Although historians have become increasingly sensitive to the contested nature of public health and the limitations of sanitary reform, studies have concentrated on the urban. In focusing on rural Wales in the period from the creation of rural sanitary authorities in 1872 to the end of the nineteenth century, the essay shifts the focus to ask questions about what the rural means in the context of public health. By making connections between ideas about the Welsh landscape, nationhood and health, and the nature of sanitary problems facing rural communities and how rural sanitary practices came to be viewed, the essay shows how enduring representations of rural healthiness masked a ‘long tale of filth, neglect, carelessness and disease’ in rural Wales. The essay demonstrates how a bifurcated view of rural Wales as healthy and unhealthy reflected ideas about nationhood and the nature of rural conditions that rendered sanitary problems less visible when they occurred in a rural environment.