Public Health versus Private Practice: The Contested Development of Compulsory Infectious Disease Notification in Late-Nineteenth Century Britain

The administrative structures established in the Victorian era for the registration of sickness exist to this day. The pivotal epidemiological role of notification for the surveillance of diseased individuals continues to be discussed globally; the issues include ethical problems regarding HIV notification and patient confidentiality, the monitoring of reemergent infectious diseases such as tuberculosis, and the politically explosive issue of food hygiene scares such as salmonella and BSE. ¹ Recent research has also begun to demonstrate the historical importance of disease notification for the development of local public health intervention in the late nineteenth century and the expansion in the volume and type of medical services. ² Nonetheless, the development of legislation for the compulsory notification of infectious disease remains largely a neglected topic. The understandable temptation thus far has been to subsume the few existing accounts of the history of disease notification under the more convenient umbrellas of cause-of-death reporting, death certification, and the collection of mortality statistics. ³ This article demonstrates that recent works examining the changing nature of public health policies toward the end of the nineteenth century in Britain, and the commodification of health care, all suggest a fresh way forward for research into infectious disease notification.

The focus of public health action in mid-nineteenth-century Britain was primarily upon large-scale projects of “preventive” sanitary engineering. ⁴ However, very important incremental moves were made toward controlling individuals with contagious or infectious diseases who were perceived as a threat to wider society. By the beginning of the 1870s, for example, common lodging-house tenants with an infectious disease were reported to the local sanitary authority; prostitutes were inspected as a precautionary measure against the spread of venereal disease; and all infected people’s public movements were restricted, under the threat of removal from the community and into hospital. But these measures provided a means of control over only a small percentage of the populace. In the absence of a national register for sickness or disease, town authorities were pressured by their salaried public health officials to legislate for infectious disease notification, which would serve to bring all infected individuals—regardless of their economic status or occupation—under the gaze of the local sanitary department. ⁵

The notification clauses that were introduced under Local Improvement Acts eventually found their way into countrywide legislation for the compulsory notification of infectious disease, but by no means was this transition from parochial to state law a smooth one. Legislation was most effectively hampered by opposition from the private medical profession—family practitioners—who maintained that notification jeopardized their confidential relationship with their patients, which was enshrined in the ancient Hippocratic oath. The inviolability of this confidentiality was contested by the public health profession, on the grounds that notification placed a greater value upon the physicians’ responsibility to the well-being of society than it did upon their relationship with individuals. In this article I will seek to evaluate the legitimacy of these claims and underline their central importance for a conflict that set the fundamental precepts of public and private medicine against one another. After providing a detailed examination of one particular case of medical opposition to notification in Liverpool, I will consider how the many theoretical and practical themes recurring in this conflict were articulated: the mode of notification—compulsory or voluntary, by either the householder or the family physician; the financial issues of remuneration and penalization; and state incursion into individual freedom. First, however, an introduction to the legislative framework is required.

Legislation Preceding Compulsory Infectious Disease Notification

Dorothy and Roy Porter have suggested that the introduction of the Infectious Disease Notification Acts in England and Wales in the 1880s and 1890s represented “a striking infringement of the traditional freedom to be sick, and to spread one’s sickness, with impunity.” ⁶ Despite this, they argue, the Acts aroused little public opposition, because “by the last quarter of the nineteenth century the public was becoming acclimated to a new medical rationality that might involve the trimming of its...