Health, Civilization and the State

A History of Public Health from Ancient to Modern Times

Dorothy Porter

• Publisher: Routledge
• Year: 2005
• eBook ISBN: 9781134637171
• Topic: History
• Subtopic: World History
• Index: History

This book examines the social, economic and political issues of public health provision in historical perspective. It outlines the development of public health in Britain, Continental Europe and the United States from the ancient world through to the modern state. It includes discussion of:

* pestilence, public order and morality in pre-modern times
* the Enlightenment and its effects
* centralization in Victorian Britain
* localization of health care in the United States
* population issues and family welfare
* the rise of the classic welfare state
* attitudes towards public health into the twenty-first century.

Part 1 Population, health and pre-modern states

In Part 1 we consider the influence of the health of populations upon the social organization, operation of power and system of beliefs and values in European societies from ancient to early modern times. This is not an attempt to find the early origins of modern systems of public health provision. Rather, the relative significance of population health is examined in different contexts. Chapter 1 investigates how and towards whom ancient societies applied their moral codes and practical advice about health and hygiene. Did the health of the poor play a role in the expansion of Christian charity in the period of late antiquity? Chapter 2 documents the increasing concerns with the economic, political and social significance of epidemic and pandemic infectious diseases in medieval and early modern European societies, especially leprosy, plague and syphilis. Chapter 3 explores the changing discourses surrounding population health in early modern societies after widespread shock invasions of diseases such as plague began to decline. Here we draw out the role of population health in the ideological interpretations of market economies, consumer societies, mercantilist states and Enlightened political constitutions. Chapter 3 documents the development of the study of population health as an early modern social science and analyses the extent to which it featured in democratic theories in both the United States and in Europe at the end of the eighteenth century.

1 Health and morality in the ancient world

DOI: 10.4324/9780203980576-3

In the ancient world the pursuit of bodily and environmental cleanliness had both spiritual and material justifications (Temkin and Temkin, 1962; Temkin, 1977; Edelstein, 1967). Concern over individual health was a patrician preoccupation, a cult of the educated and leisured (Wear, 1993; Rather, 1968; Jarcho, 1970). The rules guiding the creation of healthy settlements and early forms of sanitary engineering were a practical expression of this cult for the well-being of the ideal community, consisting of a self-governing elite (Lloyd (ed.), 1983; Miller, 1962). Health and cleanliness helped to eliminate the danger of spiritual defilement from material corruption and provided for patrician comfort. It enhanced the lifestyles and social status of the governing classes, who perceived themselves to be the bearers of civilization in an otherwise barbarian world. Repelling the stigma of disease from the community removed the symbol of spiritual backwardness from civilization (Glacken, 1967). Political concern with public health and the ideology of the civilizing process continued to be interrelated. From the time of the late Roman empire, new pagan patrician preoccupations with charity began to be concerned with the health of the poor (Horden, 1985). This was exploited further by Christianity, aiding its hegemonic expansion throughout the late ancient and early medieval world (Numbers and Amundsen (eds), 1986; Sheils (ed.), 1982). Christian charity concerned itself with the health of non-elite populations which expanded the perception of society by the powerful.

There can be no positivistic account of linear development in healing practices or in the provision of health for individuals, social groups or the population at large in the long period dating from classical Greek society to late antiquity and the early middle ages. For example, the provision of public physicians by Greek city-states was imitated and expanded with the Hellenization of the defeated Persian empire and, later, the Roman world (Jackson, 1988). Amid the social and cultural transformations which took place between late antiquity and the early medieval period, followed by the break-up of the empire in the West and the disintegration of towns, less and less opportunity existed for either the public or private practice of ‘learned’ medicine. In the Byzantine East the institution of the public doctor continued, such as those civic physicians supported in Egypt by two measures of corn per year, according to Diodorus of Sicily. Town physicians who survived at all in the West were confined to some of the few cities remaining in northern Italy and southern Gaul (Nutton, 1981b).

Collective concern about the health of populations did, nevertheless, shift ground. The institution of Roman hospitals for slaves and soldiers was absorbed into Pagan and Christian charity in late antiquity (Amundsen and Ferngren, 1986). The benefit of welfare provision as a social source of power was subsequently exploited to its fullest by the Church and the poor took on a new political significance (Greer, 1974). The Church subsequently enhanced its social authority by adapting ancient codes of spurning the spiritually unclean from society into the institutionalized isolation of the contagious (Pelling, 1993). From the ancient to the early medieval period, collective concerns about the health of populations shifted from providing a salubrious environment for patrician comfort to the provision of care for the poor (Miller, 1985; C.Jones, 1993). This chapter charts the journey from health codes designed to provide salubrity for the spiritual and material comfort of patrician elites to the early institutionalization of health and welfare provision for the needy. In the following chapter we will see how providing care established a legitimate authority for regulating social behaviour as a method of containing the spread of sickness and contagion among the urban and rural poor.

Purity of Body and Soul

When our prehistoric ancestors replaced hunting and gathering with domestication of animals and crops to sustain regular food supplies, they also created a new disease regime for human societies (Cohen, 1989; McKeown, 1988). Shortening the food chain by protecting animals and crops from large predators also enhanced the opportunity for microparasitic forms to proliferate. Agricultural settlement reconstructed the ecosystem and the door opened for hyperinfestation. For example, human settlements offered greater opportunity for constant contact with intestinal parasites carried through human faeces, whereas a band of hunters constantly on the move were much less at risk from such infections. Settlement, domestication of animals and plants and urbanization altered the disease environment of the human species for ever (Cohen, 1989; Cockburn, 1977). From the most ancient times of recorded history all societies have been affected by the contingencies of sickness and health (McNeill, 1976). From ancient times human societies used various means to ward off the dangers of sickness which were often imbued with spiritual symbolism as much as they were the product of rationalist thought (Douglas, 1974).

There has been much speculation about diseases of early agricultural societies which has largely assumed that the settlements of Mesopotamia, and those surrounding the Indus river and the Peruvian coastal region, were plagued by classical tropical diseases such as malaria and schistosomiasis—a blood fluke parasite (Cohen, 1989). Little is known about the disease regimes of prehistoric societies but ancient health and cleanliness protocols, along with relics of ancient civil and sanitary engineering, indicate that cleanliness and godliness were closely linked in many early cultures. Ancient medical systems depended heavily upon mystical and religious explanations for disease and used empirical as well as philosophical and spiritual methods for healing. Many ancient belief systems stressed the importance of warding off sickness through divination; ritual and practical methods of prevention linked spiritual and temporal purity through various codes of behaviour and dietary protocols (Lloyd, 1979).

Chinese doctors under the Chou Dynasty (1122–250 BC) advocated health preservation through exercise, deep breathing and temperance. Wine was forbidden. They linked physical health to moral well-being and spiritual serenity, which led to cosmic harmony. Intermarriage between people of different ages and physical types was thought to produce a healthy lineage. In ancient India, health regimes were equally based on a mixture of dietetics, physical and spiritual exercises and the advocated daily care of the body, paying special attention to the mouth, tongue, teeth, hair and nails (Unschuld, 1985; Epler, 1988). Ancient Egyptian medicine was similarly based upon a belief that sickness resulted from an imbalance between temporal and spiritual existence and that health could be restored by prayers, magic, rituals or through the use of an extensive pharmacopoeia of empirical cures (Whitney, 1996). The body was believed to be controlled by a system of vessels carrying the blood, urine, sperm and tears which, like Egypt's system of canals, had to be kept clean and free of obstruction. Purgings were used as preventive medicine. Bodily cleanliness, both within and without, aimed to achieve spiritual purity, so that regulations about clean food, clothes, bathing and sexual relations were largely ritualistic (Risse, 1986). In Mesopotamian health cultures, including Babylonian, Assyrian and Hebrew codes, spiritual purity and prevention of disease were given priority (Ritter, 1965:299–321). The fundamental aim of these hygiene customs was to purify the body before God. The rabbi-physicians of the Talmudic period formulated elaborate rules for disease control based on the belief that some diseases were communicable through foods, bodily discharges, clothing, beverages, water and air. Plagues were believed to be spread through contaminated water (Preuss, 1978). But the Hebrews and the Babylonians also connected epidemics to rats, flies, gnats and other creatures, although the significance of animals was probably magical. Individuals were isolated during epidemics and their houses and belongings fumigated and disinfected. The laws against leprosy set out in Leviticus chapter 13, which were also shared by the Babylonians, were derived from magical belief as much as from an aetiological explanation of the disease (Weymouth, 1938). Ritual cleanliness demanded that no well was to be dug near a cemetery or a rubbish dump, and water was to be boiled before drinking. Food had to be clean, fresh and thoroughly cooked. The Talmudic code continued to influence the development of public health throughout Europe, especially as Jewish, together with Muslim, physicians played a crucial role in transferring the traditions of classical medicine during the middle ages (Conrad, 1992).

In the ancient world the environment was both natural and supernatural. Like Mesopotamian medicine, ancient Mexican and Peruvian medicine relied upon astrology and sorcery for diagnosis and used magical and ritualistic therapeutics. Both the Aztecs and the Incas had a supernatural concept of disease-bringing winds—the wind gods sometimes brought pestilence. Both systems did observe, however, the seasonal nature of epidemic disease and crop blight. The Incas instituted an annual health ceremony which included cleaning all homes (Garrison, 1929).

Mysticism dominated many ancient health and healing cultures, but temporal and divine causes of disease began to be separated in the natural philosophy of ancient Greek culture. Priestly medicine flourished in pre-Socratic Greek society. The Homeric epics identified Apollo as the god of disease and healing until he was replaced by Asclepius, his son, who was an heroic warrior and ‘blameless physician’. Asclepius's sons were also warriors and healers. Asclepius was portrayed with a staff and a serpent, which were common symbols of magical medicine among numerous ancient Semitic cultures. By the third century BC, temples of Asclepius were set up throughout the ancient world where healing was practised through ‘incubation’. The patient slept at night in the temple, waiting for the god to appear and prescribe a cure (Edelstein and Edelstein, 1943).

Between the seventh and the fifth centuries BC, new schools of philosophy, at settlements on the periphery of the Hellenic world at Cnidus in Asia Minor, Crotona in Sicily, Rhodes, Cyrene and Cos, developed a secular conception of medicine and a non-priestly medical tradition (Longrigg, 1993). Various explanations have been offered for the rise of secular rationalism in the provincial societies of the Greek colonial world. The societies on the Aegean fringes absorbed a multiplicity of intellectual influences from the Mediterranean, Asian and Oriental cultures, and avoided the limiting rigidity of religious dogmatism. Hellenic religious traditions themselves were largely mythical and non-dogmatic because they were not linked to the political stability of the state. Greek civilization was not organized around a strong central government or priesthood, but it was primarily a trading society in which the city-state was the most important political unit (Longrigg, 1993).

A new natural philosophy of medicine emerged among the pre-Socratic schools of thought. A number of the first pre-Socratic Greek philosophers were also physicians who began to develop natural explanations of health and disease but still retained mystical elements of belief. Physicians at Cnidus established an elaborate system of disease classification and Thales of Miletus (639–544 BC) identified water as the fundamental element of life. The founder of the ‘Italic’ school of philosophy at Crotona, Pythagoras (580–489 BC), applied the lore of numerical harmony to medicine which was absorbed into the Hippocratic concepts of ‘critical days’ and crisis in sickness. Pythagoras's pupil, Alcmaeon, developed a theory of disease based on the idea that cosmic harmony resulted from the blending of opposites. For example, too much heat caused fever and too much cold caused chills. This line of reasoning was taken further by Empedocles of Agrigentum (504–443 BC) who applied the theory of harmo nious balance to the four physical elements, fire, earth, air and water, as the basis of health (Lloyd, 1987).

In the fifth century BC on the island of Cos, various features of pre-Socratic philosophy were absorbed into the Hippocratic tradition of medicine (Smith, 1979). Hippocrates was probably an historical figure who lived some time between 460–361 BC. His ancient biographers, including Aristotle and Plato, praised him as a great and honoured physician, but it is uncertain whether he authored any of the collection of essays and texts known as the Hippocratic Corpus. The Corpus was compiled by many authors and absorbed the traditions of many of the Greek medical communities. The famous oath, for example, was probably Pythagorean (Lloyd, 1983). Hippocratic medicine radically departed from the religious and mystical traditions of healing and stressed that disease was a natural event, not caused by supernatural forces. For example, one treatise claims that epilepsy was not a sacred affliction but the result of natural causes (Longrigg, 1993).

The Hippocratic tradition concentrated on the patient rather than the disease and emphasized prevention. It used a system of dietetics to preserve and restore health through appropriate regimens for acquiring fitness and treating sickness. Its emphasis on health regimens was linked to a culture which revered an idealized body in a cult of athletics. Many Hippocratic authors linked their therapeutic regimens to the health of athletes. The Hippocratic tradition represented medicine as an empirical craft which adapted methods and healing regimens and whose prime therapeutic function was prognosis based on clinical observation (Smith, 1979). Greek doctors were identified to a great extent through their reputation, especially for their ability to predict the course of disease (Edelstein, 1967a). Hippocratic physiology assumed that the four essential elements of the physical universe were mirrored in the body by four fluids or humours: blood, black bile, yellow bile and phlegm. Each of the cosmic elements possessed certain qualities: fire was hot and dry, earth was cold and dry, air was hot and moist and water was cold and moist. Bodily health was maintained through the correct balance of humours and qualities controlled by the body's heat, which was generated through pneuma, or breath, and fuel, food and drink (Smith, 1979).

The Hippocratic tradition also recognized that health and disease were affected by season and the quality of environments. Several books on epidemics (visitations) provided clinical observations of numerous diseases and examined their external causes (Longrigg, 1992). The central Hippocratic text which analysed the environmental determinants of disease, On Airs, Waters, Places, discussed the effects of winds, the properties of waters and the effect of season upon human constitutions and the development of disease (Lloyd, 1983). The treatise divided diseases into those which were ‘endemic’, always present, and ‘epidemic’, which only occurred occasionally and excessively. The text resembled a ‘how to’ book, providing advice on environmental determinants of local endemnicity as a guide for colonization, suggesting that climate, soil and water were crucial. New settlements should avoid marshy lowlands and houses should be built on elevated areas to be warmed by the sun and catch salubrious winds (Longrigg, 1992). From about 800 BC, Greek expansion slowly edged along the Aegean towards the Black Sea and westward into Italy, Sicily and Spain. The treatise suggested that physicians should help to choose sites for settling new communities by judging their s...

Table of contents

• Cover Page
• Half-Title Page
• Dedication
• Title Page
• Copyright Page
• Table Of Contents
• Acknowledgements
• Introduction: Changing definitions of the history of public health
• PART 1 Population, health and pre-modern states
• PART 2 The right to health and the modern state
• PART 3 The obligations of health in the twentieth century
• PART 4 Preparing for the twenty-first century
• Epilogue
• Bibliography
• Index