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Health Promotion International, Vol. 14, No. 4, 381-382,
December 1999
© Oxford University Press 1999
Resource Reviews |
Public Health and Social Justice in the Age of Chadwick Britain 1800–1854
Christopher Hamlin, Cambridge University Press, 1998, 368 pp
Environmental Health Unit NSW Health In 1998, the British Medical Journal commemorated the 150th anniversary of the first Great Public Health Act. Christopher Hamlin was among the authors who reflected upon the achievements and contemporary relevance of the legacy of Edwin Chadwick and his contemporaries. In this lively and readable book, Hamlin develops the idea that public health in Britain in the first half of the 19th century involved two transforming questions. Firstly, how broad public health was to be and how the ‘moral economy of medicine was to mesh with the political economy of industrial capitalism?’ The second is how Chadwick, in the name of efficiency and science, was able to equate in the public mind sanitation and sanitary works with the attainment of political stability and social justice.
Chadwick was the central actor in the sanitary movement in the turbulent 1840s. His Report on the Sanitary Condition of the Labouring Population of Great Britain, published in 1842, argued that the primary cause of pauperism and misery was not poverty or rampant capitalism, but filth. To Chadwick, the water queue, the dung heap and the cesspool were the causes of moral decline, fever and death. His arguments were a counterpoint to the more radical visions of William Cobbett and the Chartists. Frederich Engels published The Condition of the Working Class in England in 1844 and the Communist Manifesto in 1848. Work, wages and food were rejected as remedies for pauperism in favor of watering and sewering. The notion that poverty itself was the cause of illness was, for Chadwick, unthinkable. He resented the inclusion by William Farr of the category ‘starvation’ in the bills of mortality, arguing that it was impossible for a person to starve to death in London. To admit this would be to admit to a failure—not just of his sanitary agenda, but of his whole program of utilitarian reform.
As a young barrister, Chadwick became the private secretary to Jeremy Bentham, the utilitarian philosopher. After Bentham's death he became a civil servant and architect of some of the most far-reaching legislative reform in the early Victorian period. He drafted the revisions of the Poor Laws and was subsequently the administrator for the Poor Law Commissioners. The Benthamite prescription for pauperism was deterrence. The pain of the workhouse was to be greater than the pain of poverty and poor relief. Chadwick became ‘the most hated man in England’. It was the miserable failure of the workhouse system which lead Chadwick to public health. In his report, he made a case that England was ‘hideously and dangerously insanitary’. A committed miasmatist, Chadwick attributed the cause of fever to overcrowding, reeking privvies and humid marsh air. This view did not go unchallenged, and not just from contagionists. Thomas Wakley, the editor of The Lancet charged that the new poor law itself was the cause of fever. William Pulteney Alison was the most vocal medical opponent of sanitary monotheism. He rejected the prevailing view that poverty implied sin and was in favor of the retention of poor relief, knowing from his practice the corrosive effects of poverty on human health, character and conduct.
Chadwick's biographers have painted him as a fearless and centralizing bureaucrat, England's ‘Prussian’ Minister who was ultimately defeated by rich and powerful interests. To some he was the avenging angel of sanitation who rooted out corruption in local authorities and the funeral industry, and forged powerful coalitions between the bureaucracy and evangelical Christians determined to save the souls of the industrial proletariat. To others he was a stern class warrior and an uncompromising monomaniac. Upon his demise The Times trumpeted ‘We would rather take our chances with cholera than be bullied into health by the likes of Mr Chadwick’.
Hamlin, whilst remaining in awe of Victorian sanitary achievement argues strongly that it was achieved at a cost and warns against receiving too warmly the history of the victors. Then, as now, there were choices to be made and political struggles to be fought. Chadwick's ‘technical fix’ to the problems of poverty and inequality prevailed. It prevailed because he was able to manufacture the requisite authority by appeal to flawed, miasmatic science. It prevailed because he was able to pioneer a new role for government in improving health—to investigate and define real problems, to recruit problem-solving science, to develop pragmatic regulation, to evaluate effectiveness and to place these activities at the centre of State responsibility. And it prevailed because of the ineffectiveness of some groups, most notably the medical profession, to clearly articulate their understanding of the relationship between poverty and ill health.
As governments and experts grapple with the implications for human health of urbanization and population growth, the revolution in communications, the globalization of industry and government, ecological sustainability and climatic change, the ghost of Edwin Chadwick looms large. Can there ever again be value in an ideologically driven crash through approach to the paralysis induced by complex problems? Is science better able to contribute to debate and decision-making than it was in the time of Chadwick? What will it take to put public health at the centre of the agenda of government, as the environment movement has so successfully done over the last two decades?
Public health is not ‘an obscure offshoot of medicine or a marginal division of civil engineering’, but a ‘vast and unexamined part of our culture’. Beneath the veneer and language of science and medicine hide our most primitive notions of what health is and what it should be, and under what circumstances governments can or should act to defend it. Christopher Hamlin's re-examination of the life and revolutionary times of Edwin Chadwick, public health icon and inventor of civic hygiene, illustrates how the struggle for public health occurs alongside and is inseparable from other social and political aspirations. It deserves a wide readership.
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