HEALTH CARE DELIVERY SYSTEMS IN ANCIENT' GREECE AND ROME
By Dr. Warren Kump MD
Dr. Kump (ADA, Kansas, 1950), is a Minneapolis radiologist who serves on the clinical faculty of the University of Minnesota. He has been interested in medical history as a hobby, and prepared this paper as an outgrowth of that avocation.
Medical History is usually written by physicians or other health professionals. Consequently the emphasis is on the evolution of scientific knowledge and theory, on the circumstances attending various medical discoveries, or on biographical detail relating to important practitioners of the healing arts. In this day of consumerism and the rising influence of third parties it is appropriate to attempt a more general perspective, one in which the sick or injured patient occupies the center, and the physician is relegated to a supporting position as one of society's several major health resources.
When the more general consideration of health care is undertaken, the relative value of the contributions made by various cultures is subject to revision. One example is in the case of ancient Greece and Rome. Traditionally Greece has been given the credit, and rightfully, for the development of rational or scientific medicine. Rome adopted rational medicine along with many other intellectual and scientific contributions of the Greek civilization, but added comparatively little of its own to the body of medical knowledge. In the field of total health care, however, the performance of Rome was more creditable.
A differentiated medical profession was recognizable in Greek society as early as the siege of Troy in the 12th century, B.C. Its practictioners, if they attempted to gain their entire livelihood by the treatment of wounds and sickness, were dependent upon the wealth and good will of their patients. The idea that a patient's access to such treatment depended upon his ability to pay for it could not have become widespread until the position of medicine had become much more secure. It was not until the sixth century, B.C., that the Greeks considered the importance of The medical profession great enough to warrant official notice by a unit of government. In 526 B.C. the celebrated practitioner Democedes was appointed public physician of Aegina. The following year he was attracted to Athens and still later to Samos by offers of higher salaries. By the fourth century the practice of engaging public physicians or demosieuontes was widespread in Greece, with cities or districts contracting to pay them out of public funds.
The responsibilities to the community of the public physicians has long been a matter for study. Cohn‑Haft, in the most extensive modem investigation, has concluded that, contrary to previous impressions, the demosieuontes were not engaged to provide free medical care for the poor, but rather to insure the availability of medical service in the community on a dependable and stable basis. In his view the rather small salary offered by the municipalities was considered in the nature of a bonus or retainer, obligating a popular or highly regarded physician to practice in the city, but not to give his services free of charge. He practiced medicine as did any other physician, collecting his fees according to convention and the ability of his patients to pay, and with no more obligation to treat the poor free of charge than was felt by any other practitioner.5 Such an arrangement, more similar to the modem attempts to attract physicians to rural communities through scholarships, grants, and other financial inducements than to the free care offered in charity hospitals and the military, would have been in accordance with the early Greek conception of public welfare. In the classical view a public expenditure should be made to promote the interests of all citizens directly and equally, not to provide exclusive aid to any special segment of society such as the poor. In the case of the retention of a physician at public expense, however, the equal benefit would have seemed more theoretical than real to those unable to afford his services.
If public welfare programs were rudimentary, large scale private philanthropy was also limited. This was largely because of the lack of a legal concept of the corporation or foundation in classical times. A fund without a "legal personality" and unable to exist in its own right independent of the continued existence of the particular individual or body which might be administering it at any given time had little prospect of surviving beyond the lifetime of its original donor. The result was a discontinuous or sporadic approach to poor relief, consisting of isolated and occasional giving and dependent on the personal fortunes and inclinations of the wealthy. The absence of the idea of a foundation also made it impractical for men of modest means to join in raising funds for purposes of mutual aid.
Figure 1. Contemporary illustration of patient care in an asklepieion. The temple snake licks the patient's afflicted shoulder as a part of the therapeutic regimen. National Museum, Athens.
The milieu of individualism makes the socio‑economic policy of Hippocrates understandable. Various Hippocratic maxims advised selflessness on the part of physicians, such as one urging doctors to take into account the resources of the patient, and sometimes to be ready to give treatment without fee. Inscriptional evidence makes it clear that some physicians were indeed ready to regard remuneration as of secondary importance. Free service by doctors acting in a private capacity, however, was optional and not required by any moral or legal code. Plato's Republic includes evidence of separate standards of medical care for poor and rich, for example the carpenter who was expected to recover or die with minimal medical care and loss of time from work, while the rich man could continue to live, supported by his wealth and through protracted medical attention.
The individualist position was not embraced unanimously, however, as evidenced by Socrates' belief that a man, whether rich or poor, should not be encouraged to live if unable to contribute to his own welfare and that of the state. Other egalitarian sentiments, although not encountered very frequently, are manifested occasionally among the official actions of the Greek citystates. An example is the direct payment of two obols a day to the crippled and disabled of Athens whose property assessment was less than three hundred drachmae. This allowance, originally limited to injured war veterans but soon extended to all the physically handicapped, represents a rare example of the application of a "means test" in classical times.
There existed in Greek society besides the medical profession yet another health resource in the presence of temple medicine. While Apollo and the goddess Athena were renowned healers, the most important institution in the field of faith healing was the Cult of Asklepios. Its influence by the fourth century, B.C., was widespread, offering the people an attractive alternative to the rational or natural approach to health care. Matters of relative effectiveness aside, and there was probably not a great deal to choose between the natural and supernatural systems, the Cult was more appealing to the poor than was the medical profession. The pbysicians who practiced among the poor were not the most skilled and highly educated, but rather those who could not hope to attain a following among the rich. The open‑air stands in the city streets from which they dispensed their first‑aid and counsel were no match for the pastoral surroundings and the richly ornamented edifices of the Asklepieia. Neither were their simple ministrations of healing as the solumn ceremonies to be observed at the temples of, healing. The allegiance of the masses therefore went mainly to the Asklepieia.
The temples made provisions for the many ailing visitors who were unable to pay. There were inns or hostels nearby for the accommodation of the sick and their friends or relatives; these were open to rich and poor alike. Asklepios himself was a compassionate god and socially aware, widely known to be satisfied with small offerings. A cock was the most common sacrificial gift of the poor, while the rich were expected to give generously. In fact the temple practice of putting whatever was necessary at the disposal of those supplicants who were unable to pay amounted to a considerable subsidy of the poor, since the masses tended to patronize the Asklepieia while the more wealthy and sophisticated consulted physicians.
Thus with public physicians who did not necessarily treat the poor, Hippocratic physicians who charged according to opportunity and conscience, and Asklepieia with sliding scales of suggested donations the Greeks had developed not only an early model of the non‑system, but a pluralistic non‑system at that.
Ptolemy's Greek enclave in Egypt, on the other hand, with its tightly organized totalitarian state, represented another extreme of social planning. Here was developed the iatrikon, a tax levied on the Greek settlers which entitled all of them to free medical care. The treatment was provided by physicians who were in the royal service, receiving their income from the king and giving their services as directed. Undoubtedly the state medical service was under the strong influence and quality control of the prestigious medical faculty of Alexandria, itself under royal patronage and regulation. Of special interest here is the fact that, in a prophetic protofascist spirit (Ptolemy was once a general in the armies of Alexander the Great), neither the tax nor the free medical service was applied to the far larger indigenous population, which made do with second‑class citizenship or no citizenship at all.
Despite a reputation fox having a word for every need, the Greeks were remiss in developing a jargon apphcable to community health care. The Romans at first were little better; although they did come up with the S.A.C. (stationes arcarioruni Caesarianorum), the official name of Rome's welfare offices. In the early days of the Republic, however, the Romans showed little promise in the field of medical bureaucracy. Their spciety lacked even a formal medical profession. Instead they relied on a system of popular or folk medicine, treating themselves and their families according to tradition and under the direction of the head of the family. The paterfamilias presided over a small collection of household remedies which were administered in timehonored ways, a particular combination and ritual for each affliction. Many households had their own specifics: Cato's cure‑all was cabbage. The central theme of this fiercely private medicine was a strict consumer control that opposed the development of medical professionalism and refused, as Pliny records, "to give payment to profiteers to preserve their lives."
The practical Romans first approached the problem of community health in a characteristic way, utilizing one of their leading technological resources, civil engineering, in conformity with the classical philanthropic ideal of equal and direct benefit to all. The long range program was a series of public works projects to provide for an adequate supply of healthful water and a system of drainage. The results of the program are well known. The first of the aqueducts was built in 312 B.C.; by 96 A.D., there were ten aqueducts capable of supplying the city with 250,000,000 gallons of water daily. About half of this torrent flowed through the immense system of public baths. The remainder was enough to provide an average of more than 100 gallons per capita daily for a population of one million. The same provision for a plentiful supply of pure water was made in the other cities of the empire, with good examples remaining to this day in Turkey, Spain, and France.
The problem of the disposal of human wastes was mingled with that of the drainage of ground water, as both were recognized as threats to public health. The Roman author Varro anticipated the germ theory of disease in a tentative way: "in the neighborhood of swamps . . . there are bred certain minute creatures which cannot be seen by the eyes, which float through the air and enter the body through the mouth and the nose and there cause serious diseases." Although the existence of these "minute creatures" was mere speculation, we do know that as early as the sixth century, B.C., the Roman Forum was drained by the Cloaca maxima, receiving the wastes from public urinals and water closets flushed by running water. The Cloaca maxima, as the aqueducts, was copied widely throughout the Roman Empire.
The achievement in public hygiene accomplished through engineering clearly exceeded in importance any contribution which could have been made by the medicine of the day. In well planned and well executed bursts of technological creativity the Romans provided general and more or less permanent solutions to some of the most basic of public health problems. However as a community they managed a less imaginative response to the need for individual care of the sick: they imported the Greek dichotomy of temple medicine and Hippocratic medical science.
Figure 2. Interior of the Basilica of St. Bartholomew on the Tiber Island at Rome. According to Allbutt the columns are relics of the asklepieion built earlier on the same site, once the city's principal center of temple medicine.
The first major Greek import in the health field was the Cult of Asklepios. An epidemic ravaging Rome in 295 B.C., seemed to require more effective measures than were available at home, so the Romans called upon the greatest of the Greek gods of healing, whose fame was by then widespread. According to tradition a deputation of Romans applied for help at Epidauros and induced some of the temple personnel to return with them to Rome. As the homeward‑bound ship proceeded up the Tiber toward the city, an Asklepian snake swam ashore on the Tiber Island, providing a miraculous and supernatural selection of the site for the transplanted healing temple. A less romantic, though more credible version of the location on the Isola Tiberina rests with the Roman official suspicion of foreign gods which probably dictated the site outside the city proper for caution's sake.
The island, cut into the shape of a ship 300 yards in length, 80 yards in beam, and complete with mast, prow, and stem, resembled a huge vessel at anchor in the river. Near the "stern" was erected the main temple dedicated to the Great One, whose name was now latinized to Aesculapius. The site of the temple is presently occupied by the Basilica of St. Bartholomew, and fourteen of the church's columns survive from the original Aesculapian structure. Beside the main temple there were smaller satellite temples, shelters for the sick, and medicinal baths.
The Roman epidemic subsided, and Aesculapius shared in the credit. The popularity of the cult was assured as accounts of miraculous cures, once only vague tales circulated by travelers, were now recounted first hand. The influence of Aesculapius increased steadily until the end of the second century, A.D.; hundreds of temples were built and dedicated to him, and his popularity was comparable to that of any of the other transplanted Greek gods. In general the rites of the Roman Cult of Aesculapius were borrowed from the Greek ritual, with an occasional cultural modification such as the practice of praying with the head covered in the Roman fashion. Devotion to the god came from all classes of Roman society from the lowliest dwellers of the crowded apartment houses to the wealthy land owners and public officials.
The importation of Greek temple healing to Rome was eventually followed by that of its parallel natural counterpart, "rational" or theoretical medicine. The first Greek physician known to practice in Rome was Archagathos of Sparta, who arrived in 219 B.C. Archagathos, like many of the Greek physicians who came soon afterward, was probably a marginal practitioner who saw in the expanding western city an opportunity for greater success and acclaim than were likely to be his among his more talented colleagues at home. He was granted the right of free citizenship and was provided with an office at public expense. In spite of the generous welcome, however, his practice did not go well. His cruelty in cutting and searing his patients earned for him the nickname "The Butcher," and he was eventually expelled from Rome."
Besides the bad impression made by the earliest Greek practitioners there was another more culturally related reason why the Romans were reluctant to accept theoretical medicine. They were above all a practical people, disinterested in abstractions, distrustful of lofty intellectual processes, and impressed only by useful results. Hellenistic medicine made its greatest inroads in the upper strata of Roman society; the best and most highly educated of the Greek physicians found acceptance among the rich and the powerful, among intellectuals and emperors. Their role, however, was more akin to consultant or confidant than to authoritarian practitioner. They discussed theories of disease and health and suggested possibilities for treatment, but the Roman patient or his family made the final decisions about therapy.
Among Rome's poor and ignorant Greek medicine fared even worse. Only the physicians of lesser repute served the masses, and they lacked true skill and learning. The poor often resorted to another class of healers, the pharmocopolae, or drug sellers. Until the middle of the second century these were free of any kind of supervision or regulation, and were usually fraudulent. Evidence of general dissatisfaction with all these practitioners is so abundant that there is small wonder that reliance on traditional folk remedies and the Cult of Aesculapius persisted for centuries.
In discussions of the availability of physicians' services in Rome reference is often made to the well publicized and obviously well organized "house of the surgeon" unearthed at Pompeii. The building would seem to be a suitable model for a modern clinic, and its presence at Pompeii suggests that doctors' offices must have existed and functioned in ancient Rome much as they do in modern society. But it would be a mistake to consider Pompeii as representative, for it was a resort town. As a haven for the rich it was probably no more representative of Roman society than are Carmel or Miami Beach of ours. Most Romans lived in apartment buildings; because of the population density the streets were narrow and the apartment buildings dark, poorly ventilated and tall, averaging five or six stories. The ground floors were used for shops and taverns or as home for the wealthy. The masses lived upstairs in descending order of social station, the poorest reaching their humble attic rooms by ladders. In the days of the Empire a sturdy and numerous middle class still survived in the provinces and in rural areas, but in urban Rome their ranks grew ever thinner until there were few left between the plutocracy of the court and masses too poor to exist without the doles of the emperor and the charity of the rich.
In the second century, A.D., more than half a million persons, possibly half the population of the city, lived on public charity, and this figure does not include the slaves, who were not eligible. Permanent offices of public assistance (stationes arcariorum Caesarianorum) were set up in the halls of Trajans. market, and from the second century on public distributions of food or money were made from them.
The provision of physicians' services for the poor was not the serious problem one might suppose; in the minds of the poor such services were superfluous and not even necessarily desirable. They had their folk medicine, which was free, and in the case of more serious ailments there was ready access to the shrines of Aesculapius. Shrines dotted the empire and were available to citizens everywhere. The temple on the Tiber Island was the most popular at Rome, widely used and trusted by the ordinary people. Sick and worn‑out slaves were brought there, sometimes to spare their masters the trouble of caring for them. The Emperor Claudius freed such slaves and decreed that if they recovered, they should not be returned to the control of their masters. The Island of Aesculapius thus became a place of refuge for the sick poor.
The emperors, because they had a higher opinion of physicians than did the masses, occasionally took measures to increase their availability. Doctors were provided with an indirect subsidy through the offer of immunity from taxes, first by Vespasian and then on a larger scale by Hadrian. This may have been intended to place a moral obligation in favor of those unable to afford a physician's fee. It was not until the fourth century, A.D., however, that Valentinian I appointed archiatri for each of the fourteen regiones of Rome with the admonition, "honesty to attend to the poor rather than basely to serve the rich." While the Emperor had never heard the term "third party," he was obviously aware of the concept.
In Greece and early Rome there was little provision for individual health care beyond the services of the physician. Nursing and other supportive care were usually undertaken in the home by members of the patient's family. In the case of those without home or family, arrangements had to be individualized, if possible, and according to no particular system.
The growth of slavery in the Roman Empire overtaxed the non‑system of supportive care, and eventually necessitated an institutional approach. In the case of the enormous households of the wealthy where slaves might number in the hundreds or even in the thousands, medical and nursing care became a need of such magnitude as to require specialized facilities and personnel. The buildings outfitted for such use were the valetudinaria, and references to them, especially after the first century,
A.D., are numerous. They existed both in the city and on the large country estates. Columella, in his treatise on agriculture about 60 A.D., pointed out the need for providing valetudinaria for slaves as places where they could rest and recuperate when ill. He suggested that at slack times the buildings be well aired and cleansed, so that everything should be well arranged, decorated, and wholesome for the patients. He further urged that particular attention be given to the quality of the provisions and cookery.
The personnel of the larger valetudinaria undoubtedly included slaves assigned to cooking, cleaning, and assisting the sick. If the household was an especially large or wealthy one there might be a Greek philosopher physician attached to it who would provide consultation to the valetudinarium. Otherwise the only skilled care was provided by a medicus, who was the counterpart of the street physician or drug seller, a man of uncertain education or training and ranked socially as a tradesman. In many instances he might be himself a slave, and in any case the final authority in medical matters as well as in all others was the head of the household.
As a private household infirmary the valetudinariurn was not reserved for slaves alone, but was utilized by all classes. Seneca himself refers in one of his writings to "lying in a valetudinarium." In addition to the immediate family of the master the valetudinariurn might also provide care and comfort to friends and clients of the family, but scarcely in any instance where no such personal relationship existed. Galen makes mention of general hospitals in the provinces, especially the Greek provinces, under public control and with doctors officially appointed to them. Such hospitals, if they were truly public institutions, must have been few or shortlived, since there is so little evidence, either literary or archeological, for their existence. There is abundant evidence, however, for the fact that the Romans did develop a well organized system of hospitals for the military.
In the days of the Republic there was little medical care of any kind for sick or wounded soldiers, and what crude care existed was practiced by them on one another. A seriously wounded soldier was left to fend for himself or, if particularly fortunate, might be left in a friendly town to the ministrations of well‑intentioned townspeople . As long as the military campaigns were conducted within the Italian peninsula it was often possible to return the sick and injured to their homes for treatment and recuperation.
In the later days of the Republic the Hellenistic influence infiltrated the army, and Greek physicians began to accompany the ranking officers in the field. Their functions seem to have been limited to medical care of officers only and to consultation in matters involving the health of the troops. Among the common soldiers there developed a category of those judged by their fellow legionaries to be experienced and especially adept at wound‑dressing: the medici. A medicus held a position of respect among his fellows, but he was first a soldier in his duties; his quasi‑medical function was secondary. His medical knowledge, such as it was, had been obtained through observation and trial and error or gained through contact with senior medici, his knowledge of anatomy was learned from the wounds of the soldiers. He wore the same uniform as did his "patients," shared their chain of command, and enjoyed little privilege by virtue of his special skill.
The function and deployment of the army changed markedly during the early years of the Empire with the recognition by Augustus that there must be an eventual limit to the extension of Roman authority. The concept of a frontier where the area of undisputed Roman control came in contact with barbarian lands called for a system of forts, supply bases, and communications. The complex of fortified defensive boundaries, known as the limes (pl. limites), moved with changing Roman fortunes, but henceforth until the fall of the Empire required the permanent stationing of troops far from home.
Most of the Roman frontiers were located at the edges of deserts or seas where natural barriers meant that few troops were needed for adequate defense. The notable exception was the northern limes, which followed roughly the course of the Rhine and Danube Rivers. Control of the river frontier did not require a force spread evenly along the banks, but rather concentrations of troops at the main crossing points. Hence there were established major forts at Vindonissa, (Windisch), Argentorate (Strasbourg), and Mogontiagurn (Mainz) on the Upper Rhine, Bonna (Bonn), Colonia Agrippina (Cologne), Novaesiurn (Neuss), Vetera (Xanten), and Noviomagus (Nijmegen) on the Lower Rhine, and at Vindobona (Vienna), Carnuntum, and numerous other locations along the Danube. With the invasion of Britain during the reign of Claudius the northwest extension of the limes brought a need for still more fortifications culminating in Hadrian's Wall.
The establishment of these more or less permanent military installations so far from Rome meant that soldiers no longer returned to their homes at the ends of military campaigns and that the services for which they had once returned to Rome had now to be provided along the limes. The distances also meant that sick or wounded soldiers could no longer be sent home for treatment, and the need for a more effective army medical service was apparent, including facilities for the complete care of the temporarily disabled.
Figure 3. Model reconstruction of the Roman military valetudinarium (hospital) at Vetera on the lower Rhine. The floor plan and central courtyard are authentic. The raised section of roof and windows over the circulation corridor is assumed to have been necessary for lighting and ventilation. Rheinisches Landesmuseum, Bonn.
Figure 4. Plan of the Roman military hospital at Vindonissa (modern Windisch, Switzerland). The four‑membered circulation corridor flanked by rows of paired wards is typical of all. This particular hospital featured a one‑room building in the center of the courtyard, possibly a medical treatment room.
Most of the military valetudinaria were built in the first century, A.D., when the system of frontier fortifications was being developed. The major valetudinaria were located in the legionary fortresses, so named because they were designed to accommodate an entire legion or division, numbering usually 6,500‑7,000 men. Most of them appear to have had a capacity of 300‑400 patients or about 5 per cent of the camp's population, a ratio similar to that of modem military base hospitals.
The earliest military valetudinaria were constructed of wood, but by the end of the century they had been replaced by durable stone structures, more fire‑resistant and affording better protection against the colder winters of Central Europe. Typically they were built near the center of the camp, often on its main street, and near the main baths. The most characteristic architectural feature was a quadrangular plan arranged around a central rectangular court. The wards were arranged on either side of a main circulation corridor which extended continuously through all four sides ‑of the building. The external dimensions of most were in the range of 150‑200 feet by 250‑300 feet. The plan must have been workable, since it was utilized repeatedly over a period of well more than a century with only minor variations.
One other characteristic feature of the valetudinaria, found almost as consistently as the basic quadrangular plan, was the arrangement of paired small wards (Fig. 5). The wards usually measured about 12 x 15 feet and accommodated five to eight patients each. Typically two such wards shared a small anteroom by which they communicated with the circulation corridor. The indirect access from corridor to wards provided not only quiet and privacy, but freedom from drafts. A third room, intermediate in size between the anteroom and the wards. communicated with the anteroom and lay between the two wards. The function of this room has been the subject of some conjecture. Jetter10 states that it was used by the personnel of the valetudinarium as a sort of nursing station; Webster identifies it as a latrine; Simonett believed it to be a storeroom for the patients' belongings. Whatever the function of the intermediate room, The Romans seemed to have been pleased with the basic arrangement. for they repeated it in legionary hospitals from Austria and Switzerland to the Rhineiand and Scotland.
It is safe to assume that medical care in the military valetudinaria proceeded at a low level. Galen, critical of Roman military medicine, once described being summoned to the scene of a battle to give proper medical treatment where, in his opinion, little such treatment existed. He noted caustically that many doctors "talk" medicine without proving their skill. Galen's comment doubtless could also have been applied to a large segment of the civilian profession of his day.
In summation there can be no doubt that the first important steps toward the development of scientific medicine were taken by the early Greeks and merely followed by the Romans. What is less appreciated is the contribution to total health care and maintenance made by the Romans. Their technological approaches to the provision of healthful water supplies and sanitation and their development of the world's first hospital system were probably more important contributions to the solution of the health problems of their increasingly complex society than was the medical progress made by the Greeks. The appointment and official support of public physicians, the archiatri, for the express purpose of proving free medical care to the poor represented social progress, considering the ambiguous position of the Greek demosieuontes.
Figure 5. Basic paired ward arrangement common to all the Roman army's hospitals. The tortuous entry through the small anteroom must have been difficult in the case of litter patients.
If there was no public clamor for better health facilities and a more equitable distribution, it was because the quality of the care available had stimulated little demand. As long as the masses preferred supernatural medicine to the natural the competition for physicians' services was negligible. In a day when supportive care in the home was approximately as good as that available in the best valetudinaria there was a limited need for the specialized institutions. The latter success of rational medicine in displacing the cults, in eventually assuming the leadership of the community health effort, and, most important in the past century, in gaining the confidence of the public produced, through rising expectations, shortages, and high costs, a crisis in health care distribution of which the ancients would never have dreamed.
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