Public Health in the Middle Ages

Overview

Public health encompasses many aspects of disease prevention, but it has its roots in the prevention of communicable diseases. It is a science as well as an art, and has the goals of averting disease in order to prolong life and promote physical and mental well being. These goals are accomplished through various means such as medical and sanitary services, personal hygiene, control of infection, and organization of health services. Early in recorded history, governments became increasingly aware that it is in their best interest to promote health and prevention of disease. As understanding of the factors that affect disease grew, so did community programs designed to prevent them. The public health system draws heavily on medical science and philosophy, and concentrates its efforts on controlling the surrounding environment for the benefit of the public. Without the theoretical understanding of disease, any attempts to control it would likely be haphazard guesses based on intuition.

Personal hygiene practices have been utilized by most primitive societies, often in association with religious rituals. In many cases, it was a desire to be pure in the eyes of a god. As an example, the Old Testament has a tremendous amount of information regarding how a person should go about living a clean life. There were many sanitary regulations to follow, some of which dictated the preparation of food. For many people religion, law, and custom became woven into the fabric of their lives. However, cleanliness was usually the exception rather than the rule.

The concept of vitalism was rampant in early societies. This line of thought looked upon disease, epidemics, and natural disasters as a divine judgment from the gods penalizing early man for some transgression. In time, the idea that disease could be due to natural causes gradually took root and gained a foothold in Greece during the fifth and fourth centuries b.c. It was during this time that true science was born and the first attempts to explain the causes of disease were made. One of the first public health issues ever recorded comes from this period. While the mechanism was not known, the association between the disease malaria and swamps was first noted in fifth century b.c. The book Airs, Waters, and Places, most probably written by the Greek physician Hippocrates (460-377 b.c.) around the same time, noted a potential relationship between pestilence and environment. It provided the earliest theoretical constructs explaining the differences and causes of endemic (pertaining to a particular region) and epidemic (pertaining to large numbers of people) disease. It would only be supplanted by modern views of bacteriology and immunology.

The Romans furthered the application of public health with their engineering prowess. Aqueducts brought fresh water into cities, while sewers carried away waste. These waterways had a tremendous positive impact by helping to prevent disease. The availability of public baths and the encouragement to use them also helped to keep many diseases in check. The Romans also introduced the first health care system complete with physicians and hospitals by the second century. Unfortunately the fall of the Roman Empire in the fifth century halted many of these accomplishments.

Background

Diseases in epidemic proportions were often seen during the Middle Ages. The threat of disease was a constant problem confronting populations during this time. In fact, many authorities define this period as occurring between the sixth century Byzantine Empire plague and the bubonic plague of fourteenth century Europe that devastated the continent. There were many types of disease (such as leprosy and smallpox) seen in epidemic proportions, but the most severe disease of them all was the bubonic plague of 1348, known as the Black Death. While there were not many protocols in place to help prevent the spread of communicable diseases, the quarantine of people with leprosy was a common practice. People inflicted with leprosy were expelled from the community at large and made to live in separate housing. Although the mechanisms for the transfer of the disease were unknown, it was felt that the isolation of the person with the disease would prevent its transmission. This was one of the first recorded public health measures in England. This principle was later applied to people inflicted with the Black Death when Europe had to deal with the increased threat from that disease.

The Black Death reached the shores of southern Europe from the Middle East in 1348 via the trade routes. Within three years, it had taken an extreme toll on Europe and was responsible for an estimated 25 million deaths out of a population of 60 million. The chief method of combating the plague was to isolate those suspected or known to have contracted the disease. The period of isolation ranged from two weeks to 40 days. This practice of quarantine did not prevent the spread of bubonic plague because fleas from rats, not direct human contact, spread the disease. However, quarantines did alleviate some transmission of the pneumonic plague that followed, since it was transferred by contact with an infected person. The Black Death exacted a huge toll on Europe, but had a tremendous impact on public health reform.

Impact

The immediate impact seen by the institution of public health practices was to help prevent the spread of certain diseases. In addition, certain practices directly improved the standard of living and made life more comfortable. As a readily seen example, it would obviously be much more comfortable to live in a household free of fleas and bed bugs, then one infested with them. However, many of the techniques used to control disease were ineffective because of a lack of understanding regarding transmission. Likewise, many practices, which could have been instituted had there been a better understanding of the disease process, were not put into place due to this lack of knowledge. It has been often written that Medieval Europe did little to advance sanitary conditions and hygiene practices, but given the state of knowledge at the time, it seems that reasonable attempts were made to rectify these conditions. Nowhere is this demonstrated as well as in the case of the Black Death outbreak.

Beginning in Italy just after the plague ended, new initiatives were aimed at raising the level of public sanitation and governmental regulation of public life. Perhaps more importantly, there was an increased emphasis on the scientific process used to investigate disease rather than the traditional reliance of ancient theories based on Greek thought. These new theories based on scientific investigation and hypothesis helped to explain the contagion theory of the plague rather than the historical theories of corruption. Finally, by the sixteenth century a debate over the causes of plague spread in the medical community as old corruption theories inherited from Greece and Rome were replaced by new ideas of infection and disease transmission. The technology at this time was insufficient to allow for significant advances in this area, but this new channel of thought helped led to scientific breakthroughs that revolutionized medicine in the nineteenth century.

Across the English Channel, a set of "sanitary laws" were put into use in England in 1388 by Richard II (1367-1400). These were a series of laws that were intended to combat some of the negative factors that were thought to have contributed to the spread of the plague. Soon, other public officials followed suit and created similar legislation in their areas. These laws created a system of sanitary control to combat contagious diseases. They made use of observation stations, isolation hospitals, and disinfecting procedures. Major changes were made to improve sanitation, including the development of pure water supplies, garbage and sewage disposal, and food inspection. These efforts were especially important in the cities, where people lived in crowded conditions in a rural manner with many animals around their homes. It was common to have multiple pests within a household that compromised the health of the inhabitants.

The Middle Ages are often cited as a time where there was little concern for personal hygiene and health education. As mentioned before, reforms were instituted but were not very successful due in part to the ignorance of the principles of public health. The conditions at the time were so horrendous, that any improvement was needed and most welcome. The lack of technology also made it difficult for many of these principles to be instituted by the society at large. As an example, compared to modern times, even taking a bath required an enormous amount of time and effort.

The Middle Ages witnessed a number of important steps in public health administration. These included attempts to cope with the unsanitary conditions of the cities and, by means of quarantine, to limit the spread of disease; the establishment of hospitals; and provision of medical care and social assistance. Attempts were made to increase the levels of health education and personal hygiene. While these practices bear little resemblance to modern day principles, they had the effect of improving the standard of living for people at that time and perhaps more importantly, these reforms provided the basis on which the modern public health system is built.

JAMES J. HOFFMANN

CLEANING UP IN EUROPE: THE INVENTION AND SPREAD OF HARD SOAP

Soap has been with us for over 2,000 years, but not in its current form. First invented by either the Phoenicians or the Celts (or, perhaps, simultaneously by both), soap was used as a medicine by some cultures and as a cleansing agent by others. However, early soap was soft, making it hard to transport and sometimes difficult to use. This changed in the Middle Ages with the invention of hard soap. Starting in France and Germany, hard soap manufacture moved across the English Channel by the twelfth century. In spite of this, the use of soap was not widespread for another several centuries and, in fact, the gift of a box of soap in the sixteenth century caused quite a stir in Germany. Although it took a few centuries for soap to become widely accepted (primarily because it took that long for the price of soap to come within the reach of a large part of the population), by the nineteenth century soap use was viewed as a measure of a nation's advancement by some European economists.

P. ANDREW KARAM