Sanitation
Archaeological records testify to the antiquity of communal efforts to provide clean water and dispose of human and animal wastes. The engineering achievements of some peoples, such as the ancient Peruvians in the Western Hemisphere and the Etruscans in Europe, were most impressive.
They managed extensive systems for refuse drainage and clear water conveyance. However sophisticated the outcome, the motivation for these projects probably lay in fears common among tribal societies - for example, the fear of pollution offending a god or gods, who in turn could send disease and disorder. Reflecting these aboriginal values, natural springs and wells were sites of religious activity for millennia. But independently of the health benefits, the maintenance of a reliable water supply and efficient drainage of agricultural lands permitted larger human settlements, and thus, whether or not the health benefits were perceived, these practices were copied or reinvented in all the early civilizations of the Mediterranean, in the valleys of the Yellow, Indus, Tigris, Euphrates, and Nile rivers, and in the Incan and Mayan civilizations.The most celebrated early sanitary engineering achievements were those of republican and imperial Rome, c. 300 B.C. to A.D. 200. In fact, many of the conduits built by the Romans remained in use until the twentieth century. Basing drainage projects on the successes of Etruscan predecessors, who were able to construct extensive underground drainage channels because the loose, volcanic soil of southern Italy was easily worked, early Romans developed systems of wells, rainwater cisterns, and irrigation ditches that promoted rural, agricultural development. Before 300 B.C., the Romans seem to have associated the assurance of clean and abundant water with ordinary life, an ideal never specifically related to the maintenance of health, public or private.
But when they began to build cities, aqueducts became a public symbol of the Roman way of life, as well as a symbol of Roman power and sensitivity to the general welfare. Frontinus, in On Aqueducts (c. A.D. 100), says that the first one was constructed in Rome in 312 B.C.In rural areas, the prosperity of the “farm” or villa seems to have been the inspiration for securing a reliable water supply, a favorite topic for the pragmatic and aristocratic authors of treatises on Roman agriculture and medicine (Scarborough 1981). These authors fastidiously detailed the benefits and drawbacks of using plants and drugs, differentiated harmful from benign bugs, and analyzed myriad substances that promoted or undermined the well-being of the farm and the farmer. For Cato, Columella, Frontinus, Vitruvius, Varro, and Celsus, health benefits were the natural harvest of the wellmanaged farm, a pastoral ideal of Roman life that survived through the urban, imperial centuries.
Although Romans generally welcomed practical advice, the adoption of the Greek ideals of personal hygiene was delayed until after the period of early republican growth - a time of rapid development of architectural and administrative models for aqueducts, cisterns, cloacae, drains, and wells. Greeks and Romans, however, shared a passion for the details of personal hygiene, including a fondness for baths, cleansing agents for the skin, and oils, soaps, unguents, and other cosmetics used to maintain a good personal appearance and skin tone. Moreover, concern for personal hygiene went far beyond the realm of attracting sexual partners or performing religious cleansing rituals. Greeks and Romans worshiped health and consequently elevated in importance to their life-style the technical knowledge they believed would promote individual health and longevity.
Galen’s Hygiene, written shortly after the death of Emperor Marcus Aurelius in A.D. 180, represents the acme of professional health theory and advice through which Greek medical thought and pragmatic Roman farm hygiene were united in late Mediterranean antiquity (Sigerist 1956).
The Hippocratic theory of the four humors, describing health as a balance of the humors, which in turn represented the four elements of all material substance, dictated the fundamental ways of preserving equilibrium through an individual’s natural changes in age, diet, season, and exposure to noxious influences. The emphasis was on prevention, and the health seeker needed to learn which foods were right for his or her constitution, when baths promoted or jeopardized health, what exercise was appropriate, when purgation was needed, and what substances and influences were lethal. Attention was to be focused on the fine details and management of the individual’s environment.Nonetheless, despite the foregoing, which seems an idealistic portrayal of health practices in antiquity, the stark reality is that 25 years was the average life expectation for most Greeks, Romans, Egyptians, and others in the vast ancient Greco-Roman Empire. Roman elites recognized the importance of effective disposal of human wastes and so constructed miles of sewers and cloacae, as well as public and private latrines, and collected the waste for use as fertilizer in rural areas (Scarborough 1981). However, an enormous gulf separated the privileged and the poor. The hovels and lean-to shacks of the destitute, homelessness, and severe crowding (all of which mimic life in modern Western and Third World slums) dominated Roman life (Scobie 1986). The ideals promoted by the wealthiest citizens apparently had little impact on the public’s health. De facto, the drainage systems installed in individual homes were seldom connected to street drains and sewers, as archeology at Pompeii has shown, and latrines were not provided with running water. Alex Scobie (1986) has detailed the multiple health problems attending the practical aspects of Roman public hygiene, observing that a city the size of Rome with a population of approximately 8 to 10 million in early imperial times would have produced about 40,000 to 50,000 kilograms of body waste per day. Arguing that only a fraction of that output reached the “public” collection sites, he shows that the emphasis in Roman public hygiene was the maintenance of the farm and an aristocratic life-style, whatever the adverse health costs to the general population.
The emptying of public and private facilities enhanced agricultural productivity and provided a livelihood for armies of unskilled workers. The collection of urine aided the cloth industry, because fullers used urine as a mordant for certain dyestuffs. Roman literature does not adequately testify to the horrors of Roman cesspits “nauseating mixture(s) of the corpses of the poor, animal carcasses, sewage, and other garbage” (Scobie 1986).Nor have the marvels of the aqueducts fared well under recent historical scrutiny. Frontinus sang the praises of the nine aqueducts that daily supplied the city of Rome (scholars have calculated that they provided about 992,000 cubic meters of water each day), but he tells us little about the distribution of water and whether there were any mechanisms to stem the flow of water into basins and tanks. Because of their malleability, lead pipes were commonly used in the plumbing of aristocratic homes, but we do not know whether the water they carried was soft or hard. (Hard water would have prevented much of the lead from seeping into the drinking water.) Ancient pastoral fondness for rainwater probably protected many Romans outside the great city from the multiple health hazards attending advanced urban sanitary technology.
The best and worst features of Roman public health, and of the Greek traditions and theories of personal hygiene, were passed along in the books and physical artifacts that survived the piecemeal dismantling of the Roman Empire. Thus, the strong aristocratic voice that determined the ideals of public and private health and their implementation remained relatively unchanged in the societies that inherited Roman custom, such as the Byzantine and Islamic empires. But in western Europe, retreat to a rural economic base, the effective disappearance of cities and market economies, and the introduction of Germanic customs interrupted the Greco-Roman public health tradition. It is true that in Benedictine monasteries upper-class monks constructed infirmaries, baths, latrines, caldaria, or steam rooms, and cold rooms in the best of Roman aristocratic tradition.
(St. Gallen monastery in Switzerland, built in the eighth century, is one of the best surviving examples of this tradition.) But most Roman sanitary practices were adopted and gradually transformed only as Christian Mediterranean cities began to grow again in the eleventh and twelfth centuries.In the European Middle Ages, cities grew to a maximum of 100,000 to 150,000 individuals by the early fourteenth century, only one-tenth the size of ancient Rome. The Roman legal principles holding individual property owners responsible for cleaning the streets in front of their homes dominated “public” sanitary intervention. Medieval Italians were far more willing than the Romans to specify what individual behaviors put others at risk and therefore to write new legislation prohibiting the pollution of public streets with animal carcasses, human refuse, and other noisome substances. Yet we do not know to what extent laws were actually enforced, and it is probable that medieval cities were even more squalid than those of antiquity. Nonetheless, there seems to have been a new ethic of communal, collective responsibility for public health. Some of the change may have come about with the Christianization of Europe, which among other things emphasized the physical and spiritual dangers of evil. Roman baths were used in common by the wealthier classes, but medieval laws dictated strict segregation of the sexes, treating as prostitutes, for example, women who strayed near the baths on a day when only men could use the facilities.
During the Middle Ages, urban dwellers could empty chamber pots into the streets as liberally as aristocratic Romans might have done, but medieval lawmakers often prescribed the times at which such wastes could or could not be evacuated or ordered that words of warning be shouted to passersby below. For example, thirteenth-century residents of Siena were enjoined to cry “Look out!” three times before tossing the contents of a pot onto the street, and fines were specified for those who were found non- compliant.
Medieval city governments, like their Roman predecessors, hired laborers to clean streets, cisterns, and sewers and to evacuate garbage. But unlike Roman officials, who appear to have adopted a laissez-faire attitude toward enforcement, they elected or appointed district supervisors to patrol both these employees and citizen behavior, and to report infractions to judicial authorities. The medieval belief that humans were sources of pollution (by the fourteenth century, lepers were forced to wear yellow to symbolize their danger to the community) had profound consequences for the development of epidemic controls, as will be discussed in a later section.Leading the way for the rest of Europe, Italian and probably Spanish cities appropriated detailed Roman law and customs regulating the trappings of public sanitation - baths, sewers, fountains - as well as sanitary personnel and marketplace regulations, leaving most of these features unchanged, at least on paper, for hundreds of years. Public hygiene laws in 1700 strongly resembled those of 1300, with even the fines little changed. Those who could afford to follow all the recommendations of Galenic personal hygiene did so without questioning the basic premises of health maintenance, public or private. Only the creation of boards of public health, a very important late-medieval contribution to public health, and, late in the seventeenth century, medical attention to occupational disease represented significant advances in modern public health philosophy and practice.