publichealth-4c

file: hph_lec4c.mp3
A History of Modern Public Health: Surveillance - The World of
Work, Part A

In this section on medical opinion and state intervention, I am
going to be looking at the three key groups of physicians that
had an input into the factory question. We are also going to be
discussing the ways in which medical opinion didn't really force
itself into the legislation and into the minds of the legislators
when they were shaping factory reform. And we will be looking at
the reasons why the medical input tended to be sidelined. And it
is important to note that the majority of medical men who were
involved in what was known as the factory question were in favor
of intervention. Three key groups gave evidence to parliamentary
inquiries up to the 1830s. And as I said in an earlier part of
the class, it was the early part of the century between 1800 and
1830 that there is a lot of discussion and a lot of activism
around the conditions of factories and mills and their
relationship to health and work. So there is an, there is an
input here from doctors that we need to consider. And one of the
first groups to give evidence were metropolitan medical elites.
And these were particularly London professors of surgery and
anatomy who were internationally known, had prominent positions
in the London hospitals, and it was not uncommon for them to be
called to parliament to give evidence and to give their opinions
on some of the key questions of the day, relating to health.

A second group of doctors who were important in providing opinion
were provincial practitioners. And they were predominantly
surgeons and physicians who practiced in factory towns. And it is
important to note here that for these practitioners to express an
opinion about the health-threatening aspects of factory work and
mill work was rather a courageous act to undertake. What we need
to remember is that medical practice was private practice in this
period. Many of the patients that these provincial practitioners
would have served would have been drawn from the factory-owning
classes and the employers in mills, and for those practitioners
to speak out over the health conditions within those factories
would have meant them risking losing a very important patient
base and clientele in their private practice. So for them to
denounce the factory system was an important step for them to
take. So they had to be very convinced in their belief that there
was this relationship between factory system and worker health.

And a third group were medical activists. And these were people
who advocated social reform to improve health on a much wider
level than simply giving evidence at parliamentary inquiries. And
I want to just take some of the evidence and some of the opinions
that these sets of groups, that these three groups put forward as
illustrative of their arguments. So one of the well-known London
practitioners who provided evidence to parliamentary enquiries on
the relationship between factory work and ill health was Charles
Bell. And he was a professor of anatomy at the Royal College of
Surgeons of London. And he argued that factory work was very
dangerous for the constitution of the workers and that it
engendered a variety of diseases. So, and to quote: "Factory work
would be very injurious to the constitution and engender a
variety of diseases. The great disease is scrofula. Where there
is a want of exercise, deficient ventilation, depression of mind,
and want of interest in the occupations, I should say especially
in young persons, scrofula and its hundred forms would be the
consequence." Scrofula is a disease associated with tubercular
infection, as we know today. But one of the points from this
quote that is crucial is that not so much that Charles Bell is
associating factory work with the particular disease scrofula,
but it is also his comments about the general impact of factory
work on the constitution and on the range of diseases that
factory work might result in.

This is underlined by the medical opinions that were expressed by
the provincial practitioners that we noted in an earlier slide,
those physicians and surgeons who practiced in the manufacturing
towns in Britain. And what we have here are two quotes, one from
Samuel Smith who was a lead surgeon and one from Charles
Thackarey who suggest again this constitutional impairment to
health that work has. So Smith is quoted here as saying that
there is no actual disease present - he means in workers - yet
there is a continual tendency to disease. There is a diminished
power in the body of resisting the attack of disease. And
Thackarey states that workers in general were strangers to
health. They live, it is true, but life is not a full life. With
many it is but a state of lingering disease.

And what you can see on the left-hand side of this slide is an
image taken, in fact it is taken from New York City in the early
20th century that is fairly illustrative of the types of problems
that these provincial surgeons were drawing attention to in
Britain in the early 19th century. They were very worried about
the impact that work had on the physical growth and the physical
development of children. And this was expressed particularly in
high rates of child mortality and child morbidity. And this is a
picture of a stunted urban youth whose family had taken advantage
of free ice distribution in New York City in 1919. But this is
the type of physical development issues that these surgeons were
concerned with.

So these physicians are arguing that the damage done by factory
work did not necessarily manifest itself as a specific disease,
its effects were constitutional. And it was particularly
problematic for children because they were growing. So
deformities in children were attributed to the repeated motion of
machinery and tending that machinery - as I mentioned earlier,
children quite often were employed in a factory to clean large
machinery - or the harmful effects were attributed to long
periods of standing at machinery during the years of growth when
the bones were still malleable. So what we have got here is a
systematic destruction of bodies: physical bodies, the social
body, and also the spiritual body.

And a number of medical men saw political economy as the key
problem, and they sought to cultivate a political medicine in
response. And one of these examples comes from the third group of
medical opinion makers, the social reformers, who argued that the
ill health engendered by working conditions was a species of
infanticide. And this particular quote comes from John Farr who
had practiced medicine on slave plantations in Barbados and saw
an inherent opposition between medicine and political economy. So
Farr suggests that this relationship between ill health and work
was a species of infanticide, and a very cruel because lingering
species of infanticide, and the only safeguard consists in
opposing this principle of political economy by the medical voice
whenever it trenches on vital economy. So effectively what he is
saying here is that working conditions impinge upon the health
conditions of the workers and that it is up to medicine to
articulate the problems that arise through working practices in
factories and mills.

But a number of historians have drawn attention to the fact that
this political medicine never came to fruition. And they have
identified three key areas in relation to this problem. It has
been argued that the political medicine never emerged because of
resistance from supporters of the factory system, from the
priorities of working-class radicals and problems with the
medical profession and medical knowledge itself. To take the
first of these and resistance from support of the factory system,
some argued that the factory system was not a public problem at
all. Wages were paid to free laborers, and this, these wages
compensated for any injury to their health that the working
system caused. Others argued that a problem did not even exist.
As I mentioned earlier, there was a consideration that life
itself was fatal. There may not be a balance between work and
health, there was just an inescapable trade-off. And work was
seen as a way to achieve health. As one Leeds manufacturer,
Edward Banes, put it: "Food cannot be obtained without toil, but
toil is less evil than hunger." So the implication here is that,
okay, laborers might not be achieving the wages that they desire,
but at least that the wages that they get prevent them from
falling into a situation where they can't afford any food at all.
So at least work staves off death.

A second key point is that the priorities of working-class
radicals and working-class agitators did not lie with health as
such. To begin with, working-class radicals in this crucial
period of the early 19th century had an intense dislike of
bureaucracy and dependence on bureaucracy. They argued that
paternalism and paternalistic legislation always wanted something
in return. And usually in the case of workers, that was
passivity. Also, the working-class radicals were more interested
in democracy and civil rights than they were in starvation and
exhaustion. Their priorities at this period lay with control over
taxes, labor laws, tariffs, and relief policies as well as
participation in democracy and the right to vote. So health and
the consequences of ill health in the factory system were not at
the top of the working-class agenda.

And thirdly, historians have identified that there was a problem
with the medical profession itself and with medical knowledge
that meant that this political medicine never came to fruition.
It has been noted that none of the four factory inspectors who
were appointed in the 1833 legislation was a physician. And there
were three key reasons as to why this might have been the case.

First of all, medicine was a divided profession. It was poorly
united, it was an overcrowded profession, and it was prone to
squabbling. So it was very difficult for the medical profession
to present a united opinion or a united face about any of the key
problems that were emerging in this period. Secondly, the medical
profession in this time was also an intensely private profession.
Unlike the church which had roles in education and charity, and
unlike the law which had roles in writing briefs, pleading, and
judging, medicine was the only one of the three medieval
professions that continued to be practiced privately. And to
practice medicine in this period was not to make health policy.
Medical men advised, they did not dictate or rule. And in
particular medical men advised individuals about their health
rather than groups of the population. So it's been argued that
the medical approach to health which is highly individualistic
was not particularly appropriate to solving problems in the
aggregate. Medical knowledge traditionally conceived did not
recognize people in general, and so patient-initiated
consultations to resolve particular ill-health problems for
individuals have nothing to do with making policies for
populations. And so these are the three key points as to why
medicine had a restricted input into factory and work place
legislation in the early years of the 19th century.

This changed somewhat during the 1850s and the early 1860s when
there was the establishment of a Centralized Medical Department
in London. And what this Centralized Medical Department carried
out were epidemiological surveys of industrial areas and specific
occupations. And one of the members of this, the Medical
Department, Dr. Edward Greenhow, for example, undertook a major
investigation into 33 industrial towns. And using early
epidemiological techniques, Greenhow established that pottery
workers in Stoke-on-Trent, which is a town in the English
midlands, had a far higher rate of mortality from pulmonary
tuberculosis and other respiratory diseases than the rest of the
population, and this was particularly associated with grinding
and glazing that took place in the pottery-making processes. And
other investigations were undertaken into the industrial uses or
arsenic, phosphorus, lead, and mercury, and so specific diseases
were beginning to be connected with particular industrial
processes and specific industrial hazards.

And what you have in response to these epidemiological
investigations that involved physicians and early epidemiologists
collating and collecting information from across the country were
additional factory acts. So in 1864, 67, 1875 and 78 you have a
number of factory and workshop acts that looked at different
aspects of the system. So for example in 1864 legislation
instituted that factories should be kept in a cleanly state and
ventilated, and the purpose of the ventilation was as far as
possible to render harmless gasses and dust and their impurities
that were associated with disease. Other acts, the Public Health
Acts in particular of the 1870s extended the definition of
nuisances in the environment to all factories and workshops. So,
in other words, if there was any particular environmental
nuisance such as the accumulation of filth or dirt that took
place within a factory, the factory owners had a legal
responsibility to remove those nuisances.

Another factory and workshop act extended the protections that
were seen for children in the 1833 act to women. And it is
important to note that these factory acts protected them from
certain harmful processes and required for example fans in
factories to disperse dust and gasses where grinding, glazing,
and polishing took place. So as legislation gradually took hold,
albeit in a piece-meal and slow fashion, in Britain and the rest
of Europe, it is important to emphasize that there was
variability. And the United States is a good example in this
respect. And part of the reason why worker and health legislation
lagged behind Europe in the United States is simply due to the
fact that industrialization and urbanization in the United States
tended to lag behind that in Europe and Great Britain. So there
is a chronological aspect to the implementation of legislation.
You can see from this representation about working conditions
which again is taken from the publication on 50 Years of
Occupational Health that we saw at the beginning of this class,
at the beginning of the 20th century, it was recognized that
urbanization and industrialization represented hazards to health.

By the early 20th century, the United States was seen as a
progressively more dangerous working environment. And you can see
from these quotes from a popular magazine in 1904 that says it is
becoming as perilous to live in the United States as to
participate in actual warfare. There was a high level of public
awareness of this problem. And just as an example of the
differences between the United States and Europe, one statistic
that was frequently used was that in the early 20th century in
England, Germany, and France in the mining industry, there were
fewer than 1-1/2 deaths per thousand workers. But during the same
period in the United States in the early 20th century, more than
3 miners for every 1000 could expect to die while working in any
given year. So it doesn't sound a great difference, but it was
significant enough to make people aware that the doubling of the
mortality rate in the United States as compared to Europe meant
that there might be some specific legislation that was required
in the US.

And this was allied to the fact that there was a general belief
that medical opinion tended to ignore the health aspects of work.
It was known that the industrial workers' lifespan was short, and
as this excerpt suggests, in some trades, death in the thirties
(around about the age of 30, that is, not the 1930s), death in
the thirties was common, and that for all that work itself, in
other words in all trades, the workers useful life was shortened
for those who lived in their 40s and 50s by serious disabilities.
But the key point here is to make the comparison with Britain in
the 1840s before, where there tended to be also a sidelining of
the medical evidence. And there is a parallel to be drawn with
this quote where it says that even when industrial diseases and
disabilities were identified, they were ascribed to other causes.
So there is a problem here about the use and the deployment of
medical knowledge that is identified in the United States in the
early 20th century, and that was similar to Britain in the early
19th century. As the text shows, even when industrial diseases
and disabilities were identified, they were ascribed to other
causes. However, the evidence was mounting, and there was a great
deal of survey research that was undertaken in the early 20th
century that did make more concrete these relationships between
health, disease, and work.

One such example was a survey of the Jewish garment workers in
New York in 1914 that was undertaken by the International Ladies
Garment Workers Union. And this survey was assisted by the Office
of Industrial Hygiene and Sanitation that was set up in 1914 and
that we will discuss in the next slide. But for the moment, what
you see here is a concern with what are known as the "sweated
industries," the "sweated trades," trades such as garment
workers, tailors, that were undertaken in small, cramped
conditions, quite often related to what was known as piece-meal
work: So the worker would receive a small remuneration for every
piece of work that was carried out: Say every hat that was made,
every pair of stockings that was made, there would be a payment
on a piece-by-piece basis. And you can see from the
representation, these cramped, overcrowded, dark conditions were
inimical to health.

And the survey in 1914 looked at more than 2000 men and 1000
women, and it found or argued that each worker had an average of
4.36 defects. So in other words, there were more than 4
individual or specific diseases or injuries or health problems
that each worker in this garment industry had sustained. There
were also specific gender differences. So the argument of the
survey was that women tended to suffer particularly from
gynecological problems, and men tended to suffer from respiratory
problems and particularly pulmonary tuberculosis.

And what emerged from these sorts of surveys was that health was
associated in particular with the strength of the labor movement.
So labor organizations would undertake these surveys into the
relationship between health and specific forms of work, and the
knowledge that was gained and the information that was
assimilated and sifted in relation to health and work was used as
a way of measuring the strength of the labor movement itself. And
so even though one could argue from today's viewpoint that many
of the conclusions were tenuous and shaky, so for example how it
could be determined that respiratory tuberculosis in men was due
specifically to the work environment or to the home environment,
or how gynecological problems in women could be directly
connected to their working practices, they were very important
epidemiological investigations from a political point of view.

And this is also true of the investigations of Alice Hamilton who
undertook epidemiological surveys in Illinois in 1910 and 1911.
Hamilton was a graduate of the University of Michigan, and she
investigated the health problems that were associated with
exposure to lead in the early 20th century. And the types of
epidemiological studies that she conducted became part and parcel
of the sorts of responsibilities that were designated to the
Office of Industrial Hygiene and Sanitation when it was set up as
part of the public health service in 1914. However, the impact
was relatively limited, and so by 1921, 25 states had guaranteed
work compensation, that is, compensation for accidents or
diseases contracted while at work, this concession was secured at
a cost. So prompt and sure remuneration for employees regardless
of who was at fault for the industrial accident or disease came
at the expense of giving up the right to sue employers. So most
legislation was at the state level, and there was very little
federal control.

One of the additional obstacles to the progression of
legislation, as well as the fact that it was fractured at the
State level and there was relatively little central control, was
that employers organized a response to the potential
interventions that might take place. So in 1911, the National
Safety Council was set up, and it shifted the focus that had
emerged in the early 20th century over the relationships between
ill health and work, it shifted that focus to worker safety as
opposed to the wider implications for health of work and the
problems of industrial diseases. And the recognition here is that
corporate leaders were understanding that safety paid and that
employers benefited economically by taking the lead in accident
prevention. So you have a shift in focus to accident prevention,
and that is initiated by employers rather than employees. And one
of the key aspects of this shift was that workers had to be
educated to protect themselves from accidents. So it's a
reorientation of the emphasis away from the conditions of
factories and workshops towards the behaviors that workers take
to protect themselves from accidents and injuries.

And in order to fulfill that educational role, there was a key
place for the professions, particularly the medical professions.
So during the 1920s, hundreds of companies had their own
physicians, nurses, and medical personnel to monitor to the
limited level but also provide education and advice to the work
force and the best ways of preventing accidents and securing
their safety. And it was part of this self-monitoring and the
employment of this medical personnel that meant that legislation
and intervention in the work place was not necessarily ignored
but it was put on the back burner. It was seen as not being a
priority. Many of the employers and the corporate businesses were
allowed to monitor themselves and to provide this level of
education, and this was seen as being adequate for worker
protection.

However, there was a re-emergence in the 1960s - and we are
taking quite a big jump there from the early 20th century to the
middle of the 20th century - there was a re-emergence in the
1960s of wider social concerns about environmental pollution and
industrial hazards. And the overall outcome of those concerns
were 3 sets of legislative enactments. The first of all was the
Mine Safety and Health Act of 1969 which regulated conditions in
the mines. The second was the setting up of the Occupational
Safety and Health Administration in 1970 which was important in
setting and enforcing health and safety regulations in the work
place. And this was allied to the organization of the National
Institute of Occupational Safety and Health in the same year,
1970, which was set up to establish safe levels of exposure to
industrial pollutants. So you have three sets of legislation in
the United States in the 19. late 1960s and early 1970s that
reflect a growing concern over conditions in the work place, and
this is, if you like, it mirrors the slow and piece-meal
progression of legislation that we observed in Britain in the
19th century.

I'm drawing your attention to these posters as an exercise in
order for you to appreciate a little bit more fully the ways in
which the relationship between work and health concentrated
particularly on accidents and worker safety as opposed to disease
and wider problems of ill health. And what you have here is a
series of advertisement or if you like health promotion campaigns
that are directed predominantly and specifically at workers. And
what is interesting about these posters that all date from the
early to mid 20th century is the way in which they use
information to express the relationship between worker safety and
the wages that workers might lose through injury and accidents,
the relationship as well between worker safety and the
responsibility that the worker has to look after themselves. So
you can see particularly in the example in the bottom left, there
is an invocation of eye protection. You can see in the rather
striking image of the black cat, and you can also see in the
image in the top right-hand corner about recklessness that
workers are being exhorted to take particular care for themselves
and for their own responsibility. There is very little indication
in these posters, perhaps with the exception of the poster in the
middle on the bottom row that worker safety and accident
prevention is a partnership between the employers and the
employees. Very much the focus here is upon what the employee can
do for him- or herself in the prevention of accidents.

And one of the key ways in which this was expressed was to
emphasize the loss in wages to workers. So you can see in the top
row in the middle that in 1921 12 million pounds - this is in the
UK - was lost by industrial workers in wages due to accidents.
"We don't want the same carelessness," it says, "to hand in a
similar bill this year." And so it is relating an industrial
accident to the take-home pay in the worker's pocked, because it
wasn't uncommon in this era for a worker to completely lose their
wages and lack compensation if they, for example, had to take a
week off because of an accident or ill health.

So with that point we have come to an end in our discussion of
the variability of legislation and the piece-meal aspects of
intervention in the work environment from an international
perspective. There are different chronologies involved, there are
different types of intervention that are involved, but one of the
key points, in summary, and certainly in the case of the United
States is the focus on the worker themselves.

But what I want to do in the next section is to look at some of
those wider studies that highlighted the relationship between
particular trades, particular occupations and specific diseases.