England’s Reaction to CoVid19 Reflects 200 Years of Responses to Public Health Crises

In his press conference on 12 March, flanked by the nation’s leading health scientists, Prime Minister Boris Johnson defied expectations by sticking with a low key approach to containment of the Coronavirus – or CoVid-19 as it is known. Contrary to the policy in many countries in Europe and even the devolved administration in Scotland, that of the UK government is to limit interventions to advice and guidance. Whether or not one is convinced by this, the approach is reminiscent of other English responses to large scale public health crises from nineteenth century cholera to AIDS.

 

 

 Henry Heath, A sketch from the central board of health or the real ass-i-antic cholera!!
Lith 41 Dean St. Soho. HH [1832] Wellcome Library
https://wellcomecollection.org/works/f4573unh

Nineteenth century England was the epitome of the liberal, free trade nation with public rhetoric and policy devoted to individual responsibility and the removal of state barriers in business and private life. But it was also the site of a new urban landscape where thousands of poorly nourished individuals lived cheek-by-jowl in cramped and inadequate accommodation. Into this environment came the novel menace of cholera. When it first arrived in 1832 public authorities had few powers to limit its spread. Although some emergency legislation was introduced it was largely focused on cleaning the streets rather than limiting the interactions of the population. Quarantine may have been an appropriate response to keeping out ‘foreigners’ but not for free born Englishmen.

This was because miasma theory dominated mid nineteenth century public health thinking and influenced cholera management between 1832 and 1866. Miasma – the belief that diseases were caused by bad air rising from accumulated rubbish – proved resilient despite scientific advances because remedies for it were aimed at cleaning up the environment not curtailing the actions of individuals or trade. Moreover, responsibility for keeping the streets free of filth could be placed on householders and communities not the state, saving tax-payers from footing the bill.

West Lane Smallpox Hospital 1898

In the last third of the century policy did change to favour the isolation of those infected, especially with smallpox. Measures included the building of a network of isolation hospitals, stronger powers for local health officials to hospitalise the infected and the growth of a cadre of infectious disease health professionals. Yet even this policy remained focused on managing the individual sufferer rather than containing whole populations. Quarantine and restrictions on mass gatherings were used infrequently and responsibility for making these decisions lay with local health officials.

Friern Hospital, London: a young girl, head and shoulders, with smallpox. Photograph, 1890/1910.

https://wellcomecollection.org/works/qf596hg6

This approach was put to the test in the Influenza Pandemic that swept across the world in 1918. Britain had a highly advanced healthcare system, with health insurance for a substantial number of workers, an extensive general hospital system free to much of the poor, a network of poor law infirmaries providing a general safety net, and a nationwide isolation service. In the preceding years infectious disease protocols had been developed – notification, isolation in a hospital, disinfection and medical inspection of contacts – and local medical officers had considerable power to enforce isolation.

But when the Flu came this infrastructure proved completely inadequate. Victims came down with the disease quickly and many died within four days of catching it. It hit younger adults hardest – the elderly often taking to their beds and recovering while the young tried to carry on. The scale of the pandemic meant health institutions couldn’t cope with the volume of cases. Isolation was impossible at a municipal level and especially not in the home while hospitals were of limited use. The health services had been denuded by the War and the population were weakened by four years of shortages and intense working.

                               

Report on the sanitary condition of the Metropolitan Borough of Hackney for the year 1918, p21-22
https://wellcomelibrary.org/moh/report/b1811670x/20#?m=0&cv=20&c=0&s=0&z=-1.2462%2C0.1087%2C3.2771%2C1.302


So the government reverted to type and adopted an individualised, liberal response. The central state did little beyond ordering that cinemas be aired every three hours. They refused to close schools and left the management of the population to local medical officers. The response of the Medical Officers of Health varied from authority to authority – as shown by the different London boroughs. As with self-isolation today, the key message to emerge from health departments was for ‘the individual to apply such measures to him or herself…what may be termed personal or individual preventive measures’. Some health advice was given, including ‘snuffing’ a permanganate of potash, salt and water mixture two or three times a day. Some boroughs posted health advice around town. That from Hackney looked very like the advice so far released by the UK Government with: warnings that people would die; advice to self-isolate if infected; the need to prevent the spread by coughing or sneezing into a handkerchief; ensuring personal and environmental cleanliness; ventilation of homes and workplaces; warm clothing; plus the reminder that ‘excessive drinking favours the spread of the infection’ – though how was not explained.

At the time of writing the government has just proposed more stringent measures to control the behaviours of the population. But what is clear from the historical record is that the response so far is part of a long English tradition of resistance to dirigiste interventions in public health in favour of a strong emphasis on the promotion of individual responsibility for both personal and public good.

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