In Search of Hygeia

Systems, Modernity, and Public Health

In October 1875, it fell to the physician and sanitary reformer Benjamin Ward Richardson to deliver the presidential address of the health section of the National Association for the Promotion of Social Science (NAPSS). The occasion was the NAPSS's annual congress, which was taking place that year in Brighton, on England's south coast. Since its establishment in 1857, the NAPSS had brought together thousands of ministers, MPs, councillors, local and central officials, professionals, and voluntary activists in order to advance the cause of more rational ways of governing, both at home and in the British Empire. Other sections dealt with education, legal reform, and finance and trade. Richardson later wrote that he had considered giving a lecture entitled "The Statistics of Death Rates." Instead, having been advised that delegates were "worn out with statistics," he decided "to plunge into the imagination" and outline a utopian city of health."

Richardson called this city Hygeia. All houses were furnished with bathrooms and toilets, and were connected to sewerage and water-supply systems. Sewage was channeled to outlying fields, where it was put to use in agriculture. Pedestrians walked tree-lined streets; traffic was directed underground via subways. Sanitary and medical officers worked unhindered. The municipal council was free of political strife. Hospitals were plentiful. All foodstuffs were inspected. And no one smoked or drank alcohol. It was not, he stressed, entirely free of infectious diseases. Scarlet fever, measles, and whooping cough, for instance, would probably persist, even if smallpox, dysentery, cholera, typhoid, and typhus would likely be banished; otherwise, most would die from diseases that arose from "uncontrollable causes," among them cancer and those of a "strong hereditary character." Nonetheless, Hygeia was within reach: Richardson estimated it was only a generation away. The "details" existed in places — the particular technologies, practices, and forms of expertise — and had been "worked out by those pioneers of sanitary science, so many of whom surround me today." It was a question of pulling these elements together to form a coherent and seamless urban system. Like all earthly utopias, it is a vision of wholeness and goodness, and of people and things at their most exemplary, somehow emerging from history at the hands of humans. "Utopia itself is but another word for time," Richardson concluded, having noted that Hygeia contained "nothing whatever but what is at this present moment easily possible."

Richardson's presentation of Hygeia is but a scene within the bigger story that this book seeks to retell: the making of a modern public health system in England, roughly 1830 to 1910. The aim is to rethink the modernity of this system by looking at how it was assembled, reformed and, above all, practiced. We begin with Hygeia because it captures something of the epidemiological priorities of public health in this particular pocket of space and time. In Victorian and Edwardian England, the principal focus of public health efforts was the eradication of infectious diseases of a bacterial and viral sort — diseases that would, mercifully, as part of what demographic historians call an "epidemiological transition," lose their deadly salience in the twentieth century, when more chronic and degenerative conditions became the principal causes of death. It captures, too, the growing administrative capacities of public health. Already more than twenty-five years had passed since the establishment (in 1848) of the General Board of Health (GBH), England's first centralized, specialized public health office. By 1875, it was a bureaucratic function that had passed to the Local Government Board (LGB). Since 1872, local authorities had been obliged to appoint medical officers of health (MOsH) and sanitary inspectors. Large-scale sewerage systems were in the process of being constructed. In fact, the largest of these had been completed just that year: London's Main Drainage Scheme, which carried away the waste of more than three million people. Only months before Richardson spoke, parliament had passed the 1875 Public Health Act, a mammoth piece of legislation that consolidated existing statutes passed during the preceding three decades. Its sprawling scope included regulations relating to the supply of water and the disposal of sewage; the sale of food and the slaughter of animals; the disinfection of insanitary homes and business premises; and the provision of hospitals for those suffering from infectious diseases.

It is easy, then, to understand Richardson's confidence: progress was being made, and might not more be had — significantly more? And yet, quite simply, Hygeia was never realized. In some respects, Richardson's imaginary city is the last place we should begin if we wish to understand, as this book does, the practices and practicalities of governing public health in Victorian and Edwardian England. For a real flavor of what happened we might turn to the papers that followed Richardson's address as part of the deliberations of the health section. For sure, there was no sense of fatalism or powerlessness, but there was frustration and dispute in abundance. Acts had been passed, yet some local authorities, whether out of lethargy or active opposition, had still to implement them; and where they had, the results were disappointing. Any kind of uniformity of practice was wholly absent. At the same time, there was no consensus regarding some basic questions of administration: should water-supply systems, for instance, be publicly or privately owned? Some thought the former, others the latter, invoking as they did so conflicting examples of good practice. Meanwhile, delegates delved into a maddening world of technical intricacies, from those that featured as part of the reform of England's portside quarantine system — an urgent matter, given Britain's global-economic dominance at this point — to those that might strike us as somewhat inconsequential. One paper, for instance, was entitled "Roof Pipes for Ventilating Sewers."

Where, we might ask, is Hygeia in all of this? An editorial in the Times was suitably skeptical. It welcomed the ambitions and ideals that informed what it called "Hygeiopolis"; but it was quick to point out that the people of England were just not ready for such a city, given its costs and regulatory burdens. A "model city can never exist," it declared, "until the community intended to inhabit it is educated to render...