Public health and insurance: American addresses

by Sir Arthur Newsholme

Reform in Industry

The industrial revolution meant the subjection of large masses of working class families to evil conditions of housing and work in crowded and insanitary dwellings and factories. The public conscience first rebelled in regard to boarded out and apprentised pauper children; and the first Factory Act in 1802 concerned itself with them; and with this Act emerged the germ of machinery for securing compliance with the law, magistrates and clergymen being appointed as inspectors under the Act.

The Act was largely futile; but it meant the beginning of the gradual breaking down of laissez faire doctrines; and there followed a more widely operative Factory Act in 1833, restricting hours of labor of children, and initiating professional inspectors controlled and paid by the Government. In 1842 the underground employment of women in mines was forbidden; and at intervals since then numerous factory and allied acts have been passed, restricting the duration and conditions of work of women and children, improving rules as to sanitation, insuring systematic inspection by government inspectors, and constituting a far reaching system of supervision and control.

The inspectors, on whom falls the burden of ensuring compliance with the Factory Laws and regulations made under them, are controlled by the department of the central government known as the Home Office; their work on the whole has been well done, and the conditions of factory and workshop life have greatly improved. Some portion of the sanitary supervision of these work-places falls on the local Sanitary Authority; but in the main the system is one of absolutely centralized government control. This secures almost complete absence of improper influence of interested local persons, whether masters or workmen; but it is arguable that this system should be replaced by a localized system, the inspectors being officers of the 144 larger authorities. These local officers could be placed in direct touch with the Home Office or the Ministry of Health and with the central staff of inspectors having expert knowledge in the different branches of industrial work.

Public Health Reform

Public health reform was a direct consequence of the Poor-Law Amendment Act, 1834. Anxious to diminish the enormous expense of the existing Poor Law, and realizing that a large share of this sickness was due to fever and other illnesses, surveys and inquiries were set on foot by the commissioners administering this Act, and the reports which followed revealed a state of things urgently calling for sanitary reform, in the interest of national economy as well as of health. “An Act for Promoting the Public Health” was passed in August, 1848, which created a General Board of Health consisting of four members and a secretary. These Commissioners, among whom was Edwin Chadwick, former Secretary of the Poor Law Board, initiated a system of procedure which was largely on the lines of poor-law action, and which involved constant pin-pricking by the Central Authority of the grossly indifferent local authorities. The commissioners were more zealous than discreet; and after six years they were no longer tolerated. At that time centralization was as much a bogie as socialism has become in more recent years. Parliament and the localities represented by its members doubtless feared the reforming activity of Chadwick and his colleagues, though they sheltered themselves behind their exaggerated fears of bureaucracy and centralization.

A new board replaced the old, parliamentary in character, its president being a member of the Government. This repeated, so far as concerns Parliamentary headship, the story of the Poor-Law Board, and established once more the theory of the administrative control of the representatives of the people. Nor, although the change meant for the time serious slackening in sanitary reform, can objection be taken to it. In a democratic government the elected representatives of the people must take first place; and it is the rôle of officials to educate them in the direction of needed reforms. Reforms which do not carry public opinion with them are not likely to be permanently successful; and, whether in administration or in legislation, attempts to sidetrack or ignore this fact are not likely to be permanently effective.

Public Health Reforms

When the Local Government Board was formed in 1870, a second opportunity was lost of developing Public Health Administration on lines which we now know to be the best adapted for a complete service of preventive medicine. The first lost opportunity was when sanitary authorities, completely separate from poor-law authorities, were created for administering the sanitary laws. Probably this arose from Chadwick’s despair of getting effective sanitary reform from poor-law guardians; but the creation of separate authorities was scarcely consistent with the fact recognized by him that pauperism is largely, if not predominantly a question of sickness; or with the less recognized fact that its treatment forms an essential part of prevention. It was recognized that the care of the sick was largely idle until the unnecessary causes of disease had been cut off, but not that the adequate treatment of sickness is an important means of preventing it or of curtailing it. Rumsey,[7] in 1856, stated the unrealized possibilities of the poor-law medical officer’s domiciliary attendance on paupers in the following words:

There are much higher functions of a preventive nature than those of a mere “public informer” which the district medical officer ought to perform. He should become the sanitary adviser of the poor in their dwellings ... he (should) be in a peculiar sense, the missionary of health in his own parish or district,—instructing the working classes in personal and domestic hygiene,—and practically proving to the helpless and debased, the disheartened and disaffected, that the State cares for them, a fact of which, until of late, they have seen but little evidence.