 1853 many working people could not afford soap – the government had placed a tax on the product – no wonder cleanliness was an issue!

Cholera first struck in Britain in 1831. The outbreak killed thousands of people.

After another outbreak in 1848, the government passed the First Public Health Act. This act created local boards who would be responsible for disposing of sewage and improving the water supplies to towns and cities.

This sounded good in principle but these boards could only be set up if 10% of the local ratepayers agreed to it. Unfortunately, many viewed this departure from laissez-faire policy as an invasion of their individual freedoms.

A total of 182 towns set up local health boards and improved their local areas; however the rest of Britain was untouched by reforms and therefore the population still suffered.

It took over 20 years before another public health act was passed.

The 1875 Public Health Act made it compulsory for local councils to do the following to improve public health:

• improve sewers and drainage
• provide fresh water supplies to the population
• appoint medical officers and sanitary inspectors to oversee public health facilities

These improvements went on to save many lives but the pace of change was very slow.

By 1900, the average life expectancy was below 50 years of age. Three out of every 20 babies died in their first year and the majority of families could not afford a doctor.

The chronic ill health of much of Britain’s population was made apparent in 1899 at the outbreak of the Second Boer War. One third of applications to join the army were rejected due to health reasons.

8000 volunteers in Manchester were rejected in 1899 as they couldn’t even hold a rifle! If Britain were to retain its position as a great global power, something needed to be done.

At the end of the 19th century, two men carried out research into the lives of people living in poverty in the UK and improved public understanding of links between poverty and poor health.

Between 1886 and 1903 Charles Booth carried out interviews with people in poverty, doctors, teachers and priests in London.

His report Life and Labour of the People in London concluded that 30 per cent of people in London lived in poverty and that the poor were not to blame for their condition.

Seebohm Rowntree conducted research in York between 1899 and 1901.

His report Poverty, A Study of Town Life found that a person needed to earn 21 shillings per week to stay out of poverty. Anything less than this was below the Poverty Line. Rowntree found that 30 per cent of people in York were living in poverty.

Booth and Rowntree both identified the main causes of poverty as being illness, unemployment and age. Both the very young and the old were most at risk of poverty.

The Liberal Party won the 1906 General Election and began to pass a series of reforms to improve the lives of the British people.

These reforms were based on the findings of Booth and Rowntree and targeted the young, old, sick, and unemployed.

These reforms marked a major departure from laissez-faire and, on the whole, were welcomed by the population.

In 1906 and 1907, the Liberal Government passed two reforms aimed at improving the lives of children.

The Education (Provision of Free School Meals) Act provided councils with half of the funding needed to give each child one hot meal a day during term time. This aimed to help them to perform better in school and break out of the cycle of poverty.

Under the Education (Administrative Provisions) Act, children were given three inspections during their time in primary school. In Glasgow as a result of these inspections, a third of the pupils were found to be infected with fleas and lice!

Limitations

• children had to go without a free meal outside of term time
• the authorities were not expected to provide any treatments if any medical issues were identified during health inspections

In 1908, the government passed the Old Age Pensions Act.

The act provided anyone over seventy, who had an annual income of between £21 and £31 (roughly between £1641 and £2423) a pension of up to five shillings each week. In today's money, that would be the equivalent of £19.50 every week.

Even at the time many people thought this was a small sum of money but it was seen as a start to improving life for older people. Winston Churchill, then an MP for the Liberal Party, said: "It is not much unless you have not got it."

The aim of the pension was that it would allow people to retire, preventing them from having to carry out work that they were too old to do without risking damage to their health.

Limitations:

• In order to qualify for a pension, an individual had to meet a series of strict criteria which disqualified many from receiving the benefit
• Many people did not live to the age of 70 and so could not claim the benefit

In 1911, the Liberal Government introduced the concept of National Insurance to help with the cost of healthcare.

If a worker took ill, they were awarded sick pay and free doctor's care. This enabled them to seek professional help and take the time that they needed in order to fully recover.

Women were also offered Maternity Grants for the first time so they, too, could take the time they needed to look after their newborn child.

Whilst these reforms were welcomed, and provided many with support they needed, the reforms were not far-reaching. It could be seen that the government was only addressing the consequences of ill-health rather than the causes.

Limitations:

• No provision was made for people who were sick long term or were prevented from working due to disabilities.
• Free doctors' care was for the worker only – this was not extended to their family members
• National Insurance did not cover any hospital treatments

Unfortunately, the outbreak of World War One in 1914 put an end to the reforms.

Britain would have to wait until the end of World War Two for the next major medical reform to be passed. This was the creation of the NHS.