Epidemic Controls

Refuse disposal and the provision of clean water were regarded as aesthetic problems for growing cit­ies as much as they were means to improve health. Nevertheless, by the thirteenth century, all Italian cities with statutes of laws had incorporated a sys­tem of sanitary provision modeled on ancient Roman patterns.

The first of these two models was influential among public physicians when boards or offices of public health were created. The second model of con­tagion was not widely accepted during antiquity and the Middle Ages, at least among the educated elite. One exception, the practice of isolating lepers in special hospitals (leprosaria), is noteworthy because the custom was later adapted and justified as a means of epidemic control. Strict social isolation of individuals designated as lepers, whatever condi­tions may have been responsible for cases of ad­vanced skin infection and/or physical deformities, was a practice derived from the Jews of antiquity. In biblical times priests identified those suffering from “leprosy” and used their authority to cast these peo­ple out of a settlement. Drawing on this practice, medieval Christian communities permitted priests to identify lepers and, at least in northern Europe, subject them to a ritual burial and banish them from the community.

Unlike Jews, medieval Christians accepted a com­munal responsibility for providing lepers with orga­nized care - food, clothing, shelter, and religious services —but rarely medical care.

Nonetheless, lepers were ostracized. Guards often kept them outside city gates. Those formally identi­fied as lepers were made to wear symbols of their infection and perhaps to carry a bell or clapper to warn those who might get too near them. They could shop at markets only on designated days and hours, and could touch things only with a long pole. More­over, practices such as these survived throughout the early modern period even when leprosaria were turned to other uses.

In other societies (e.g., Chinese and Muslim) in which leprosy was considered to be a communicable disease, social restrictions were often linked to legal restraints on lepers’ activities. In Muslim lands, “mortal” illnesses, including both leprosy and men­tal illness, cast their victims into a state of depen­dency, somewhat like that of a child or slave. They lost the right to make and maintain contracts, in­cluding the right to continue a contract of marriage. Though a wide variety of behavioral responses to lepers existed across Islamic society, ranging from pity, to aggressive medical assistance, to isolation of the sufferers in leper hospitals, Michael Dols (1983) emphasizes the distinctiveness of Western Judeo- Christian tradition. In Europe, but not in the Middle East, lepers were considered diseased in soul as well as body, were ritually separated from the commu­nity, were deemed fiercely contagious to others, and were subjected to religious penance and other pun­ishments even after diagnosis and isolation.

Apart from exaggerated responses in the West to lepers (as well as to prostitutes, homosexuals, here­tics, and Jews), collective action to protect public health was, as a rule, crisis-oriented. Plague and other epidemics may not have been the most impor­tant manifestations of disease in earlier societies in terms of mortality, but they were certainly the most visible.

For whatever reason, during the following century there seems to have been no deliberate reappraisal of the sanitary methods used in the earliest plague epidemic, and no temporary re-creation of boards of health other than in Milan, the only northern Ital­ian city not stricken during the 1348 epidemic. Most cities relied instead on maintaining order, particu­larly in the burial of bodies, acquiring information about cities that were havens from disease (or, con­versely, cities that were stricken with plague), pro­viding physicians and other service personnel, and transferring property and goods after the plague to heirs or to the state.

The tiny Dalmatian colony of Venice, Ragusa (now Dubrovnik), invented the quarantine in 1377. This was a response to impending plague whereby a tem­porary moratorium on travel and trade with the town was decreed. The Ragusan practice, actually then a trentino, or 30-day waiting period, became standard maritime practice by the sixteenth and seventeenth centuries. Although the quarantine in common parlance has acquired a more aggressive meaning, in the maritime context it was a passive measure designed to prevent incursions of plague rather than to segregate active cases. Through repro­duction of a typographical error in the early nine­teenth century, many surveys of quarantine and pub­lic health have credited Marseilles with the use of the quarantine by 1483. In reality the Ragusan mari­time quarantine was not widely used until the six­teenth century.

Another feature of what was to become regular plague control, the pest house, or lazaretto, was used during the first plague century, 1350 to 1450, but chiefly as a means of delivering medical care to the poor. After the 1450s both quarantine (passive, pre­ventive isolation of the healthy) and active hospital isolation of the ill became more popular antiplague measures in city-states, which can be taken as evi­dence for the increasing acceptance of a contagion theory of plague.

Only during the fourteenth century do descrip­tions of plague note the loss of many principal citi­zens. After that period, elites seem to have worked out effective patterns of flight, so that only those who remained in the cities were exposed to danger. Unfortunately, in urban areas, plague control mea­sures may have inadvertently augmented the death tolls. Standard practices developed in Italian cities during the fifteenth century - practices that would be followed by northern Europeans during the late sixteenth and seventeenth centuries - included the house arrest or hospital confinement of all family members of plague victims as well as others who may have had contact with them, whether or not the others were sick. This led to the Constmction of ram­shackle buildings, lazarettos, that could segregate as many as 5,000 to 10,000 individuals at a time. By the sixteenth century, larger urban areas were quar­antining the still-healthy contacts of plague victims in one place, isolating the ill together with immedi­ate family members in a medically oriented hospital, and placing those who recovered in houses or hos­pices for a second period of quarantine.

By 1500 many of the principal Italian city-states had created permanent boards of health to monitor urban sanitation and disease threats even when no crisis arose. Rarely were physicians members of these aristocratic boards, though in many cities the lay directors employed medical officers of health. Nevertheless, local colleges of medicine and univer­sity medical faculties assumed the responsibility of providing diagnostic and therapeutic advice when crises threatened. By the second half of the sixteenth century, boards of health routinely consulted mem­bers of the medical establishment, one group helping the other in publication efforts to dispense both health advice and sanitary legislation and in the provision of public “debriefings” after a plague had passed.

In Italy and the Mediterranean, generally, the boards of health developed into tremendously power­ful bureaucracies, commanding sizable portions of state resources and the cooperation of diplomats in securing information about the health conditions in other states. Carlo Cipolla (1976) identifies both ver­tical and horizontal paths of transmitting such infor­mation, emphasizing the aristocratic character of health boards and their successes in superseding any authority that merchants might claim from the state. Detailed information about plague or other diseases thought to be contagious was gathered from the reports of ambassadors as well as from broad networks of informants and spies at home. Armed with these data, health magistracies could impose quarantine at will, confiscate goods, and impound, fumigate, disinfect, or burn them. Though they usu­ally agreed to reimburse the owners at half to two- thirds the value of their property, dire necessity and heavy expenditures during great epidemics left many boards of health bankrupt in all but their broad judicial authority. In fact, despite all efforts and a rigorous interpretation of the contagion theory of plague, the plagues of the late sixteenth and seven­teenth centuries were catastrophic in the Mediterra­nean countries, in terms of both human and finan­cial losses.

Not surprisingly, with the sweeping powers Ital­ian boards of health were given, permanent magis­tracies required greater justification for their exis­tence and their policies than the control of plague. They could argue that plagues would have been even worse without their efforts, but the economic costs of quarantine and isolation policies were more than early modem populations could bear without the creation of widescale human misery. Yet as strong monarchies emerged, legislators, physicians, and concerned aristocrats of the seventeenth and early eighteenth centuries were able to weave some public health controls into the evolving theories of mercan­tilism. Apart from epidemic surveillance, medical “police” extended state medicine into the licensure of midwives, the control of drugs and markets for drugs, stricter control of nonlicensed practitioners, and a variety of other matters. The results were optimistically summarized at the end of the eigh­teenth century by an Austrian state physician work­ing in Lombardy, Johann Peter Frank (Sigerist 1956).

Outside the Italian sphere, where state medicine and public health carried the longest and strongest tradition, public health boards and epidemic con­trols did not evolve into permanent magistracies concerned with all aspects of public health. As Caro­line Hannaway (1981) has indicated, at the begin­ning of the eighteenth century, the French, British, German, and, ultimately, U.S. traditions of public health relied mainly on the traditional Galenic- Hippocratic discourse about what ensured an indi­vidual’s good health. Superimposed on those inter­ests was makeshift machinery of epidemic control borrowed from the Italians. Concern for the health of “the people,” however, spurred by general mercan­tilist goals and the early Enlightenment passion for order and reason, was pan-European. During the eighteenth century, the impetus for change and re­form in public health thus moved northward. Reject­ing the political bases for state medicine that had led to the Italian boards of health, northern Europeans turned their energies to the production and consump­tion of health information: popular handbooks and manuals, such as those by William Buchann and S. A. Tissot; the proliferation of foundling homes, hospi­tals, and infirmaries; and the earliest efforts at sys­tematic information gathering. As we move closer to the modern world, the rhetoric and rationale on which sanitation, care for the indigent, provision of public physicians, and epidemic controls were based before 1700 are blended into a new campaign for cleanliness and order, public and private.

Ann G. Carmichael