SECTION IV

WOMEN AS SANITARY INSPECTORS AND HEALTH VISITORS

The introduction of women into the public health service is a modern development, although they have been engaged in it longer than is usually known.

Women who are employed in Public Health Work hold office under Local Sanitary Authorities, and their work must not be confused with that of the Women Home Office Officials, who were first appointed in 1895; these inspect factories and workshops, but their powers and duties are of a different character. For instance, the Women Home Office Inspectors deal, amongst other things, with the cleanliness of factories, but not with the cleanliness of workshops, and with the heating of workshops, while the ventilation of the same workshops is under the control of the local sanitary officials.

Glasgow was the first county borough to utilise the services of Women Health Officials, for in May 1870 four "Female Visitors," afterwards known as Assistant Sanitary Inspectors, were appointed in connection with the Public Health Department. Their duties were: "by persuasion principally, to induce the women householders to keep the interiors of their dwellings in a clean and sanitary condition, and to advise generally how best this can be maintained." They possessed the same right of entry to premises as the men inspectors, and were required to hold the certificate of the Incorporated Sanitary Association of Scotland. They reported certain nuisances, but themselves dealt with others, such as "dirty homes or dirty bedding, clothing, and furnishing."

The work of Women Health Officials in England, dates from the passing of the Factory and Workshops Act of 1891, when certain duties with regard to workshops, which had previously been performed by the Home Office Inspectors, were laid upon Sanitary Authorities.

In the opinion of Dr Orme Dudfield, late Medical Officer of Health for Kensington: "It soon became apparent that, not only was systematic inspection necessary, but also that many of the duties involved were of so special and delicate a nature that they could not be satisfactorily discharged by male inspectors." He therefore recommended the appointment of two Women Inspectors of Workshops in Kensington. In the meantime the city of Nottingham had appointed a Woman Inspector of Workshops in May 1892, and in accordance with Dr Dudfield's recommendation two Women Inspectors were appointed in Kensington in 1893.

These ladies were appointed as inspectors of workshops only. They did not hold Sanitary Certificates, nor had they the status of Sanitary Inspectors. In practice, this entailed a visit by a male inspector every time it was necessary to serve a legal notice for the abatement of any contravention of the Factory and Workshops' Act. Therefore, when these ladies resigned upon their appointment as Factory Inspectors, it was decided to appoint the in-coming ladies as Sanitary Inspectors, with power to deal with these matters themselves. It was, however, Islington which appointed the first woman with the legal status of Sanitary Inspector in 1895.

By 1901, eleven women had been appointed in the Metropolitan area as Sanitary Inspectors, nearly all of them exclusively engaged in the inspection of workshops. Since that time the number of women appointed by Local Sanitary Authorities has increased considerably, both in London and the Provinces. The exact number outside London is only known approximately, as no register exists which is available to the public. It is to be hoped that this information may be obtainable from the last census returns. The figures with regard to London are published annually by the London County Council, and there are now forty-one Women Sanitary Inspectors in the Metropolitan area.

Sanitary inspectors in London, whether men or women, are required to hold the certificate of the Sanitary Inspectors' Examination Board, the examination for which is the same for men and women.[1] Outside London no definite qualification is required by the Local Government Board, but it is usual in county and municipal boroughs for a sanitary certificate to be demanded from candidates for the position of Inspector of Nuisances (the term used outside London for Sanitary Officials). Men and Women Sanitary Inspectors possess equal rights of entry to premises and equal statutory powers for enforcing compliance with the law.

The duties of Women Sanitary Inspectors have become very varied and numerous during the past ten years; they differ considerably according to locality and to the opinions of the local Medical Officer of Health. Broadly speaking, before 1905 women in London were mainly engaged in the inspection of workshops, whereas in the Provinces (with the exception of Nottingham, Leicester, and Manchester) they were engaged in house-to-house visitation in the poorer parts of the towns, with a view to the promotion of cleanliness, giving advice to mothers concerning the feeding and care of infants and young children, and the detection of sanitary defects. The inspection of workshops in the Provinces was a later development.

These varied duties have called for special qualifications, and, in addition to certificates in sanitation, Women Sanitary Inspectors usually hold qualifications in nursing or midwifery. The general education of the women who take up this profession is, on the whole, superior to that of the men. Most of the women have had a high school education, and many are University graduates, while the men, as a rule, come from the elementary schools.

The duties of a Woman Sanitary Inspector are sufficiently varied to avoid monotony, and may comprise any or all of the following:—

A. (1) The inspection of factories in order to see that suitable and sufficient sanitary accommodation is provided for women, in accordance with the requirements of the Public Health Acts.

(2) The carrying out of the provisions of the Public Health and Factory and Workshops Acts, with regard to the registration and inspection of

(a) laundries, workshops, and workplaces (including kitchens of hotels and restaurants) where women are employed;

(b) Outworkers' premises.

(3) The inspection of tenement houses and houses let in lodgings, and the enforcement of the bye-laws of the Sanitary Authority affecting these.

(4) House-to-house inspection in the poorer
parts of the district.

(5) The inspection of public lavatories for
women.

(6) The carrying out of duties and inspection
concerning

(a) Notifiable infectious diseases,
such as scarlet fever.

(b) Non-notifiable infectious diseases
such as measles.

(7) Taking samples under the Food and Drugs Acts. (This work is rarely given to women.)

For many of the above duties, women are obviously better fitted than men, but for the following most important group of duties men are practically disqualified by reason of their sex:—

B. Health visiting. Work in connection with the reduction of infantile mortality :—

(1) Notification of Births Act, 1907. Visiting
infants and giving advice to mothers
about the feeding and general management
of young children.

(2) Advising expectant mothers on the
management of their health and as
to the influence of ante-natal conditions
on their infants.

(3) Work in connection with milk depôts and
infant consultations.

(4) Promotion of general cleanliness in the
home and discovery of sanitary defects

remediable under the Public Health
Acts.

(5) Investigation of deaths of infants under one year of age.

(6) Lecturing at mothers' meetings.

(7) Organisation of voluntary Health Workers in the district and arrangement of their work.

C. The following duties may also be required in the Provinces:—

(1) Work relating to the administration of the Midwives' Act, 1902 (where the County Council have delegated their powers to the District Council).

(2) The inspection of shops under the Shop Hours Act, 1892-94, and the Seats for Shop-Assistants Act, 1899.

The work described under C. 1 and 2, is performed in London (except in the City) by special inspectors appointed by the London County Council, who also inspect employment agencies where sleeping accommodation is provided and carry out certain duties under the Children's Act.

(3) Work in connection with the medical inspection of school children (performed in London by the London County Council school nurses).

The duties of Men Sanitary Inspectors are very clearly defined, and differ considerably from those of the women. Men are mainly engaged in the inspection and reconstruction of drains, the detection of structural defects in the houses of the working classes, the carrying out of bye-laws with regard to tenement houses, the investigation of cases of notifiable infectious diseases, the inspection of workshops and factories, the enforcement of the law with regard to the sale of foods and drugs and the abatement of smoke nuisances.

As will be seen from the duties enumerated above, Women Inspectors, as a general rule, are brought into very close and intimate contact with the homes of the people, and this necessitates the exercise of much tact and patience. The large demands thus made upon their powers of persuasion and teaching capacity, involve a considerable strain upon their nervous energy as well as their physical strength. The work of the Men Inspectors, on the other hand, being of a more official character, does not involve the same strain.

There is no uniformity of practice with regard to hours of work, holidays, remuneration or superannuation, either within or without the metropolitan area. Each Local Authority makes its own arrangements. Many have no superannuation scheme and give no pensions. Men and women working for the same Authority usually work under the same conditions as to hours and holidays: the rate of remuneration, however, is by no means the same. The salaries of Women Sanitary Inspectors within the Metropolitan area range from £100 to £200 per annum, the latter figure being reached only in two boroughs and in the City of London: whilst the salaries of the men range from £150 to £350. The average maximum salary of the women is £150, and the average maximum salary of the men is £205. Outside London, the salaries of both men and women are lower, those of the women ranging from £65 to £100, a few rising to £150. Payments are made monthly, and a month's notice can be demanded on leaving, though it is frequently not enforced. Another unjust distinction frequently made between men and women is that the latter are generally compelled to retire upon marriage, thus enforcing celibacy on some of our most capable women.

The hours of work are usually from 9 A.M. to 5 or 6 P.M. and to 1 P.M. on Saturdays. If we consider the nature of the work, the holidays appear most inadequate—viz.: only from two to three weeks per annum are allowed in London, and from ten to fourteen days in many provincial towns.

The Health Visitor, as a public official, was not known until 1899, when several were appointed by the City Council of Birmingham. The name "Health Visitor" was thought to be more feminine and suitable than that of Inspector, and it was imagined that she would in consequence be better received in the homes of the people. As a private society in Manchester had previously engaged women of an inferior class and education with the title of "Health Visitor," this designation was deprecated by women already in the profession. Many smaller provincial towns, however, followed the example of Birmingham, and appointed Health Visitors instead of Women Sanitary Inspectors. It was not until later that the Health Visitor was introduced into London, and in the following way:—

In the Metropolitan area (exclusive of the City) half of the salary of all Sanitary Inspectors is paid out of the County Rate, and their duties are defined in Sections 107 and 108 of the Public Health (London) Act, 1891. As Medical Officers of Health and the public generally became more and more interested in the question of infant mortality, Women Inspectors were employed to investigate infant deaths, to visit houses where a birth had taken place and advise mothers on infant care, to manage milk depôts, to weigh babies, and to assist at infant consultations, and to do a great deal of work which hitherto had not been considered the work of a Sanitary Inspector. There was never any question as to the value of the work done nor of the efficiency with which it was performed, but the Local Government Board Auditor took the view that it did not come within the scope of the order of 1891, defining the duties of a Sanitary Inspector, and he refused to sanction the payment out of the County Rate of half the salary of those women who were engaged in Health Visiting work. In March 1905, the borough of Kensington solved the difficulty for itself by appointing a Health Visitor and paying the whole of her salary out of the Local Rate; but less wealthy boroughs felt unable to do this. It was work which the Sanitary Authorities wanted to undertake; it was work which the London County Council and the Local Government Board were desirous of seeing performed, but this technical difficulty stood in the way. It was overcome by the inclusion in the London County Council General Powers' Act of 1908, of Section 7, which empowered Sanitary Authorities in the Metropolitan area to appoint Health Visitors, and this enabled the London County Council to contribute half their salaries out of the County Rate. As a matter of fact, at the present time (November 1913) the whole of the salary of Health Visitors in London is being paid out of the Local Rate, as the Exchequer contribution account is completely depleted by the payment of the moiety of the salary of Sanitary Inspectors.

The essential difference between a Woman Sanitary Inspector and a Health Visitor is that the Woman Sanitary Inspector is a statutory officer with a legal position, having definite rights of entry and certain statutory powers for enforcing the Public Health Acts, while a Health Visitor is a purely advisory officer, with no legal status or right of entry or power to carry out any of the provisions of the Public Health Acts.

In actual practice, the title of Inspector has in no way proved an obstacle to successful health visiting, as may be demonstrated by an enquiry into the work now being carried on by Women Sanitary Inspectors in Sheffield, Leeds, Liverpool, Bradford, London, and other places. On the contrary, it has enabled officials to obtain an entry into dirty and insanitary places and to expose cases of neglect, which might otherwise have remained undiscovered.

The Health Visitor is usually paid a lower salary than the Woman Sanitary Inspector; this ranges in London from £100 to £120; in the provinces it may be as low as £65 per annum, and rarely rises above £100. The hours of work and holidays are, as a rule, the same as for Women Sanitary Inspectors. The difference in salary has proved a great temptation to Local Authorities in London to appoint Health Visitors when Women Sanitary Inspectors would have been more useful and efficient officers. Indeed, it is to be deplored that very few members of Local Authorities understood the advantages to be gained by the appointment of the more highly qualified official. The immediate effect of Section 7 was that several boroughs, having no women officials, proceeded to appoint Health Visitors; other boroughs, which possessed Women Sanitary Inspectors, also appointed Health Visitors. Seven or eight boroughs re-appointed their women officials in the dual capacity of Sanitary Inspector and Health Visitor so that the work in those cases went on as before. An indirect effect has been the almost complete cessation of the appointment of Women Sanitary Inspectors and the diminution in their number in some boroughs by the lapse of appointments on resignation or marriage. The inspection of workshops where women are employed has, in several instances, fallen back into the hands of Men Inspectors, whose unsuitability for this work first called women in England into the Public Health Service.

In September 1909 the Local Government Board issued the following order with regard to Health Visitors in London:—

"Art. 1. Qualifications. A woman shall be qualified to be appointed a
Health Visitor if she

(a) is a duly qualified medical practitioner ; or

(b) is a duly qualified nurse with three years' training in a hospital or infirmary, being a training school for nurses and having a resident physician or surgeon; or

(d) has had six months' nursing experience in a hospital receiving children as well as adults, and holds the certificate of the Royal Sanitary Institute for Health Visitors and School Nurses, or the Diploma of the National Health Society; or

(e) has discharged duties similar to those presented in the regulations in the services of a Sanitary Authority and produces such evidence as suffices to prove her competency; or

(f) has a competent knowledge and experience of the theory and practice of nurture, and the care and management of young children, of attendance on women in and immediately after child-birth, and of nursing attendance in cases of sickness or other mental or bodily infirmity.

"Art. 2. Every appointment must be confirmed by the Board.

"Art. 6. Enables a Sanitary Authority to determine the appointment of a Health Visitor by giving her three months' notice, and no woman may be appointed unless she agrees to give three months' notice previous to resigning the office or to forfeit a sum to be agreed.

"Art. 8. Outlines the duties of the Health Visitor but prohibits her from discharging duties pertaining to the position of a Sanitary Inspector (unless with the consent of the Board she holds the dual appointment).

"Art. 9. The Board's approval is required to the salary to be paid to the Health Visitor, and an allowance in respect of clothing, where uniform or other distinctive dress is required, may be made."

The Board in their circular letter state that they consider that, in consideration of the importance of the duties and of the salaries often paid to Women Sanitary Inspectors in London, the salary ought not to be less than £100 per annum.

It will be seen from the above that it is quite possible for a Health Visitor to be appointed practically without any qualification for the position, and with absolutely no knowledge of Public Health Law and sanitation.

It is, therefore, apparent that there are two classes of women officials in connection with Public Health Departments, one on the same footing as the men, with equal powers and responsibilities, but remunerated at a much lower rate, and another with a lower status and a still lower rate of remuneration. The duties of the second class may be performed equally well by the first, but the duties of the first cannot be performed by the second. The introduction of the Health Visitor has therefore lowered the status of the Public Health Service.

The remedy for this state of affairs is for competent woman officials in the future to be appointed in the dual capacity of Sanitary Inspector and Health Visitor at an adequate remuneration, and for the order of 1891 defining the duties of a Sanitary Inspector to be expanded to meet the developments which have been taking place in the Public Health Acts since that date.

There are two organisations which Women Sanitary Inspectors may join:—

(1) The Women Sanitary Inspectors' Association, which includes as members Women Sanitary Inspectors and Health Visitors holding recognised certificates in sanitation. (Health Visitors holding official appointments but without these recognised certificates in sanitation may become associates.)

(2) The Sanitary Inspectors' Association, which is composed of a large number of Men Sanitary Inspectors and a few Women Sanitary Inspectors. This is not open to Health Visitors.

There is no approved society for Sanitary Inspectors under the Insurance Act. The income of the majority of Men Inspectors exempts them from the operation of the Act, but a large number of Men and Women Inspectors receiving less than £160 per annum, have joined the approved society of the National Association of Local Government Officers.

To sum up, we may say that on the whole the life of a Health Official is a healthy and suitable one for a woman of average physique; it demands great activity, with many hours spent out of doors, and whoever undertakes it must be prepared for surprises and difficulties. She may find herself in an office staffed entirely by men, with chief, committee, and council composed entirely of men—indeed everything looked at from the male standpoint. She either works singly or in small groups of two or three, except in a few large towns where the women officials may number from ten to twenty. Thus isolated and scattered, it is extremely difficult for the Women Health Officials to form an effective organisation. What is accomplished under one Authority may have little or no effect upon another.

One condition which presses heavily on many women is the shortness of the holidays. The work is always arduous, particularly in poor districts where one is brought face to face with poverty, disease, and suffering, and from two to three weeks is not sufficient for rest and recuperation, particularly as the years pass on.

The creation of public opinion and the advent of a greater number of women on Municipal Councils and Health Committees is greatly needed to improve the conditions under which women officials work, and to support their reasonable demands.[2]

[Footnote 1: Full particulars of this can be obtained from the
Secretary, Sanitary Inspectors' Examination Board, Adelaide Buildings,
London Bridge.]

[Footnote 2: The above article considers under the term "Health Visitors" such women only as are serving under public Municipal Authorities. Unfortunately, since it gives rise to confusion, the name is also used in connection with officials privately appointed by various charitable institutions. These have no universally recognised standard of attainments: some of the so-called "Health Visitors" are without any qualifications, others, e.g., those employed by the Jewish Board of Guardians, are fully trained and do excellent work, comparable with that performed by Hospital Almoners. We hope, in a later volume of this series, to publish an article on their duties and position.[EDITOR.]