THE ANCIENT WORLD
Development of agriculture served growing populations
unable to exist solely from hunting, stimulating the organization
of more complex societies able to share in production
and in irrigation systems. Division of labor, trade, commerce,
and government were associated with development
of urban societies. Growth of population and communal
living led to improved standards of living but also created
new health hazards including spread of diseases. As in
our time, these challenges required community action to
prevent disease and promote survival.
Eastern societies were the birthplace of world civilization.
Empirical and religious traditions were mixed.
Superstition and shamanism coexisted with practical
knowledge of herbal medicines, midwifery, management
of wounds or broken bones, and trepanation to remove
“evil spirits” that resulted from blood clots inside the
skull. All were part of communal life with variations in
historical and cultural development. The advent of writing
led to medical documentation. Requirements of medical
conduct were spelled out as part of the general legal Code
of Hammurabi in Mesopotamia (circa 1700 BCE). This
included regulation of physician fees and punishment for
failure and set a legal base for the secular practice of
medicine. Many of the main traditions of medicine were
those based on magic or that derived from religion. Often
medical practice was based on belief in the supernatural,
and healers were believed to have a religious calling.
Training of medical practitioners, regulation of their practice,
and ethical standards evolved in a number of ancient
societies.
Some cultures equated cleanliness with godliness and
associated hygiene with religious beliefs and practices.
Chinese, Egyptian, Hebrew, Indian, and Incan societies
all provided sanitary amenities as part of the religious
belief system and took measures to provide water, sewage,
and drainage systems. This allowed for successful urban
settlement and reinforced the beliefs upon which such
practices were based. Personal hygiene was part of religious
practice. Technical achievements in providing
hygiene at the community level slowly evolved as part
of urban society.
Chinese practice in the twenty-first to eleventh centuries
BCE included digging of wells for drinking water;
from the eleventh to the seventh centuries BCE this
included use of protective measures for drinking water
and destruction of rats and rabid animals. In the second
century BCE, Chinese communities were using sewers
and latrines. The basic concept of health was that of countervailing
forces between the principles of yin (female)
and yang (male), with emphasis on a balanced lifestyle.
Medical care emphasized diet, herbal medicine, hygiene,
massage, and acupuncture.
Ancient cities in India were planned with building
codes, street paving, and covered sewer drains built of
bricks and mortar. Indian medicine originated in herbalism
associated with the mythical gods. Between 800 and 200
BCE, Ayurvedic medicine developed and with it, medical
schools and public hospitals. Between 800 BCE and 400
2 Chapter | 1 A History of Public HealthCE, major texts of medicine and surgery were written. Primarily
focused in the Indus Valley, the golden age of
ancient Indian medicine began in approximately 800
BCE. Personal hygiene, sanitation, and water supply engineering
were emphasized in the laws of Manu. Pioneering
physicians, supported by Buddhist kings, developed the
use of drugs and surgery, and established schools of medicine
and public hospitals as part of state medicine. Indian
medicine played a leading role throughout Asia, as did
Greek medicine in Europe and the Arab countries. With
the Mogul invasion of 600 CE, state support declined,
and with it, Indian medicine.
Ancient Egyptian intensive agriculture and irrigation
practices were associated with widespread parasitic disease.
The cities had stone masonry gutters for drainage,
and personal hygiene was highly emphasized. Egyptian
medicine developed surgical skills and organization of
medical care, including specialization and training that
greatly influenced the development of Greek medicine.
The Eberus Papyrus, written 3400 years ago, gives an extensive
description of Egyptian medical science, including
isolation of infected surgical patients.
The Hebrew Mosaic Law of the five Books of Moses
(circa 1000 BCE) stressed prevention of disease through
regulation of personal and community hygiene, reproductive
and maternal health, isolation of lepers and other
“unclean conditions,” and family and personal sexual conduct
as part of religious practice. It also laid a basis for
medical and public health jurisprudence. Personal and
community responsibility for health included a mandatory
day of rest, limits on slavery and guarantees of the rights
of slaves and workers, protection of water supplies, sanitation
of communities and camps, waste disposal, and food
protection, all codified in detailed religious obligations.
Food regulation prevented use of diseased or unclean animals,
and prescribed methods of slaughter improved the
possibility of preservation of the meat. While there was
an element of viewing illness as a punishment for sin,
there was also an ethical and social stress on the value
of human life with an obligation to seek and provide care.
The concepts of sanctity of human life (Pikuah Nefesh)
and improving the quality of life on Earth (Tikun Olam)
were given overriding religious and social roles in community
life. In this tradition, the saving of a single human life
was considered “as if one saved the whole world,” with an
ethical imperative to achieve a better earthly life for all.
The Mosaic Law, which forms the basis for Judaism, Christianity,
and Islam, codified health behaviors for the individual
and for society, all of which have continued into the
modern era as basic concepts in environmental and social
hygiene.
In Cretan and Minoan societies, climate and environment
were recognized as playing a role in disease causation.
Malaria was related to swampy and lowland areas, and prevention
involved planning the location of settlements.
Ancient Greece placed high emphasis on healthful living
habits in terms of personal hygiene, nutrition, physical fitness,
and community sanitation. Hippocrates articulated the
clinical methods of observation and documentation and a
code of ethics of medical practice. He articulated the relationship
between disease patterns and the natural environment
(Air, Water, and Places) which dominated epidemiologic
thinking until the nineteenth century. Preservation of health
was seen as a balance of forces: exercise and rest, nutrition
and excretion, and recognizing the importance of age and
sex variables in health needs. Disease was seen as having natural
causation, and medical care was valued, with the citystate
providing free medical services for the poor and for
slaves. City officials were appointed to look after public
drains and water supply, providing organized sanitary and
public health services. Hippocrates gave medicine both a
scientific and ethical spirit lasting to the present time.
Ancient Rome adopted much of the Greek philosophy
and experience concerning health matters with high levels
of achievement and new innovations in the development
of public health. The Romans were extremely skilled in
engineering of water supply, sewage and drainage systems,
public baths and latrines, town planning, sanitation
of military encampments, and medical care. Roman law
also regulated businesses and medical practice. The influence
of the Roman Empire resulted in the transfer of these
ideas throughout much of Europe and the Middle East.
Rome itself had access to clean water via 10 aqueducts
supplying ample water for the citizens. Rome also built
public drains. By the early first century the aqueducts
allowed people to have 600–900 liters per person per day
of household water from mountains. Marshlands were
drained to reduce the malarial threat. Public baths were
built to serve the poor, and fountains were built in private
homes for the wealthy. Streets were paved, and organized
garbage disposal served the cities.
Roman military medicine included well-designed sanitation
systems, food supplies, and surgical services.
Roman medicine, based on superstition and religious rites,
with slaves as physicians, developed from Greek physicians
who brought their skills and knowledge to Rome
after the destruction of Corinth in 146 BCE. Training as
apprentices, Roman physicians achieved a highly respected
role in society. Hospitals and municipal doctors were
employed by Roman cities to provide free care to the poor
and the slaves, but physicians also engaged in private
practice, mostly on retainers to families. Occupational
health was described with measures to reduce known risks
such as lead exposure, particularly in mining. Weights and
measures were standardized and supervised. Rome made
important contributions to the public health tradition of
sanitation, urban planning, and organized medical care.
Galen, Rome’s leading physician, perpetuated the fame
of Hippocrates through his medical writings, basing medical
assessment on the four humors of man (sanguine,
Chapter | 1 A History of Public Health 3phlegmatic, choleric, and melancholic). These ideas dominated
European medical thought for nearly 1500 years
until the advent of modern science.