Sunday, January 30, 2011

The Impact of the Plague in Tudor and Stuart England

by Paul Slack, Routledge & Kegan Paul, 1985

When he wrote this book Paul Slack (at the time a Fellow and Tutor in Modern History at Exeter College in Oxford) was more interested in the social response to the disease than in the disease itself, devoting almost half of the book to this subject.  But he also realized that to understand the social response he needed to understand aspects of the disease itself, such as frequency of occurrence, which social groups and locales were affected and the mortality rates.  The addressing of these questions occupies the first half of the book.  The time period that he is covering, as indicated by the title, is the sixteenth and seventeenth centuries.

Part I of the book gives us an introduction to the disease and its manifestations, as well as an overview of its impact on society and the attitudes and actions that resulted.  The cause of the plague was not known, and it was attributed to both natural and supernatural agents.  Similarly, the treatment of it incorporated both natural and supernatural elements.  Books and pamphlets were published that included both herbal remedies and prayers.  Special sermons were preached during plague outbreaks, and sometimes plague fasts were held.  Diagnosis was not exact and there were other diseases prowling the populations such as typhus, the sweating fever and malaria, leading to further confusion and uncertainty.  The plague itself was manifested in several ways.  There was the bubonic plague with its carbuncles, buboes and spots, which sometimes occurred in a mild form, without marked visible symptoms.  A more deadly variant of the disease was septicaemic plague, in which the bacilli invaded the blood stream, causing death before the external symptoms of plague had time to appear.  A third variety is pneumonic plague, which may begin as a case of bubonic plague that becomes complicated by pneumonia.  This latter variant changes the disease vector from fleas to humans as the bacteria is coughed out in the sputum of the victims and inhaled by the people around them.  It was highly contagious, had a shorter incubation period than bubonic plague, and left untreated was almost 100 percent fatal.

Along with the fear and uncertainty that an outbreak of plague invoked, it also placed a much more practical strain on the society in the loss of its members, sometimes in large numbers (a quarter to a third of a town’s population).  This depressed the economy as well as straining the infrastructure as those as yet untouched by the disease struggled to deal with the dead bodies that needed to be disposed of as quickly as possible.  Knowledge of the plague was passed down essentially unchanged from the time of the Black Death.  The first medical book printed in English was a Little Book on plague, published in 1486 probably as a result of an outbreak of the sweating sickness.  Outbreaks of diseases often seemed to inspire the printing of books on the plague, and in the second half of the sixteenth century a growing number of them were religious tracts and sermons.

Part II of the book examines the frequency and severity of outbreaks using parish records and the number of wills probated as indicators of the presence of plague.  Slack examines the records of Essex and Devon counties in an attempt to understand what kinds of communities were most likely to be affected by the plague.  From there he moves on to the urban settings of Exeter, Bristol and Norwich and then to the metropolitan setting of London.  From his case studies in the counties of Essex and Devon he draws two conclusions: 1) bubonic plague could cause a greater number of mortalities in a shorter time span than any other epidemic disease; and 2) that most communities suffered at least one epidemic during the course of a century and were lucky if they did not suffer more.  The risk was generally greater in towns than in rural areas, although living in the country was not a guarantee of safety.

He finds a more consistent picture when he examines the records of Exeter, Bristol and Norwich.  Although they differ in the timing and severity of the epidemics in all three cities the occurrence of plague was connected with the economic and social conditions of the communities.  Plague was a part of urban life.  It was a regular visitor to all three cities.  It struck Norwich in 1544, 1554, 1579, 1584 and 1589.  The frequency and severity in Norwich may be due to the fact of its nearness to the Low Countries and its large immigrant population.  It struck Bristol in 1565 and 1575 and Exeter in 1570 and 1590.  It tended to be concentrated in fringe parishes that were primarily inhabited by poor laborers.  In urban areas the occurrence of plague had a definite social dimension.

By the sixteenth century London had already gained a reputation as being filthy and plague was seldom completely absent from it.  The best records come from the city itself in the bills of mortality that it published in the seventeenth century.  These documented not only the number of deaths but also their locations, making possible the charting of the progress of the disease through the city.  A fresh outbreak would often begin, as would be expected, in the east, near the river and the docks, although that was not always the case.  Once again, the most affected parishes were on the fringes of the city where the poor resided.

Part III of the book examines the social reactions to the plague and the actions that resulted. The strategies to battle the plague began in London as part of the government’s general pursuit of social policies that might benefit the common man and improve social order.  England lagged behind other countries in their adoption of measures to control the spread of plague and often simply adopted and adapted strategies already in use abroad.  In 1518 Cardinal Wolsey founded the College of Physicians to improve English medical care, which also marked the beginning of public policy regarding plague.  Those policies primarily focused upon separating out the infected to pesthouses or shutting them up in their own homes.  Neither policy was rigorously enforced, the former because of the cost of establishing and running pesthouses and the latter in part because of the humanitarian issues raised and in part because of the difficulty of enforcing the isolation.  It was much better to prevent the outbreak of plague itself, and to that end quarantines were enforced on ships and goods arriving from areas where a plague outbreak was known to have occurred.

The publication of the bills of mortality in London documented for all to see the incidence and location of plague deaths.  The advent of newspapers helped to spread this information outside of the city.  This unprecedented supply of information allowed patterns of infection to be seen and helped to rationalize the reactions to plague, at least among the educated.  Although the carriers of the plague were not identified and without a germ theory of disease its cause remained unknown it did help to destroy the claims of its supernatural origins.

Plague broke down the social order, existing divisions were often exacerbated.  The people resisted the efforts of the officials to impose plague regulations because they saw them to be as threatening as the disease itself.  The public resisted the imposition of the regulations and the plague rate rose, which led the government to go to greater and greater lengths to enforce them.  While the public were concerned with the suffering of themselves and their fellows, the officials were concerned with maintaining order, and they viewed the plague as part of the broader problem of poverty.

Sunday, January 9, 2011

Mission and Method

The early nineteenth-century French public health movement
Ann F. La Berge, Cambridge University Press, 1992

Drawing from official archives, this book is more a history of institutions than it is of the people who were affected by those institutions.  Instead it focuses on a select group of men who served on the Paris health council and as editors of the Annales d’hygiéne publique et de médecine légale and how they created and institutionalized the idea of public health and hygiene, as well as how they put those ideas into practice through their work on health councils, in their publications and in their investigations.

Public health measures have generally been dominated by two different missions, emergency measures whose primary purpose is to deal with epidemics and regulations for dealing with public nuisances and waste disposal.  The former measures were usually temporary, enforced only in times of crisis, and the latter measures were applied mainly to larger towns and cities, where the higher population density made such regulations a necessity.  The idea of public health prominent in late-eighteenth-century France was dominated by an Enlightenment approach that emphasized progress, rational reform, education, natural law, empiricism and humanitarianism.  It included preventive medicine as well as practices aimed at improving the quality of life, and reducing mortality and morbidity.

While it had its foundation in the Enlightenment, the public health movement developed amidst the competing ideologies of liberalism, conservatism, socialism and statism, with liberalism and statism dominating.  The liberals wanted a minimal amount of state intervention, preferring solutions that were local and individual with the private practice of medicine, while the statists felt that the state should assume the primary role in public health reform and management and that public health experts should serve as advisors to the state, even proposing a medical civil service.  The debate between liberalism and statism took place within the context of scientism, the idea that science was the key to progress and that the scientific approach was the best way to achieve positive knowledge.

During the Revolution the national government had accepted responsibility for national health, and both Napoleon and the Bourbons had continued the tradition.  By the 1820s several public health programs were in place including a nationwide vaccination program, a national health care program of both epidemic physicians and health officers, a national administration of sanitation and a Royal Academy of Medicine to replace the Royal Society of Medicine.  There were institutions at the national level as well as at the local level with municipal and departmental health councils.  There also arose the idea of a public hygienist.  These were not simply physicians, but rather physicians who were willing to practice empirical science in order to understand the causes of disease and death, who would undergo special training for their job and who would work in cooperation with other specialists including chemists and engineers.

A major component of the mission of public hygienists was to investigate all possible causes of disease and death and to make recommendations for their solution.  In the process they encountered a wide range of health problems and issues.  Not only were they involved in sanitary reform and ensuring the purity of food and drink, but they also examined more complicated social welfare issues such as prostitution, wet nursing, foundlings and child labor laws.  Their approach to such problems varied but they all recommended regulation, inspection, and legislation to help improve public health.

They were aided in their work by the existence of the Annales d’hygiéne publique et de médecine légale, which was unique to France.  It was the first journal in the West devoted to public health and legal medicine.  In it ideas were exchanged and research published.  The journal also reviewed or published most of the major French works on public hygiene and served as an international forum on public health issues, including the coverage of foreign developments and publications.  This commitment to promoting and publishing their ideas was also mirrored by their educational efforts at the local level.  Because many programs were voluntary (vaccination against small pox, for example), their effectiveness depended upon the public understanding the advantages of compliance and the public hygienists were instrumental in that education process by providing reports of their benefits that were based on more scientific foundations.

This period also saw the application of statistics to the effort to understand the contributing factors of disease and death, if not their causes.  Louis-René Villermé did extensive statistical studies of Paris and his findings linking poverty and death contributed to the notion of death as a social disease.