Care of the Indigent and Public Physicians
The organization of basic health services within a community involves the provision of medical care to all members of that community and a conscious attempt to prevent or minimize disease.
A relatively recent innovation is the appropriation of communal resources for hospitals devoted principally to medical intervention, that is, to hospitals that are something other than a refuge for the sick, the poor, or pilgrims. The earliest hospital in the modem Western sense was probably the Ospedale Maggiore of Milan. It was built in the mid-fifteenth century, funded by church properties, and managed by a lay board of governors, who in turn were appointed by state officials. Most medieval cities acknowledged the need for city hospitals, symbols of good Christian governance, and thus hospitals became as characteristic of this society as the aqueducts had been of Rome.The public employment of physicians was another significant development in the history of public health before 1700. Even ancient Greece, where many physicians were itinerant healers forced to wander in search of patients, established political and economic centers and provided salaries and other privileges to individuals who would agree to minister to their populations (Nutton 1981). Yet wherever a settlement grew large enough to support ethnic, linguistic, or even economic diversity, it was more difficult to ensure a sufficient number of healers.
In some places, such as Mesopotamia, the provision of physicians could extend the power of rulers or of a religion if people were assured that the proper gods would be summoned when intervention was necessary. With politically or religiously less important illnesses, a patient’s family could post the patient at their doorway or in the marketplace, giving passersby the opportunity to make a diagnosis or offer therapeutic suggestions.
In Egypt, India, and China where political upheaval was not as common as in Mesopotamia and Greece, highly individualized solutions to the communal responsibility for providing physicians were devised. Thus, Egypt may have developed a state system for the use of doctors as expert witnesses and provided a living allowance to all physicians, and by the period of the New Kingdom had established a formal hierarchy of doctors, the chief palace physician at its pinnacle. Similarly, in ancient India the king and other extremely wealthy individuals were obliged to provide medical care for their people by underwriting the services of priestlike Ayurvedic physicians (Basham 1976).
It was the Greek tradition that was ultimately transmitted to western Europe. From as early as the fourth century B.C., the Greeks had established a network of salaried physicians throughout the Hellenistic world. The terms of their contracts to individual communities varied widely, but the arrangement assured healers of some measure of personal stability. Unlike physicians in the more monolithic Egyptian society, who were natives subject to the same legal privileges and restrictions as their patients, physicians in the mobile Greek world were often foreigners who received salaries as well as tax immunities and special privileges (e.g., citizenship, the right to own land, rent-free housing, or even choice theater tickets) in return for contractual service to a community. This “system” - if indeed one can so call a functional solution to the provision of medical care - was adopted by the Romans in the designation of archiatri, or public physicians, whose duties were extended and to some extent redefined over the centuries. Later Renaissance European elaborations of the concept of public health mediated by public physicians was a rediscovery of ancient practices lost during the Middle Ages.
By the second century of the common era, large Roman cities designated up to 10 archiatri, their salaries set by municipal councilors, to minister to the poor.
Physicians often competed for these communal posts, suggesting that there were financial rewards beyond the salary itself - most likely access to a wealthy patient population. Public physicians seem to have been selected by laymen. Sources are largely silent on how their performance was assessed or how they typically sought access to their clientele. It is unlikely that they had any responsibility for the maintenance of public health in other respects, such as epidemic control or sanitation. Other salaried physicians in the Roman Empire included physicians to gladiators (Galen began his professional career in such an assignment), to baths, and to coιπts or large households.The financial privileges and immunities granted to public physicians may have ensured the survival of the office well into the early Middle Ages, for with inflation and the heavy fiscal demands on Roman citizens around A.D. 200, these inducements were considerable. In the early fourth century, the emperor Constantine the Great extended state salaries to teaching doctors irrespective of their medical services to the community, thus linking the interests of public physicians to those of local medical personnel. That association would become paramount in the later Middle Ages, leading to the monitoring and licensing of medical practice, ostensibly for the public good but equally obviously for the financial benefit of particular groups of healers. Under Emperor Theodoric, in the early sixth century, Roman doctors were given an overseer, an imperial physician called “count of the archiatri,” who may have formed the first formal link between lay interests and medical elites because he could nominate and appoint physicians to a college of medicine. Specialized medical services, such as those of official public midwives, may also date from this period. The Islamic state, which replaced most of the Roman Empire in the Middle East, brought regulatory power over physicians under the control of the state, which paid the salaries of physicians appointed to hospitals and even administered licensing examinations (Karmi 1981).
The medical institutions of late Rome did not persist through the early Middle Ages, even in relatively urbanized Italy and Spain. The practice of community hiring of salaried physicians was not reestablished until the twelfth and thirteenth centuries. Vivian Nutton (1981) argues persuasively that early Italian interest in jurisprudence and their editions of Roman law texts led to the reestablishment of public physicians in Italy. Thus, the office acquired legal responsibilities not typical of the ancient world. Perugia’s first medicus vulnerum (before 1222) probably had to provide expert testimony in cases of assault and battery. Public physicians in succeeding centuries typically had to judge whether a wound or injury had caused death. By the end of the fifteenth century, the system of hiring physicians was almost universal in Mediterranean western Europe, a system undoubtedly reinforced by the recurrence of plagues, which necessitated state intervention to ensure medical care. Yet public physicians were not true public health physicians or medical officers of health, positions that Renaissance Italians seem to have invented. The institutions addressing communal medical responsibility for health surveillance arose instead from epidemic controls.
Richard Palmer (1981) has demonstrated that in large metropolitan areas the system of medici condotti, the Italian medieval name for archiatri, fell into disuse by the sixteenth century. But in small towns the system continued or even increased in popularity because it was a means of securing quality medical care without being at the mercy of itinerant quacks or “specialists.”
The system of rural public physicians was able to absorb the late medieval expansion in the number of medical professionals, which brought about a more equal distribution of medical goods and services. Cities no longer needed to import physicians. The financial benefits they offered, the opportunities they provided for other, similarly trained practitioners, and often the presence of a university provided ample inducements for urban medical practice.
The major cities of Italy and Spain provided the prototype in medicine for the northern European cities of the seventeenth and eighteenth centuries: They developed local medical colleges dedicated to defending professional standards, restricting practice to the “qualified,” regulating pharmacies, and mediating the state’s charitable obligations to the poor in areas the church had abandoned (Lopez Pinero 1981; Palmer 1981). Tightening the restrictions on membership became common in Italy, foreshadowing the mercantilistic objectives of state medicine.