Toward the middle of the nineteenth century, people’s fatalistic acceptance of their overcrowded, unsanitary surroundings began to give way to a growing interest in reform and improvement. Edwin Chadwick, one of the commissioners charged with the administration of relief to paupers under Britain’s revised Poor Law of 1834, emerged as a powerful voice for reform. Chadwick found inspiration in the ideas of radical philosopher Jeremy Bentham (1748–1832), whose approach to social issues, called utilitarianism, had taught that public problems ought to be dealt with on a rational, scientific basis to advance the “greatest good for the greatest number.” Applying these principles, Chadwick soon became convinced that disease and death actually caused poverty because a sick worker was an unemployed worker and orphaned children were poor children. Most important, Chadwick believed that government could help prevent disease by cleaning up the urban environment.

Chadwick collected detailed reports from local Poor Law officials on the “sanitary conditions of the laboring population” and published his hard-hitting findings in 1842. This mass of widely publicized evidence proved that disease was related to filthy environmental conditions, which were in turn caused largely by lack of drainage, sewers, and garbage collection. In 1848, Chadwick’s report became the basis of Great Britain’s first public health law, which created a national health board and gave cities broad authority to build modern sanitary systems.

The public health movement won dedicated supporters in the United States, France, and Germany from the late 1840s on. Governments accepted at least limited responsibility for the health of all citizens, and by the 1860s and 1870s, European cities were making real progress toward adequate water supplies and sewerage systems. Though pollution remained a serious problem, city dwellers started to reap the reward of better health, and death rates began to decline (Figure 22.1).