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Among the factors significant in identifying Melbourne as being one of the world's most liveable cities were the good health and well-being experienced by its citizens. Australians generally enjoy a high standard of living, nourishment and economic wellbeing and this is particularly true of a major metropolitan centre like Melbourne. Its climate is beneficial, although colds and influenza often accompany the winter months. Another contributing factor to the health of citizens is the widespread availability and high standards of medical services, including dentistry and dental health, optometry, physiotherapy and chiropractic, podiatry and alternative medicine. Many improvements in wellbeing are due to interventions on the part of government, advances in the practice of medicine and the regulation by public authorities and professional bodies of both a professional and commercial nature; also the capacity of the population to pay for the expensive services of the medical profession and medical technology through individual means or the public purse. Health facilities resourced by government contribute to the economy and tourism. Basic health services are subsidised by the federal government but Melburnians also have access to extensive ancillary, specialist and alternative health services, including physiotherapy and occupational therapy, Chinese medicine, herbal medicine, podiatrists, dentistry and dental health, dieticians, and nursing services. A system of public and private hospitals, financed by State Government and private and public health insurance systems, is, by international standards, well endowed and equipped, although the location, adequacy and cost of health care are a frequent subject of political debate. The extent to which issues of poverty and wealth have a bearing on health and access to health care is a subject of continuing concern. Old age is a factor with the risk of cancer, heart disease, stroke and dementia all increasing. Elderly citizens are more likely to use services provided by the medical profession and, although Melbourne remains a healthy place, the cost of maintaining that status is increasing as the population ages.

Earlier generations did not find Melbourne particularly healthy. A Melbourne City Council report of 1848 drew attention to the want of drainage, the filthy condition of narrow streets, courts, lanes and alleys, the prevalence of stagnant pools of water, the habit of slaughtering animals in the city proper, and 'Lake Lonsdale', a large unhealthy swamp on the east side of the city named after the police magistrate. The city's defects included the crowding of people, the want of water, the absence of sewerage, the non-removal of decayed animal and vegetable refuse and 'poisonous liquid and gaseous matters generated within the city'. These were blamed for the seasonal round of diseases. Enteric disorders and diarrhoea were common, with 'colonial fever' a particular killer of infants. Almost certainly this was typhoid fever, which was to remain a killer of young people well into the 1880s. Children's health suffered also through diphtheria, scarlet fever, measles and whooping cough, in periodic waves of severity. The statistician W.H. Archer observed of the 1850s that infant mortality in Melbourne was 20% compared with 13% for the rest of Victoria. By 1860 general death rates compared favourably with English statistics, but this was still disturbing given the city's younger population profile. Part of the problem was a lack of precise knowledge about the origin and means of transmission of disease. Not until the 1870s did contagionist and germ theory make headway in Melbourne medical circles. Before this the atmospheric, or pythogenic, theory of disease held that malignant exhalations were responsible. Streptococcal infections, in the form of scarlet and puerperal fevers, erysipelas and pyaemia, were endemic in the 1870s, particularly in the (Royal) Melbourne and Lying-In (Royal Women's) hospitals, and scarlet fever and diphtheria were epidemic. But quite early infectious diseases known as 'zymotic' were understood to be preventable and many English examples of reform initiatives were followed in the city.

Located at the end of long sea lanes of transport, Melburnians were spared cholera and saw few cases of smallpox as travelling times were longer than the incubation period of these diseases, and individual cases could be isolated on arrival. The government introduced a system of quarantine after 1850 and the Central Board of Health created in 1855 and municipal government also took on health responsibilities.

Melbourne General Cemetery was located beyond the confines of the city proper for reasons of public health. The water supply, turned on in 1857, was a mixed blessing. As no provision was made for sewerage or main drainage it added considerably to the city's pollution. Cases of lead poisoning soon came to light and there were continuing complaints about the quality, availability, colour and even the smell of Yan Yean water. In 1889 the biochemist Auguste de Bavay discovered typhoid bacillus in the water for which defectively placed fireplugs in the city streets were blamed.

Noxious trades, rubbish and garbage disposal were influenced by politics and the different aspirations of individual communities. Richmond and Collingwood sought to retain wool washing, slaughterhouses, tanneries and boiling-down works on the Yarra River upstream from the city. However, these were progressively relocated to the Saltwater (Maribyrnong) River into which historian John Lack has estimated some 2000 tons of blood alone found its way in 1870-71.

The closure of the city manure depot in North Melbourne in 1866 was followed by trenching of 'nightsoil' (human excrement) in the city parks and a move against cesspits by the Melbourne City Council. By the 1880s the filth of the city was being removed by an army of nightmen but the process still contributed to the smell and stench. In 1879 politician James Service complained that 'no one could walk in Elizabeth and Swanston streets without being disgusted by the abominable smells arising from their foul channels'. Municipal government was divided on underground sewerage, but finally the Melbourne and Metropolitan Board of Works, constituted in 1891, proceeded to sewer the metropolis and take over the water supply. Melburnians endured more epidemics, including incidences of typhoid worse than in Britain or other European-style cities, although pulmonary tuberculosis (consumption) was always a greater killer. The city's health began to improve in the 1890s before the introduction of sewerage, suggesting that the downturn of the economy and the introduction of health education, through the Australian Health Society, and the work of the new Board of Public Health, established from 1889 as a result of a royal commission into the sanitary state of Melbourne, were also influential. The opening of the Fairfield Infectious Diseases Hospital in 1904 allowed for the isolation of victims of infectious diseases in later decades.

Contagious disease and ill-health had many negative impacts. The novelist Henry Handel Richardson, for example, was traumatised by her father's mental and physical collapse from tertiary syphilis. Prior to the invention of modern medicines in the 20th century, sexually transmitted diseases were generally incurable and treatment was limited to removing symptoms of the disease. Patients with tertiary syphilis joined others with mental health problems in the Yarra Bend and Kew asylums.

Reflecting increasing concerns with women's health, race and eugenics in the 20th century, public health initiatives moved from cleaning up the urban environment to food and health regulation, including regulation of dairying and milk supply - but compulsory pasteurisation of milk as protection against typhoid and tuberculosis was delayed until 1943. The buildings of the Melbourne Hospital were pulled down in 1910 and replaced with a more modern institution.

The medical profession enjoyed a rise in status, assisted by improved medical education and professional support (nursing). Masseurs (physiotherapists) enjoyed the patronage of the doctors and formed themselves into an association in 1905. Where, prior to the 20th century, many patients would have sought help from chemists and druggists, in the 20th century the medical profession consolidated its position as the primary source of advice.

The outbreak of 'Spanish' influenza that reached Melbourne late in 1918 challenged the sense of security many considered their right as a consequence of distance and quarantine. With the hospital system overburdened the Royal Exhibition Building was converted to a temporary facility, accommodating 4046 people, 392 of whom died by 1919. Poliomyelitis (also known as infantile paralysis) proved more enduring, with epidemic outbreaks in 1908, extensively in the 1930s and 1940s and as late as the 1950s before the discovery of the life-saving vaccine by the American scientist Dr Jonas Salk, in 1953. The early application of vaccine in 1956 saw an immediate reduction but prior to this Melbourne medical practitioner (Sir) William Colin Mackenzie had pioneered treatment in his advocacy of the early movement of weakened muscles. The central facility for treatment of poliomyelitis in Melbourne was the Royal Children's Hospital, with Dr Jean MacNamara a leading authority on the disease. Polio's casualties were primarily young people, many of whom were left with substantial disabilities.

In the final decades of the 20th century public health activists focused increasingly on prevention, successfully lobbying to have lead levels in petrol reduced and mental health treatment reformed. Following adoption, and bipartisan endorsement, of national mental health policies de-institutionalisation of the Victorian system involved the closure or conversion in the 1990s of places such as the Kew Asylum, Larundel and Mont Park. As a result of the introduction of advanced medications and community-based support services - which are not yet adequate - the mentally ill are no longer 'inmates' or 'patients' but these days exist in the community in a non-medicalised world of 'carers' and 'clients'.

Health has long been a positive concern, notably so in city planning. Melburnians' preference for seaside and suburban living reflects a desire for a healthy lifestyle. Carlton and Fitzroy Gardens were conceived as places of leisure and recreation, 'the city's lungs'. Baths and bathing were seen as beneficial for public health, as were the beaches. The widespread enthusiasm for sport has also been harnessed to the public health cause. Jogging, cycling, power walking and tai chi all have their adherents and are subject to fashion. Houses and flats reflect standards of building and construction, the regulation of which has been for the public's health, safety and wellbeing, although the use of asbestos has proven a hazard. The food trades provide plentiful, good and inexpensive local produce. However, fast-food outlets are proliferating and obesity is a problem.

Much of the poor health of Melburnians, including the major killer, heart disease, is the result of excessive alcohol and drug use, tobacco smoking, avoidable accidents, poor diet, obesity and lack of exercise. Extensive use has been made of advertising for education and attitudinal change, controversially in the case of AIDS. The promotional activities of VicHealth (formerly the Health Foundation of Victoria) with its Quit campaign, punitive taxes on tobacco and restrictions on smoking in public and work places, and on sales and advertising, have reduced dramatically the numbers who smoke with concern now turning to the impact of passive smoking. Rising levels of stress-related disease, particularly depression, however, would suggest that, at the beginning of the 21st century, Melbourne's liveability is still not accessible to all.

David Dunstan