A History of Public Health

By Tim Lambert

Ancient Public Health

In the ancient world, public health was often surprisingly advanced. Stone Age farmers lived in a village at Skara Brae in the Orkney Islands about 3,000 BC. Some of their stone huts had drains built under them and some houses had cubicles over the drains. It’s believed they were inside toilets.

In the Indus Valley civilization (c.2,600-1,900 BC) streets were built on a grid pattern and networks of sewers were dug under them. The toilets were flushed with water.

On the island of Crete, the Minoan civilization flourished from 2,000 to 1,600 BC. They too built drainage systems, which also took sewage. The toilets were flushed with water.

The Romans also built sewers to collect rainwater and sewage. (They even had a goddess of sewers called Cloacina!). Wealthy people had their own toilets but the Romans also built public lavatories. Despite the public lavatories many people still went in the street.

The Romans also built aqueducts to bring water into towns.

Medieval Public Health

There were public lavatories in some towns in the Middle Ages. For instance, we know there was one over the River Fleet in London. In some towns, water was brought along pipes from higher elevations to public fountains. For instance, in Southampton friars were given a spring north of Southampton at the end of the 13th century and they built a lead pipe to the friary. In 1311 they gave the townspeople permission to use their water supply.

In the Middle Ages, the church ran the only hospitals. In many towns, monks, and nuns cared for the sick as best they could. Many towns had public bathhouses where you could pay to have a bath.

People could be fined for leaving garbage in the streets. In London, Men called rakers cleaned the streets.

Furthermore outside many towns were leper ‘hospitals’ (really just hostels as nothing could be done for the patients). Leprosy was a dreadful skin disease. Anyone who caught it was an outcast. They had to wear clothes that covered their whole bodies. They also had to ring a bell or a wooden clacker to warn people they were coming. Fortunately, leprosy grew less common in the 15th century and it died out in Britain in the 16th century.

In the Middle Ages monasteries had good sanitation. Streams provided clean water. Dirty water was used to clean toilets, which were in a separate room. Monks also had a room called a laver where they washed their hands before meals.

At Portchester Castle in the 12th century monks built stone chutes leading to the sea. When the tide went in and out it would flush away the sewage.

Public Health in the 18th Century

In the 18th century conditions in most towns improved (at least for the well-off). Bodies of men called Improvement Commissioners or Paving Commissioners were formed with powers to pave, clean, and light the streets (with oil lamps).

Meanwhile, several hospitals were founded in London in the 18th century including Westminster (1720), Guys (1724), St Georges (1733), London (1740), and Middlesex (1745). However, despite some improvements, 18th-century towns would seem dirty and crowded to us.

In 1775 Alexander Cumming was granted a patent for a flushing lavatory. Joseph Bramah made a better design in 1778.

However, flushing toilets were a luxury at first and they did not become common till the late 19th century. Also popular in the 19th century were earth closets. An earth closet was a box of granulated clay over a pan. When you pulled a lever clay covered the contents of the pan. In rural areas, flushing lavatories did not replace earth closets until the early 20th century.

Modern Public Health

In the early 19th century working-class homes often did not have their own toilet and had to share one. Sometimes you had to queue to use it.

Even in the late 19th century inside toilets were a luxury. Working-class homes almost always had outside lavatories. About 1900 some houses were built for skilled workers with bathrooms and inside toilets. However, it was decades before inside toilets became universal.

The first modern public lavatory, with flushing toilets, opened in London in 1852.

From the late 18th century the industrial revolution transformed Britain. Many villages or small market towns rapidly grew into industrial cities. However, although most towns gained gas light in other ways conditions were appalling. They were dirty, overcrowded, and unsanitary. The lack of building regulations meant poor people’s houses were often hovels. Not surprisingly British towns suffered outbreaks of cholera in 1832 and 1848. However, conditions in Victorian towns gradually improved.

There were outbreaks of cholera in London and other towns in 1831, 1848-49, and finally in 1866. In 1859 work began on building a system of sewers for the whole city but it was not complete till 1875. After that death from diseases fell drastically.

Other towns also built networks of sewers. In 1865-70 Portsmouth council built sewers. In 1875 a bylaw stated that any house within 100 feet of the main sewer must be connected to it. However, not all towns in Britain were so keen to build sewers. Many people in Chichester were reluctant to build a network of drains and sewers because of the expense. They were finally built in 1893-96.

In the 18th century, a piped water supply was available in many towns – for those who could afford it. Water was pumped along elm pipes. In the 19th century, local councils took over the water supply from private companies. People began to use sand filters and chlorination so the water supply became much cleaner. In the early 19th century most people obtained water from wells but in the late 19th century piped water became much more common.

Meanwhile, in 1842 Joseph Whitworth invented the mechanical street sweeper.

In the 18th century, people took baths in portable tubs. However, bathrooms were very rare. But from the mid-19th century, the middle class began to have them. In the 20th century, the working class began to have bathrooms. Also gas made it much easier to heat water for washing. Bathrooms and running hot water made it much easier to keep clean.

Furthermore, in the 19th century, public parks were laid out in many towns. Before the industrial revolution parks were not necessary as towns were very small and anybody could easily walk out into the countryside. As towns and cities grew much larger they provided a very useful place for fresh air and exercise. Local councils also began to take responsibility for collecting refuse. Manchester council took that responsibility as early as 1845. Also in the 19th century, hospitals were founded in towns and cities across Britain.

Another source of ill health in the early 19th century was overcrowding. At that time houses for poor people were often built back-to-back. They were joined to one another with the back of one house joining the back of another. Fortunately in the 1840s town councils banned the building of new back-to-backs. In the late 19th century living standards rose steadily and ordinary people began to live in houses with more rooms. Less overcrowding was an important factor in making people healthier.

Meanwhile, in the 18th century, some people realized that milkmaids who caught cowpox were immune to smallpox. Edward Jenner introduced vaccination. (Its name is derived from the Latin word for cow, Vacca). The patient was cut then matter from a cowpox pustule was introduced. The patient gained immunity to smallpox. (Jenner was not the first to think of this idea but because of his work it became a common practice). In the late 19th century and the early 20th century, it became possible to vaccinate people against many infectious diseases, which greatly improved public health.

Louis Pasteur invented a way of sterilizing liquids by heating them (called pasteurization). It was first used for wine (in 1864) and later for milk.

In the 19th century, adulteration of food was common. Cheap substances were added to food and drink e.g. water was added to milk. Food adulteration could be lethal. Calcium sulfate was added to peppermints. In 1858 a sweet maker in Bradford sent somebody to obtain some from a druggist. However, by mistake, the druggist’s assistant picked up some arsenic thinking it was calcium sulfate. Arsenic was added to the sweets. As a result, 200 people became seriously ill and 20 died. In Britain, food adulteration was eventually controlled by the Sale of Food and Drugs Act of 1875 and the Food Adulteration Act of 1899.

Public health was transformed in Britain between the mid-19th century and the mid-20th century and today people are much healthier than they were.

Last revised 2024