On the State of Rural Hygiene

Public Health System Provides Health Care to Rural Areas

Essay

By: Florence Nightingale

Date: 1893

Source: Lucy Ridgeley Seymer, ed. Selected Writings of Florence Nightingale. New York: Macmillan, 1954.

About the Author: Florence Nightingale (1820–1915)—nurse, pioneer of hospital reform, and humanitarian—was born in Florence, Italy, on May 12, 1820. She was raised in Derbyshire, England, and was tutored at home by her father. At the age of 29, she journeyed throughout Europe, with the intention of studying European hospital systems. In 1850, she began nursing school in Alexandria, Egypt, at the Institute of Saint Vincent de Paul. She concluded her nursing studies at the Institute for Protestant Deaconesses in Kaiserwerth, Germany. By 1853, she had completed her schooling and had accepted a position as Superintendent of London's Hospital for Invalid Gentlewomen. During the Crimean War, Florence Nightingale served as Director of Nursing for the war effort; she had great success in instituting sanitary methods, and in limiting the growth and spread of infection among the sick and wounded. After the war ended, in 1860, she founded the Nightingale School and Home for Nurses at Saint Thomas' Hospital in London. Florence Nightingale pioneered professional nursing education. In addition, she wrote the first widely published textbook on nursing, Notes on Hospitals, in 1860. Nightingale was a prolific writer and she has had a profound impact on the fields of nursing and medicine, on hospital reform, and on the development of the rural public health system. Florence Nightingale dedicated her life to the betterment of life circumstances for her fellow citizens and was given many awards, both within her country and internationally, for her efforts. In 1907, Nightingale became the first female to be awarded the British Order of Merit. In 1915, the Crimean Monument in London's Waterloo Place was built and dedicated to honor her memory.

INTRODUCTION

In the early decades of the 1800s, the concept of public health in the United Kingdom was largely an oxymoron, particularly for the socioeconomically disadvantaged, and especially so for those living in urban settings, where crowded housing conditions were (and are until the present day) the norm.

Trash and raw sewage were commonly dumped out of the windows of dwellings, and piled in yards, on public streets, and wherever there was empty space. Wells were relatively scarce, and were often contaminated, with the result that numerous families might share the same polluted water source. In 1831, there was an epidemic of cholera in Asia and Europe, although this was attributed by many scientists of the day to air and atmospheric conditions rather than to bacteria spread though tainted water.

In 1838, the Poor Law Commissioners created, and widely published, a report on the effects of rampant epidemic diseases on the poor of London's Bethnal Green and Whitechapel. Edwin Chadwick, a socially prominent proponent of social justice reform and the need for instituting sanitary conditions as a normal part of life for the poor and underprivileged classes, spent several years as the Secretary of the Poor Law Commission. It was his contention that poverty, disease, and living in squalor were inextricably intertwined. This did not imply that the wealthy were living under appreciably more sanitary conditions. They were merely able to afford somewhat cleaner living conditions and were less likely to share contaminated well water. In 1840, Chadwick conducted his own research on the prevalent environmental settings among the poor, and in 1842 the Poor Law Commissioners published his report on the Sanitary Conditions of the Labouring Population of Great Britain. The report attributed the rampant spread of disease to "atmospheric impurities" brought about by the decomposition of vegetable and animal wastes in open trash heaps, dampness, filth, and close and overcrowded housing and working situations. In addition to laying out the causes of the health problems among the poor and oppressed in Great Britain, Chadwick proposed solutions to minimize the spread of infection and disease. He recommended the creation of adequate drainage and water systems, and proposed that a plan be created for regular waste and trash removal from homes, yards, alleys, and streets.

The Poor Law Commissioners were able to induce the British House of Commons to create a work group tasked with the investigation of health problems in urban areas. The group recommended the creation and institution of a variety of regulations aimed at improving the sanitary conditions of dwellings and worksites. They also recommended the passage of a Sewerage Act and the opening of offices of the Board of Health in every town. The Board of Health would be charged with the regulation of the cleanliness and availability of water systems, as well as with the disposal of waste and prevention of vermin infestation. There was also an attempt to legislate the construction of homes and neighborhoods. Because people worked very long hours and there was a scarcity of public transportation—particularly for those who earned only subsistence wages—homes were built as close as possible to the workplace. As a result, homes also were built very close together, people and homes were overcrowded, and streets were narrow. The further result of this type of mass construction was a lack of adequate airflow and proper ventilation, leading to the widespread proliferation of airborne infection-causing contaminants.

Florence Nightingale read her essay on the state of rural hygiene at the Conference of Women Workers in Leeds, England, in 1893. It is excerpted below.

PRIMARY SOURCE

We will now deal with the PRESENT STATE OF RURAL HYGIENE, which is indeed a pitiful and disgusting story, dreadful to tell.

For the sake of giving actual facts,—it is no use lecturing upon drainage, watersupply, wells, pigsties, storage of excrement, storage of refuse, etc., etc., in general; they are dreadfully concrete,—take leave to give the facts of one rural district, consisting of villages and one small market town, as described by a Local Government Board official this year; and I will ask the ladies here present whether they could not match these facts in every county in the kingdom. Perhaps, too, the lady lecturers on Rural Hygiene will favour us with some of their experiences.

A large number of the poor cottages have been recently condemned as "unfit for human habitation," but though "unfit" many are still "inhabited," from lack of other accommodation.

Provision for conveying away surface and slopwater is conspicuous either by its absence or defect. The slopwater stagnates and sinks into the soil all round the dwellings, aided by the droppings from the thatch. (It has been known that the bedroom slops are sometimes emptied out of window.) There are inside sinks, but the wastepipe is often either untrapped or not disconnected.

It is a Government Official who says all this.

Watersupply almost entirely from shallow wells, often uncovered, mostly in the cottagegarden, not far from a pervious privy pit, a pigsty, or a huge collection of house refuse, polluted by the foulness soaking into it. The liquid manure from the pigsty trickles through the ground into the well. Often after heavy rain the cottagers complain that their wellwater becomes thick.

The water in many shallow wells has been analysed. And some have been closed; others cleaned out. But when no particular impurity is detected, no care has been taken to stop the too threatening pollution, or to prohibit the supply. In one village which had a pump, it was so far from one end that a pond in an adjoining field was used for their supply.

It may be said that, up to the present time, practically nothing has been done by the Sanitary Authorities to effect the removal of house refuse, etc.

In these days of investigation and statistics, where results are described with microscopic exactness and tabulated with mathematical accuracy, we seem to think figures will do instead of facts, and calculation instead of action. We remember the policeman who watched his burglar enter the house, and waited to make quite sure whether he was going to commit robbery with violence or without, before interfering with his operations. So as we read such an account as this we seem to be watching, not robbery, but murder going on, and to be waiting for the rates of mortality to go up before we interfere; we wait to see how many of the children playing round the houses shall be stricken down. We wait to see whether the filth will really trickle into the well, and whether the foul water really will poison the family, and how many will die of it. And then, when enough have died, we think it time to spend some money and some trouble to stop the murders going further, and we enter the results of our "masterly inactivity" neatly in tables; but we do not analyse and tabulate the saddened lives of those who remain, and the desolate homes in our "sanitary districts."

Storage of Excrement in These Villages. This comes next. And it is so disgustingly inefficient that I write it on a separate sheet, to be omitted if desired. But we must remember that if we cannot bear with it, the national health has to bear with it, and especially the children's health. And I add, as a fact in another Rural District to the one quoted above, that, in rainy weather, the little children may play in the privy or in the so-called "bam" or small outhouse, where may be several privies, several pigs, and untold heaps of filth. And as the little faces are very near the ground, children's diarrhœa and diseases have been traced to this miasma.

Cesspit Privies. The cesspits are excavations in the ground; often left unlined. Sometimes the privy is a wooden sentrybox, placed so that the fœcal matter falls directly into a ditch. Cesspits often very imperfectly or not at all covered. Some privies with a cubic capacity of 18 or 20 feet are emptied from once to thrice yearly. But we are often told that all the contents "ran away," and that therefore emptying was not required!

These privies are often close to the well—one within a yard of the cottagers' pump.

Earth closets are the exception, cesspit privies the rule. (In another place 109 cesspit privies were counted to 120 cottages. And, as might be expected, there was hardly a pure well in the place.)

In one, a market town, there are waterclosets, so called from being without water.

Storage of Refuse and Ashes. Ashpits are conspicuous by their absence. Huge heaps of accumulated refuse are found piled up near the house, sometimes under the windows, or near the well, into which these refuse heaps soak. Where there are ashpits, they are piled up and overflowing. Privy contents are often mixed up with the refuse or buried in a hole in the refuseheap.

As to the final disposal, in most cases the cottagers have allotments, but differing in distance from but a few yards to as much as two miles from their homes. Their privy contents and ash refuse are therefore valuable as manure, and they would "strongly resent" any appropriation of it by the Sanitary Authority.

And we might take this into account by passing a byelaw to the effect that house refuse must be removed at least once a quarter, and that if the occupier neglected to do this, the Sanitary Authority would do it, and would appropriate it. This amount of pressure is thoroughly legitimate to protect the lives of the children.

Health Missioners might teach the value of cooperation in sanitary matters. For instance, suppose the hire of a sewagecart is ls. the first day, and sixpence every other day. If six houses, adjacent to each other, subscribed for the use of the sewagecart, they would each get it far cheaper than by single orders.

The usual practice is to wait until there is a sufficient accumulation to make worth while the hiring of a cart. The ashes, and often the privy contents too, are then taken away to the allotments. A statement that removal takes place as much as two or three times a year is often too obviously untrue.

But, as a rule, the occupiers have sufficient garden space, i.e., curtilage, for the proper utilisation of their privy contents. (I would urge the reading of Dr. Poore's "Rural Hygiene" on this particular point.)

Often the garden is large enough for the utilisation of ashes and house refuse too. But occupiers almost always take both privy and ashpit contents to their allotments. Thus hoardingup of refuse matters occurs. In some cases the cost of hiring horse and cart—the amount depending on the distance of the allotment from the dwelling—is so serious a consideration that if byelaws compelled the occupiers to remove their refuse to their allotments, say every month, either the value of the manure would be nothing, or the scavenging must be done at the expense of the Sanitary Authority. From the public health point of view, the Sanitary Authority should of course do the scavenging in all the villages.

The health Economy of the Community demands the most profitable use of manure for the land. Now the most profitable use is that which permits of least waste, and if we could only regard economy in this matter in its true and broad sense, we should acknowledge that the Community is advantaged by the frequent removal of sewage refuse from the houses, where it is dangerous, to the land, where it is an essential. And if the Community is advantaged, the Community should pay for that advantage. The gain is a double one—safety in the matter of health, increase in the matter of food, besides the untold gain, moral as well as material, which results from the successful cultivation of land.

There are some villages without any gardens—barely room for a privy and ashpit. But even in these cases the occupiers generally have allotments.

Plenty of byelaws may be imposed, but byelaws are not in themselves active agents. And in many, perhaps in most, cases they are impossible of execution, and remain a dead letter.

SIGNIFICANCE

The Public Health Act of 1848 led to the creation of a Central Board of Health, as well as many Local Boards of Health, each imbued with its own duties and responsibilities. Although the Central Board of Health only lasted until 1854, the work that it had accomplished, along with that of Edwin Chadwick, Robert Peel, and Florence Nightingale eventually raised sufficient public and governmental ire and concern to cause local authorities to turn their attention to issues of public health. Between 1854 and 1871, particularly during the time that Sir John Simon served as Chief Medical Officer for the Board of Health, sanitary processes underwent dramatic improvements. There were several acts passed in Parliament, leading to the development of adequate drainage and sewer systems across many areas of the country. The Local Government Board replaced the Central Board of Health in 1871, paving the way for modernization of the public health system progressing through the end of the nineteenth and into the twentieth century and beyond. In 1872, the Public Health Act transferred responsibility for rural sanitation to the Boards of Guardians; and in 1875 the Disraeli Public Health Act was passed. In effect, the 1875 Act shifted the power and responsibility for oversight of public health, in both urban and rural areas, from central back to local government—finally ensuring that rural public health would be at the forefront of the local public consciousness.

As public methods of regulating drainage, containing sewage, and preventing contamination of the land and water systems continued to improve, the spread of disease markedly diminished. This made cities far safer and more appealing to inhabit, particularly as they typically formed the centers for industry and commerce and, therefore, were where the highest paying jobs were located. With the advent of the Industrial Revolution, leading to a burgeoning technical job market, more and more people flocked to the cities in hopes of learning and advancing trades, and earning significantly more money than ever before.

In addition, health care became centered in cities and more densely populated suburban areas—larger hospitals were built, and medical practitioners of all types moved to areas where more money could be earned. This led to a the rise of health practitioner groups, clinics, and more specialized practice of medicine—and resulted in a dearth of adequate care in outlying, less densely populated areas.

The Hospital Survey and Construction Act, commonly known as the Hill-Burton Act of 1947, attempted to address the growing health facility disparities in the United States. At the start of the Second World War, there were 3,076 named counties in the U.S.—of those, 1,282 counties had no community hospitals. There were 1,794 existent community hospitals, and a significant proportion of those were grossly inadequate or outdated. In 1944 and again in 1945, President Roosevelt declared a pressing need for adequate and appropriate health care for all people in America. In response, Senators Lister Hill and Harold Burton sponsored the above-mentioned bill, which led to a comprehensive plan in which the location, size, and type of health care and hospital facilities were determined for each state in the nation. For the first time in many areas, hospital licensure laws were created and implemented. Hospital construction plans were created and approved by the U.S. Public Health Service, and local communities were able to receive large-scale funding in order to construct clinics, health centers, and hospitals. This was of great benefit to the poorest and most rural areas, which typically had no health care whatsoever. Although most of the construction was for general health care facilities, increasing attention was also paid to specialized facilities for tuberculosis, psychiatric and chronic illness units in general hospital facilities, as well as development of rural and public health centers. Between 1947 and 1975, the last year in which Hill-Burton monies were expended, 6,900 hospitals received funding. By the middle of the 1970s, the nationwide average for community hospital beds had risen from fewer than 3 per thousand people to 4.5 per thousand. For the first time, many rural areas had access to health care and hospital facilities.

Although the Hill-Burton Act has had a tremendous and lasting impact on medical care in the U.S., the problem of ensuring adequate and appropriate access to health care for the poorest of the poor in rural and outlying areas remains. In rural areas, particularly in sparsely populated or largely impoverished regions, it is difficult to attract and retain health care providers. Generally, there is often a lack of available public transportation and a scarcity of people who can afford to access care. Some indigent people without significant education or ready transportation in rural areas often find it difficult to manage the requirements for remaining on the rolls of public health care systems, such as Medicaid. Without sufficient paying customers to ensure an adequate cash flow, there is little incentive for health care providers to locate their offices in rural areas.

FURTHER RESOURCES

Web sites

A Web of English History: The Peel Web. "Public Health: Inadequate Cleansing." 〈http://www.historyhome.co.uk/peel/p-health/clean.htm〉 (accessed August 29, 2005).

A Web of English History: The Peel Web. "Public Health: No Waste Disposal." 〈http://www.historyhome.co.uk/peel/p-health/dirt.htm〉 (accessed August 29, 2005).

The Internet Modern History Sourcebook. "Florence Nightingale: Rural Hygiene." 〈http://www.fordham.edu/halsall/mod/nightingale-rural.html〉 (accessed August 29, 2005).