1. Disease and Public Health Lecture 11 Medicine, Disease and Society in Britain, 1750 - 1950

2. Lecture Themes and Outline Disease, mortality and demography –McKeown thesis –More recent interpretations Three diseases prevalent in c18th and c19th demonstrating varying degrees of state intervention with varying degrees of success –Smallpox – inoculation, vaccination, protests –TB/phthisis – nutrition vs state intervention –Cholera – widespread public health reforms: sanitation

3. Disease, mortality and demography Epidemic = prevalent in waves; attacks populations indiscriminately. Endemic = regularly or usually found among the population. 1836 Registration Act – compulsory for births and deaths to be registered.

4. McKeown thesis Challenged the assumption that improvements in medicine directly accounted for population growth. Falling death rates from disease, particularly childhood disease, were due to better nutrition and living standards rather than immunization.

5. Smallpox

6. Edward Jenner (1749-1823) Vaccination developed in 1796. Observed that milkmaids and stockmen rarely developed smallpox. Inoculated James Phipps with cowpox and 6 weeks later with smallpox – proved immunity to smallpox.

7. Cartoon by James Gillray on vaccination against Smallpox using Cowpox serum, 1802., Engraving-hand colour

8. Tuberculosis Major killer in the C19th. 1839 TB was responsible for 17.6% of all deaths in England and Wales. In the early C20th it remained the most prominent chronic illness – 75,000 deaths per year. Spread through close personal contact – important to remove sufferers from their environment.

9. c. 1930

10. Cholera Outbreaks 1826 – second global pandemic, travelled from Asia 1831-2 - first hits Britain 1849 – second British epidemic 1853-4 1865-6

11. Edwin Chadwick (1800-1890) 1842, Report on the Sanitary Condition of the Working Population of Great Britain. Emphasised the need for experts to be employed by government and believed the role of the state should be regulatory rather than directive. His report cited disease as a major cause of poverty – reduced earning capacity of the working classes.

12. John Snow (1813-1858) j 1855 ‘On the Mode of Communication of Cholera’. Argued that cholera was ‘water-borne’ and not just based on miasmas and insanitary conditions.

13. Snow’s map of Broad Street Soho district in London. Called the ‘cholera field’ by Snow. Over 500 people died in 10 days from 1 to 10 September 1854. Snow linked the deaths to the source of water.

14. ‘King Cholera’

15. Public Health Legislation 1848 Public Health Act 1855,1860 and 1863 Nuisance Removal Acts 1866 Sanitary Act 1872 Public Health Act 1875 Public Health Act 1889 Infectious Diseases Notification Act

16. Conclusion Actions against epidemics greatly reduced the numbers of deaths from diseases such as cholera and smallpox. Sanitary reform saved lives and improved living conditions. Public health reform was delivered unevenly across the population – poorer classes often last to receive it. Implementation of reform was affected by the concerns of central and local government – financial, social and legal.

17. ‘In order to re-create the epidemiological landscapes of the past and track the routes and pathways of the world’s major epidemics, we need to understand these dynamics in an ever-changing natural and human world. The ecological and biological chains of disease transmission – where and how each epidemic is spread; the environmental parameters and constraints – geographical and seasonal variations in the natural and physical world; the demographic variables – the density and age structure of a population needed to support an epidemic disease, levels of contact and crowding, and the prior immunological experiences of a community; the multifactorial social, economic, domestic, and personal factors that enter into the equation – standards of living, the nutritional status of a host population, its level of domestic and public hygiene, patterns of residence, occupation, and migration – have each combined with a multitude of elusive factors, from disease mutations to animal-human disease transfers, to govern and determine the spread of each epidemic disease and its global impact.’ Mary Dobson, ‘Epidemics and the Geography of Disease’, in Irvine Loudon (ed.), Western Medicine: An Illustrated History (Oxford: Oxford University Press, 1997), pp. 187-8.