WOMEN AS SANITARY INSPECTORS AND HEALTH VISITORS
The introduction of women into the public health service is a modern
development, although they have been engaged in it longer than is
usually known.
Women who are employed in Public Health Work hold office under Local
Sanitary Authorities, and their work must not be confused with that
of the Women Home Office Officials, who were first appointed in 1895;
these inspect factories and workshops, but their powers and duties
are of a different character. For instance, the Women Home Office
Inspectors deal, amongst other things, with the cleanliness of
factories, but not with the cleanliness of workshops, and with the
heating of workshops, while the ventilation of the same workshops is
under the control of the local sanitary officials.
Glasgow was the first county borough to utilise the services of Women
Health Officials, for in May 1870 four "Female Visitors," afterwards
known as Assistant Sanitary Inspectors, were appointed in connection
with the Public Health Department. Their duties were: "by persuasion
principally, to induce the women householders to keep the interiors
of their dwellings in a clean and sanitary condition, and to advise
generally how best this can be maintained." They possessed the same
right of entry to premises as the men inspectors, and were required
to hold the certificate of the Incorporated Sanitary Association of
Scotland. They reported certain nuisances, but themselves dealt
with others, such as "dirty homes or dirty bedding, clothing, and
furnishing."
The work of Women Health Officials in England, dates from the passing
of the Factory and Workshops Act of 1891, when certain duties with
regard to workshops, which had previously been performed by the Home
Office Inspectors, were laid upon Sanitary Authorities.
In the opinion of Dr Orme Dudfield, late Medical Officer of Health
for Kensington: "It soon became apparent that, not only was systematic
inspection necessary, but also that many of the duties involved
were of so special and delicate a nature that they could not
be satisfactorily discharged by male inspectors." He therefore
recommended the appointment of two Women Inspectors of Workshops in
Kensington. In the meantime the city of Nottingham had appointed a
Woman Inspector of Workshops in May 1892, and in accordance with
Dr Dudfield's recommendation two Women Inspectors were appointed in
Kensington in 1893.
These ladies were appointed as inspectors of workshops _only_.
They did not hold Sanitary Certificates, nor had they the status of
Sanitary Inspectors. In practice, this entailed a visit by a male
inspector every time it was necessary to serve a legal notice for
the abatement of any contravention of the Factory and Workshops'
Act. Therefore, when these ladies resigned upon their appointment as
Factory Inspectors, it was decided to appoint the in-coming ladies as
Sanitary Inspectors, with power to deal with these matters themselves.
It was, however, Islington which appointed the first woman with the
legal status of Sanitary Inspector in 1895.
By 1901, eleven women had been appointed in the Metropolitan area as
Sanitary Inspectors, nearly all of them exclusively engaged in the
inspection of workshops. Since that time the number of women appointed
by Local Sanitary Authorities has increased considerably, both in
London and the Provinces. The exact number outside London is only
known approximately, as no register exists which is available to the
public. It is to be hoped that this information may be obtainable
from the last census returns. The figures with regard to London are
published annually by the London County Council, and there are now
forty-one Women Sanitary Inspectors in the Metropolitan area.
Sanitary inspectors in London, whether men or women, are required to
hold the certificate of the Sanitary Inspectors' Examination Board,
the examination for which is the same for men and women.[1] Outside
London no definite qualification is required by the Local Government
Board, but it is usual in county and municipal boroughs for a sanitary
certificate to be demanded from candidates for the position of
Inspector of Nuisances (the term used outside London for Sanitary
Officials). Men and Women Sanitary Inspectors possess equal rights of
entry to premises and equal statutory powers for enforcing compliance
with the law.
The duties of Women Sanitary Inspectors have become very varied and
numerous during the past ten years; they differ considerably according
to locality and to the opinions of the local Medical Officer of
Health. Broadly speaking, before 1905 women in London were mainly
engaged in the inspection of workshops, whereas in the Provinces (with
the exception of Nottingham, Leicester, and Manchester) they were
engaged in house-to-house visitation in the poorer parts of the towns,
with a view to the promotion of cleanliness, giving advice to mothers
concerning the feeding and care of infants and young children, and
the detection of sanitary defects. The inspection of workshops in the
Provinces was a later development.
These varied duties have called for special qualifications, and, in
addition to certificates in sanitation, Women Sanitary Inspectors
usually hold qualifications in nursing or midwifery. The general
education of the women who take up this profession is, on the whole,
superior to that of the men. Most of the women have had a high school
education, and many are University graduates, while the men, as a
rule, come from the elementary schools.
The duties of a Woman Sanitary Inspector are sufficiently varied to
avoid monotony, and may comprise any or all of the following:--
_A_. (1) The inspection of factories in order to
see that suitable and sufficient sanitary
accommodation is provided for women,
in accordance with the requirements of
the Public Health Acts.
(2) The carrying out of the provisions of
the Public Health and Factory and
Workshops Acts, with regard to the
registration and inspection of
_(a)_ laundries, workshops, and workplaces
(including kitchens of
hotels and restaurants) where
women are employed;
_(b)_ Outworkers' premises.
(3) The inspection of tenement houses and
houses let in lodgings, and the enforcement
of the bye-laws of the Sanitary
Authority affecting these.
(4) House-to-house inspection in the poorer
parts of the district.
(5) The inspection of public lavatories for
women.
(6) The carrying out of duties and inspection
concerning
(_a_) Notifiable infectious diseases,
such as scarlet fever.
(_b_) Non-notifiable infectious diseases
such as measles.
(_c_) The notification of consumption.
(7) Taking samples under the Food and
Drugs Acts. (This work is rarely
given to women.)
For many of the above duties, women are obviously better fitted than
men, but for the following most important group of duties men are
practically disqualified by reason of their sex:--
_B_. Health visiting. Work in connection with
the reduction of infantile mortality :--
(1) Notification of Births Act, 1907. Visiting
infants and giving advice to mothers
about the feeding and general management
of young children.
(2) Advising expectant mothers on the
management of their health and as
to the influence of ante-natal conditions
on their infants.
(3) Work in connection with milk depôts and
infant consultations.
(4) Promotion of general cleanliness in the
home and discovery of sanitary defects
remediable under the Public Health
Acts.
(5) Investigation of deaths of infants under one year of age.
(6) Lecturing at mothers' meetings.
(7) Organisation of voluntary Health
Workers in the district and arrangement
of their work.
_C._ The following duties may also be required
in the Provinces:--
(1) Work relating to the administration of
the Midwives' Act, 1902 (where the
County Council have delegated their
powers to the District Council).
(2) The inspection of shops under the Shop
Hours Act, 1892-94, and the Seats for
Shop-Assistants Act, 1899.
The work described under _C._ 1 and 2, is performed in London (except
in the City) by special inspectors appointed by the London County
Council, who also inspect employment agencies where sleeping
accommodation is provided and carry out certain duties under the
Children's Act.
(3) Work in connection with the medical
inspection of school children (performed
in London by the London
County Council school nurses).
The duties of Men Sanitary Inspectors are very clearly defined, and
differ considerably from those of the women. Men are mainly engaged
in the inspection and reconstruction of drains, the detection of
structural defects in the houses of the working classes, the carrying
out of bye-laws with regard to tenement houses, the investigation of
cases of notifiable infectious diseases, the inspection of workshops
and factories, the enforcement of the law with regard to the sale of
foods and drugs and the abatement of smoke nuisances.
As will be seen from the duties enumerated above, Women Inspectors, as
a general rule, are brought into very close and intimate contact with
the homes of the people, and this necessitates the exercise of much
tact and patience. The large demands thus made upon their powers of
persuasion and teaching capacity, involve a considerable strain upon
their nervous energy as well as their physical strength. The work
of the Men Inspectors, on the other hand, being of a more official
character, does not involve the same strain.
There is no uniformity of practice with regard to hours of work,
holidays, remuneration or superannuation, either within or without the
metropolitan area. Each Local Authority makes its own arrangements.
Many have no superannuation scheme and give no pensions. Men and women
working for the same Authority usually work under the same conditions
as to hours and holidays: the rate of remuneration, however, is by no
means the same. The salaries of Women Sanitary Inspectors within the
Metropolitan area range from £100 to £200 per annum, the latter figure
being reached only in two boroughs and in the City of London: whilst
the salaries of the men range from £150 to £350. The average maximum
salary of the women is £150, and the average maximum salary of the men
is £205. Outside London, the salaries of both men and women are lower,
those of the women ranging from £65 to £100, a few rising to £150.
Payments are made monthly, and a month's notice can be demanded
on leaving, though it is frequently not enforced. Another unjust
distinction frequently made between men and women is that the latter
are generally compelled to retire upon marriage, thus enforcing
celibacy on some of our most capable women.
The hours of work are usually from 9 A.M. to 5 or 6 P.M. and to 1
P.M. on Saturdays. If we consider the nature of the work, the holidays
appear most inadequate--viz.: only from two to three weeks per
annum are allowed in London, and from ten to fourteen days in many
provincial towns.
The Health Visitor, as a public official, was not known until 1899,
when several were appointed by the City Council of Birmingham. The
name "Health Visitor" was thought to be more feminine and suitable
than that of Inspector, and it was imagined that she would in
consequence be better received in the homes of the people. As a
private society in Manchester had previously engaged women of an
inferior class and education with the title of "Health Visitor," this
designation was deprecated by women already in the profession. Many
smaller provincial towns, however, followed the example of Birmingham,
and appointed Health Visitors instead of Women Sanitary Inspectors.
It was not until later that the Health Visitor was introduced into
London, and in the following way:--
In the Metropolitan area (exclusive of the City) half of the salary
of all Sanitary Inspectors is paid out of the County Rate, and their
duties are defined in Sections 107 and 108 of the Public Health
(London) Act, 1891. As Medical Officers of Health and the public
generally became more and more interested in the question of infant
mortality, Women Inspectors were employed to investigate infant
deaths, to visit houses where a birth had taken place and advise
mothers on infant care, to manage milk depôts, to weigh babies, and to
assist at infant consultations, and to do a great deal of work which
hitherto had not been considered the work of a Sanitary Inspector.
There was never any question as to the value of the work done nor of
the efficiency with which it was performed, but the Local Government
Board Auditor took the view that it did not come within the scope of
the order of 1891, defining the duties of a Sanitary Inspector, and
he refused to sanction the payment out of the County Rate of half the
salary of those women who were engaged in Health Visiting work. In
March 1905, the borough of Kensington solved the difficulty for itself
by appointing a Health Visitor and paying the whole of her salary out
of the Local Rate; but less wealthy boroughs felt unable to do this.
It was work which the Sanitary Authorities wanted to undertake; it was
work which the London County Council and the Local Government Board
were desirous of seeing performed, but this technical difficulty stood
in the way. It was overcome by the inclusion in the London County
Council General Powers' Act of 1908, of Section 7, which empowered
Sanitary Authorities in the Metropolitan area to appoint Health
Visitors, and this enabled the London County Council to contribute
half their salaries out of the County Rate. As a matter of fact, at
the present time (November 1913) the whole of the salary of Health
Visitors in London is being paid out of the Local Rate, as the
Exchequer contribution account is completely depleted by the payment
of the moiety of the salary of Sanitary Inspectors.
The essential difference between a Woman Sanitary Inspector and a
Health Visitor is that the Woman Sanitary Inspector is a statutory
officer with a legal position, having definite rights of entry and
certain statutory powers for enforcing the Public Health Acts, while
a Health Visitor is a purely advisory officer, with no legal status
or right of entry or power to carry out any of the provisions of the
Public Health Acts.
In actual practice, the title of Inspector has in no way proved an
obstacle to successful health visiting, as may be demonstrated by
an enquiry into the work now being carried on by Women Sanitary
Inspectors in Sheffield, Leeds, Liverpool, Bradford, London, and other
places. On the contrary, it has enabled officials to obtain an entry
into dirty and insanitary places and to expose cases of neglect, which
might otherwise have remained undiscovered.
The Health Visitor is usually paid a lower salary than the Woman
Sanitary Inspector; this ranges in London from £100 to £120; in the
provinces it may be as low as £65 per annum, and rarely rises above
£100. The hours of work and holidays are, as a rule, the same as for
Women Sanitary Inspectors. The difference in salary has proved a great
temptation to Local Authorities in London to appoint Health Visitors
when Women Sanitary Inspectors would have been more useful and
efficient officers. Indeed, it is to be deplored that very few members
of Local Authorities understood the advantages to be gained by the
appointment of the more highly qualified official. The immediate
effect of Section 7 was that several boroughs, having no women
officials, proceeded to appoint Health Visitors; other boroughs, which
possessed Women Sanitary Inspectors, also appointed Health Visitors.
Seven or eight boroughs re-appointed their women officials in the dual
capacity of Sanitary Inspector and Health Visitor so that the work in
those cases went on as before. An indirect effect has been the almost
complete cessation of the appointment of Women Sanitary Inspectors
and the diminution in their number in some boroughs by the lapse of
appointments on resignation or marriage. The inspection of workshops
where women are employed has, in several instances, fallen back into
the hands of Men Inspectors, whose unsuitability for this work first
called women in England into the Public Health Service.
In September 1909 the Local Government Board issued the following
order with regard to Health Visitors in London:--
"Art. 1. Qualifications. A woman shall be qualified to be appointed a
Health Visitor if she
(_a_) is a duly qualified medical practitioner ; or
(_b_) is a duly qualified nurse with three years' training in a
hospital or infirmary, being a training school for nurses and having a
resident physician or surgeon; or
(_c_) is certified under the Midwives' Act, 1902; or
(_d_) has had six months' nursing experience in a hospital receiving
children as well as adults, and holds the certificate of the Royal
Sanitary Institute for Health Visitors and School Nurses, or the
Diploma of the National Health Society; or
(_e_) has discharged duties similar to those presented in the
regulations in the services of a Sanitary Authority and produces such
evidence as suffices to prove her competency; or
(_f_) has a competent knowledge and experience of the theory and
practice of nurture, and the care and management of young children,
of attendance on women in and immediately after child-birth, and of
nursing attendance in cases of sickness or other mental or bodily
infirmity.
"Art. 2. Every appointment must be confirmed by the Board.
"Art. 6. Enables a Sanitary Authority to determine the appointment of
a Health Visitor by giving her three months' notice, and no woman may
be appointed unless she agrees to give three months' notice previous
to resigning the office or to forfeit a sum to be agreed.
"Art. 8. Outlines the duties of the Health Visitor but prohibits
her from discharging duties pertaining to the position of a Sanitary
Inspector (unless with the consent of the Board she holds the dual
appointment).
"Art. 9. The Board's approval is required to the salary to be paid
to the Health Visitor, and an allowance in respect of clothing, where
uniform or other distinctive dress is required, may be made."
The Board in their circular letter state that they consider that,
in consideration of the importance of the duties and of the salaries
often paid to Women Sanitary Inspectors in London, the salary ought
not to be less than £100 per annum.
It will be seen from the above that it is quite possible for a Health
Visitor to be appointed practically without any qualification for the
position, and with absolutely no knowledge of Public Health Law and
sanitation.
It is, therefore, apparent that there are two classes of women
officials in connection with Public Health Departments, one on the
same footing as the men, with equal powers and responsibilities, but
remunerated at a much lower rate, and another with a lower status and
a still lower rate of remuneration. The duties of the second class may
be performed equally well by the first, but the duties of the first
cannot be performed by the second. The introduction of the Health
Visitor has therefore lowered the status of the Public Health Service.
The remedy for this state of affairs is for competent woman officials
in the future to be appointed in the dual capacity of Sanitary
Inspector and Health Visitor at an adequate remuneration, and for
the order of 1891 defining the duties of a Sanitary Inspector to be
expanded to meet the developments which have been taking place in the
Public Health Acts since that date.
There are two organisations which Women Sanitary Inspectors may
join:--
(1) The Women Sanitary Inspectors' Association, which includes
as members Women Sanitary Inspectors and Health Visitors holding
recognised certificates in sanitation. (Health Visitors holding
official appointments but without these recognised certificates in
sanitation may become associates.)
(2) The Sanitary Inspectors' Association, which is composed of a large
number of Men Sanitary Inspectors and a few Women Sanitary Inspectors.
This is not open to Health Visitors.
There is no approved society for Sanitary Inspectors under the
Insurance Act. The income of the majority of Men Inspectors exempts
them from the operation of the Act, but a large number of Men and
Women Inspectors receiving less than £160 per annum, have joined
the approved society of the National Association of Local Government
Officers.
To sum up, we may say that on the whole the life of a Health Official
is a healthy and suitable one for a woman of average physique; it
demands great activity, with many hours spent out of doors, and
whoever undertakes it must be prepared for surprises and difficulties.
She may find herself in an office staffed entirely by men, with chief,
committee, and council composed entirely of men--indeed everything
looked at from the male standpoint. She either works singly or in
small groups of two or three, except in a few large towns where the
women officials may number from ten to twenty. Thus isolated and
scattered, it is extremely difficult for the Women Health Officials
to form an effective organisation. What is accomplished under one
Authority may have little or no effect upon another.
One condition which presses heavily on many women is the shortness
of the holidays. The work is always arduous, particularly in poor
districts where one is brought face to face with poverty, disease, and
suffering, and from two to three weeks is not sufficient for rest and
recuperation, particularly as the years pass on.
The creation of public opinion and the advent of a greater number of
women on Municipal Councils and Health Committees is greatly needed
to improve the conditions under which women officials work, and to
support their reasonable demands.[2]
[Footnote 1: Full particulars of this can be obtained from the
Secretary, Sanitary Inspectors' Examination Board, Adelaide Buildings,
London Bridge.]
[Footnote 2: The above article considers under the term "Health
Visitors" such women only as are serving under public Municipal
Authorities. Unfortunately, since it gives rise to confusion, the
name is also used in connection with officials privately appointed by
various charitable institutions. These have no universally recognised
standard of attainments: some of the so-called "Health Visitors" are
without any qualifications, others, _e.g._, those employed by the
Jewish Board of Guardians, are fully trained and do excellent work,
comparable with that performed by Hospital Almoners. We hope, in a
later volume of this series, to publish an article on their duties and
position.[EDITOR.]]