Liverpool’s Dr Duncan – Britain’s First Medical Officer of Health is presented by Jan Grace from Liverpool Record Office and forms part of the Liverpool Through the Archives series, produced for the Connecting Our Communities project…
In recent months we have become much more aware of the role of Public Health in our lives. Professor Chris Whitty, as the country’s Chief Medical Officer has now taken a prominent role in the media as he advises the government on how to respond to the COVID-19 epidemic in England. He is seen standing by the Prime Minister and senior government figures at the podia of the daily briefings from Number 10 Downing Street. Professor Whitty is ultimately responsible for the course of action taken by the government to prevent the spread of the Coronavirus, a hugely challenging job as there are many unknowns about the deadly virus. He is an expert on infectious diseases and took on the role of CMO in October 2019 – a very short time before being catapulted into the public sphere and changing our lives in a way many of us would never have thought possible.
Professor Chris Whitty Chief Medical Officer for England, the UK government’s chief medical advisor and head of the public health profession
He follows a trajectory begun in Liverpool by Dr William Duncan, the country’s first ever Medical Officer of Health, who took up his newly created role during a deadly epidemic of cholera that killed large numbers of the town’s population. London and other towns followed on, but Dr Duncan was the first who had to fight for often unpopular measures, to change behaviour and improve the environment. Liverpool’s current Director of Public Health is Mathew Ashton, a different title and the role has grown and evolved enormously, but essentially Mathew is a professional successor of Dr Duncan.
Dr William Henry Duncan
Does the name sound familiar?
The name Dr Duncan is probably well known to many in Liverpool because of the two buildings named after him, the Dr Duncan pub in St John’s Lane, by Queen Square (it used to be the Pearl Insurance office) and the Duncan Building at the current Royal Liverpool Hospital.
Who was Dr Duncan?
Dr William Duncan was born in Liverpool in 1805. He went on to study medicine in Edinburgh before returning to Liverpool. Not content with simply being a physician at Liverpool Royal Infirmary he also worked at the three local dispensaries of the town and lectured in Medical Jurisprudence at the Royal Institution in Colquitt Street. He is known to have lived a modest, albeit busy life.
In 1701 Liverpool had a population of 5000, as the port became increasingly successful the town grew rapidly – by 1801 the population was 77,653.
The town had transformed as a result of its successful port.
Successful Port….but at a cost
The mercantile prosperity made it possible for magnificent new buildings to be created in Liverpool and civic pride was high. Even then Scousers were proud of their town and what it had achieved, by the mid-1800s Liverpool was frequently referred to as the country’s second city.
However, unlike Manchester and Leeds, where many of the poorer classes worked full time in mills and factories; Liverpool’s work was unreliable, casual, low paid work on the docks or in jobs supporting the port. The resulting overcrowding and lack of consistent pay had dire consequences for many if the town’s inhabitants. Behind the superb facades were labyrinths of hazardous housing where the work force that enabled the efficient running of the town’s commerce had to live.
Cheap housing was put up quickly to accommodate the influx of an unskilled labouring population. Landlords made their money by building maximum density, cramped housing around a central court that resulted in dark, poorly ventilated houses with cellars. There was no running water and no water closet toilets until into the 1860s, they had earth privy middens for human waste and water carts delivered water. The court area was either simply earth or cinders on top of earth, with a small passageway connecting the court to the surrounding streets, none of which were ever cleaned.
Dr Duncan’s role in challenging commonly held assumptions and making the evidence known
From Liverpool Dr Duncan was one of the many medical practitioners who submitted reports to the Poor Law Commission that contributed to Edwin Chadwick’s Report on the Sanitary Condition of theLabouring Population of England, produced in 1842.
As a result of the Reform Act in 1832, a Commission of Inquiry into the working of the Poor Laws was set up by Parliament. In London, Edwin Chadwick became the Commissioner: he supported the idea of a centralised department of Government supervising the provision of Poor Law – making Poor Law Unions run by Boards of Guardians and Workhouses take control from the small independent parishes that were proving to be too small to cope with the increasing numbers of destitute poor throughout the country.
Dr Duncan’s contribution publicised the link between poor living conditions and the spreadof disease. He believed that the Government should allow local councils to provide the much needed improved sanitation.
Both Duncan and Chadwick challenged the commonly held conception that it was the fault of the poor themselves that they became ill; they viewed social poverty as the cause, not individuals, and looked into things like improving sanitation and housing to help the situation. They wanted government intervention to support much needed change.
In 1843, Dr Duncan gave two lectures to the Literary and Philosophical Society – On the Physical Causes of the High Rate of Mortality in Liverpool. This was then published as a pamphlet, which had a great influence on the Town Council and resulted in them promoting the Liverpool Sanitary Act in 1846.
From the Physical Causes of the High Rate of Mortality in Liverpoolby Dr Duncan: ‘It has long been known that where a number of individuals are gathered together within a narrow compass, as in towns, the mortality among them considerably exceeds that occurring among an equal amount of population scattered over an extended surface, as in country districts’
This had an immediate effect upon the Council: Council Minutes, 2ndAugust 1843:
‘…they have been deeply impressed by the novel and appalling statements made in a pamphlet recently published by their respected and able Townsman Dr W H Duncan by which it appears that Liverpool so far away from one of the healthiest as they had thought is actually the most unhealthy town in England owing to the extreme density in which the lower classes of its population are crowded together in confined Courts and Cellars constructed without due regard to ventilation and drainage and without adequate arrangements for the removal of filth.’
Council Minutes 2ndAugust 1843
This was a shock to the local Council, who realised that something had to be done, Dr Duncan had made them aware and it was now their duty to take action, the problem was too large and complex to be left to charities. Liverpool Town Council promoted a private Bill in Parliament which became the Liverpool Sanitary Act. This Sanitary Act was promoted by the Local Authority, not Central Government, and led to the first ever appointment of a Medical Officer of Health – Dr Duncan in Liverpool.
A section from Liverpool Sanitary Act 1846 with the decision to appoint a Medical Officer of Health for Liverpool
Living conditions deteriorated rapidly after Dr Duncan’s Physical Causes of the High Rate of Mortality in Liverpool was published in 1843 as unplanned events overtook the town.
The Irish Potato Famine began in 1845 and carried on throughout 1846 and 1847. Faced with no food, many thousands of unskilled Irish families emigrated, arriving in Liverpool weakened by starvation and malnutrition. The census of 1841 shows the population in Liverpool to be 223,003, by 1851 this had risen to 376,065 – the majority of the increase in population is believed to be Irish famine victims. There had always been strong links between Liverpool and Ireland, the desperate Irish immigrants settled mainly to the north of the town in areas in and around Vauxhall and Scotland Road.
This is an excerpt from Dr Duncan’s first report in post as Medical Officer of Health in 1847: ‘…found this pauper immigration steadily increasing and it continued in such rapidly progressive rates that by the end of June not less than 3000,000 Irish had landed in Liverpool. Of these it was moderately estimated that from 60,000 to 80,000 had located themselves amongst us, occupying every nook and cranny of the already overcrowded lodging-houses, and forcing their way into cellars which had been closed under the provisions of the Health Act 1842.’
This map shows Beaufort Street with the Court housing coloured in pink for a City of Liverpool Health Report in 1904
It had been recognised as far back as 1802 that living in tiny, overcrowded, unlit cellars could not be healthy, but it took 40 years to bring in legislation to prevent it from happening. The Liverpool Building Act of 1842, gave the Council power to act if any cellar of less than 7ft high, more than 5ft below street level, or had not an area of 2ft wide was occupied.
By 1842 many of the court houses were occupied by several families with 50 or 60 people living in three to four rooms with 40 sleeping in the cellar. While the intentions behind banning habitation of cellars were good, at the time, it meant that many people were displaced and dispossessed, with nowhere to live or sleep.
As the many waves of influx of poor Irish immigrants continued, they simply had nowhere else to go, so many ended up back in the dirty, dark, damp cellars. These overcrowded Court homes were a breeding ground for rats, fleas and lice that contributed greatly to the rise of infection rates of diseases. At this time these blocks of Court housing had no running water, with one earth privy midden being shared by all the inhabitants. Cholera bacteria is found in water and food contaminated by the faeces of an infected person, so it can be seen how easily cross infection could happen in these living conditions. It is also evident how the large numbers of Irish immigrants exacerbated the already desperate overcrowded conditions in the areas of poorest housing. Cholera and Typhus had a devastating impact as the epidemics became established here.
Bostock Street Court 1900 – This image showing Court housing in Liverpool, evidencing the improvements to drainage and paving, the majority of Court houses were condemned and demolished towards the end of the 19th century, although many remained occupied with the last remaining ones destroyed in the 1960s.
Dr Duncan and his Public Health Team begin their work
In January 1847, Dr Duncan began the ground-breaking labour of forming a new department, essentially a Public Health Team within the Council structure. Dr Duncan was the Medical Officer of Health and Thomas Fresh ( Freshfield is named after him) had the wonderful title of Inspector of Nuisances, later changed to the much more mundane sounding, but very significant Sanitary Inspector. James Newlands was appointed slightly later in 1847, he was a Civil Engineer. Thomas Fresh reported incidences such as when drainage from abattoir premises seeped into cellars of homes, he visited and this was followed up by further visits to ensure that action had been taken to prevent it from happening again. James Newlands was the first Borough Engineer, he was responsible for building the first purpose designed sewer system under Liverpool that removed toilet waste and dirty rainwater.From 1847 to 1858 80 miles of sewers werebuilt and 66 miles of main drains. It took time, but eventually the privy middens were replaced by water closets which were still shared by many families in the Court houses, but was clearly a vast improvement. Newland’s contribution to the health of the lives of Liverpool’s population is vast.
The town’s water supply, originally from two wells in Bootle and Toxteth Park were bought by the Council in 1848, in 1852 the Rivington scheme was begun to increase the water supply which served the area well until Lake Vyrnwy Reservoir was needed, it opened in 1892.
Cholera Map of 1866 – a later outbreak, but demonstrates the areas most affected. Each red dot marks a death, you can see that it is the poorer, most densely populated areas where most deaths occurred.
Highest mortality rate ever known in Liverpool
It was not possible then to clinically distinguish between Typhus, Typhoid and other Fevers, at this time they were frequently referred to as ‘Irish Famine Fever’. Dysentery, infection of the intestine caused by infectious pathogens including parasites and bacteria, also presented with fever and was classed simply as Diarrhoea at this time. In 1847 when Liverpool had a population of 250,000, 5,845 people died of ‘Fever’ and 2,589 died of ‘Diarrhoea’. This was the highest mortality rate ever seen in Liverpool. It must have been a desperate time in Liverpool’s history with so many people helplessly affected by death and disease.
While being aware that overcrowding and appalling living conditions had a direct impact on the number of deaths within an area, Dr Duncan and his colleagues did not identify the reason for the rapid spreading of illness in areas of dense population, however, they did go about improving conditions to help limit the spread of infection and communicable diseases. At that time it was believed that there was a ‘miasmatic’ cause, the atmosphere in closely packed living areas where decaying vegetation with human and animal refuse combined to pollute the atmosphere. Despite not understanding the reason, they did all the right things to combat spread of disease and cross infection.
Relentless, co-ordinated work progressed
Dr Duncan, James Newlands and Thomas Fresh worked with the Council to provide the first co-ordinated response to what was needed to improve the mortality rate of the people of Liverpool, by striving to prevent the physical, social and cultural causes of disease.Dr Duncan worked with the poor and the sick, visiting them in their homes, he was systematic and worked relentlessly to advance both conditions and treatments as this excerpt from his letter book evidences:
You are probably aware that Fever is becoming prevalent in the lower districts of the town. Within the last ten days, four instances have occurred to me of parties residing in crowded Lodging homes whom the Medical Officer had recommended to be removed to the Fever Hospital, but who were not admitted in consequence of the Hospital being full. This is the statement of the parties themselves, and if true, the want of Hospital accommodation must involve serious danger to the health of the inmates of those houses in which fever occurred.
Perhaps you will be kind enough to bring this matter under the notice of the subcommittee to whose province it belongs and represent to them the expediency of providing additional accommodation if what has been stated to me is correct, for patients suffering from Fever.
I am Dear Sir,
W H Duncan
Another of Dr Duncan’s concerns was the dangerously poor quality of school rooms at this time. Dame schools were often run by elderly women in their own homes, which frequently meant small cellars or garrets in areas of Court housing:
I beg to acknowledge your note of for 30th ultimo, and to inform you that the Health Committee have ordered Back Gill Street to be cleared and notice to be served on the owner to pave and channel Back Gill Street and Back Chatham Street, both being unadopted streets.
The School you allude to in the latter street is held in a room which is in every respect Unfit for the purpose; and if you have any influence with the parties connected with the school you cannot exert it more usefully than in inducing them to remove the children to premises where their health will be less likely to suffer injury.
I am Dear Sir,
W H Duncan
Both letters are from Dr Duncan’s Letter Book, 4th May 1853 – 16 July 1855
Pioneer in the role of Medical Officer of Health
Dr Duncan had worked among the poor sick people of Liverpool as a Doctor of Medicine for many years, but had no training or role models to prepare him for becoming the Medical Officer of Health, he worked unremittingly and ultimately defined what the role was. The duties of the Medical Officer Health included engaging with communicable and infectious diseases, water supply, improving the environment, sewerage, fever hospitals and removing nuisances. Dr Duncan proved to be an effective pioneer and led the way in Public Health in Britain.
In 1848, following the Public Health Act, London appointed its first Medical Officer of Health, John Simon, by 1855 it was decided to divide London into 46 districts and each then appointed a MOH. The Chief Medical Officer is the most senior Medical Officer of Health involved in advising government.
Legacy of Dr Duncan
The success of Dr Duncan is evident; in 1846 the mortality rate in Liverpool was 36 per 1000, to 28 per 1000 in 1860, which represents the saving of thousands of lives. There were further cholera epidemics in Liverpool, in 1854 and 1866, after which there were no further major outbreaks. Duncan died at Elgin on 23rdMay 1863, aged 57, his last signed official document, a monthly report to the Health Committee on 20thApril 1863. His legacy is that Liverpool ceased to be the ‘Black Spot on the Mersey’, the most unhealthy town in the country, while there was still much to be done, things had begun to move forward and living conditions had begun to improve for the whole population of Liverpool.
It is perhaps appropriate to leave the final word to his colleague, Borough Engineer James Newlands:
Having then glanced at the progress of sanitary matters….we arrive at the period when the publication of a masterly report by Dr Duncan, our present Medical Officer of Health, stirred up the authorities of Liverpool, and the report of Mr Chadwick, on the condition of the poor, roused all England from its death sleep. Immediately succeeding it the Commission on the Health of Towns published the result of its labours, and the public began to see that much of the misery, the moral degradation, the death and the crime of the land were preventable. The incubus of ignorance was removed and action in a right direction became possible.
Getting to know Dr William Henry Duncan
Animation: A Day in the Life of Dr Duncan
This amazing animated short-film was made by Twin Vision and patients from Alder Hey Children’s Hospital, in collaboration with Liverpool Record Office. The film was made as part of the National Lottery Heritage Fund project, ‘Medical Mavericks’.
Behind the Scenes with Twin Vision and the kids at Alder Hey…
This heartwarming mini-documentary details how the children from Alder Hey worked alongside Twin Vision to produce the above animation, A Day in the Life of Dr William Henry Duncan.
- Liverpool Record Office – 352 HEA/1 The main source of information about the Cholera epidemic of 1854 is contained in one of Duncan’s letter-books, 352 MIN, Council Minute Book, Cholera Map and City Engineer photographs.
- Roger Hull, Liverpool Record Office
- Frazer, W Duncan of Liverpool (1847)
- I C Taylor MA, The Court and Cellar Dwelling The Eighteenth Century Origin of the Liverpool Slum
- Bertie Dockerill, Liverpool Corporation and the origins of municipal social housing 1842-1890
- SPW Chare, The Duncan Memorial Lecture ‘Duncan of Liverpool – and some lessons for today’ in Community Medicine 1984
- UK website, image of Professor Chris Whitty May 2020