Plague and Public Health in Europe, with Special Reference to Sixteenth-Century England: An Introduction to Orders thought meete by her Maiestie ..., 1578
Duane J. Osheim, Ph.D., Professor and Chair, Corcoran Department of History, University of Virginia
Queen Elizabeth's "Orders thought meete ..." testifies to the impact of plague in the European World. The pestilence which seemed to move out of Central Asia through the Mediterranean and eventually to northwest Europe first arrived in 1347-48 and was to return regularly until a last important outbreak in Marseilles in 1720-22. A furious debate continues over the exact causes of "the Great Mortality" or "the Black Death." Since the early twentieth century most scholars have assumed that the series of epidemics that returned almost generationally were caused by bubonic plague, the bacterial disease first identified by Alexandre Yersin and Shibasaburo Kitasato at the end of the nineteenth century. Recently there has been a storm of controversy as historians and epidemiologists have speculated that it might have been anthrax or even a sort of "hemorrhagic plague." There is, however, some DNA evidence found in plague cemeteries suggesting the presence of Yersinia pestis, the bacterium that causes bubonic plague.
Whatever the outcome of the debate over retrospective diagnosis, the "Orders thought meete ..." offers a glimpse at the issues of public health brought on by recurrent plague in late Medieval and Early Modern Europe. The first epidemic of 1347-51 may have destroyed as many as 28,000,000 people, that is 30-40 percent of the European population. And it seems that for the next 50 years plague returned on average every 11 years! Recurrent plague ended the possibility of significant population growth and stagnated the economy for nearly two centuries.
The first chroniclers reported with some exaggeration that family members abandoned loved ones to die alone, that many were buried in mass graves without mourners or even religious services. We know as well, that in some parts of Europe, fears of plague were transformed into fears of mass poisonings and secret conspiracies to destroy Christendom. Terrified populations in some parts of Europe quickly attacked lepers, Jews, and others who seemed outsiders. The first mention of gypsies in Swiss chronicles was in a plague report.
The initial wave of plagues in the 1340s and 1350s were certainly deadly and disruptive, but in subsequent epidemics we begin to see outlines of concerns that in most parts of western Europe would eventually produce ordinances like Elizabeth's. The first response was simply a rejection of abandonment. Writers complained about "the death of charity" apparent in the reports of social breakdown—a response "unworthy of Christians" one Florentine writer concluded. And, in fact, across Italy, we find reorganized hospitals, new religious brotherhoods dedicated to helping the sick and abandoned, and a celebration of individuals who like the legendary St. Roch chose to risk their lives to care for the sick.
Local governments also responded quickly. By the end of the fourteenth century, most Italian towns had well established plague ordinances designed to respond to what they believed to be the greatest dangers to public health. Town patricians were often practical men, but like the educated physicians, they believed that disease was caused by various sorts of corruptions that could upset the humoral balance in the body and bring on deadly illness. The most obvious sources of corruption were the noxious smells that were ubiquitous in a medieval city. Regulators looked to the sale of meat and fish, rotting fruits and vegetables, and industrial processes like tanning. It is easy to dismiss their concern about whether the methods used to skin a cow might introduce corruptions in the meat, but the important point is that by the end of the fourteenth century, towns and provinces in Italy had accepted their responsibility for the regulation of public health.
By the end of the fifteenth century, Venice had established a permanent health board, the Provveditori alla Sanità, with powers to regulate the clothing trade, retail sales of foods and drink, and public festivals. The board also oversaw a series of plague hospitals or Lazzaretti. There was one for the sick and another for those who had been exposed to the disease. By the second decade of the sixteenth century, the Provveditori were receiving regular reports from throughout Italy, Europe, and the Middle East about epidemics. In addition they had begun tracking deaths throughout the city and its surrounding regions. The recurrent plague had forced the towns and regions of Europe to take action.
The English were slow to catch up with the Italians and the French, but by the end of the sixteenth century, they too recognized the importance of coordinated public actions. And Elizabeth's "Orders thought meete ..." of 1578 established the parameters of the English response.
The Orders contained with the book show a quite traditional understanding of disease. As doctors had known since the time of Hippocrates and Galen, bad air (mal aria, after all) was always a danger best avoided by use of a spice apple or a nosegay. Our "best learned in Physicke" suggested "some things of sweete savour in their hands." He also provided a recipe for Mythridatium, an antidote for poisons popular since the Roman Empire. Although Europeans had come to know a great deal about this deadly disease, this section of the "Orders thought meete ..." shows how easily they had managed to accommodate their new knowledge into a traditional frame.
The Orders themselves, however, demonstrate how old and new could be combined in important ways. They further indicate just how complex public health could be. While the Venetians had created a standing public health board in the late fifteenth century, the Orders show that the English envisioned a system that functioned only in emergencies. It depended on the well developed English system of local, participatory government. The first part of the "Orders thought meete ..." makes clear just how this was to happen. Like most European governments, the English assumed that isolation and quarantine were essential first steps. The problem faced by every government was how to insure popular acceptance of quarantine and how to ameliorate the hardship isolation might cause.
The Orders also show how ambivalent most people were to isolating their neighbors. It seems that there was a fatalism that made quarantine unnecessary. Item 16 records that many people thought "it is not charitable to forbid [visiting the sick], pretending [i.e. believing on the other hand] that no person shall dye but at their type prefixed [i.e. if they were destined to die of that disease]. The key issue was the apparent lack of charity in isolation and quarantine policy. Readers in the sixteenth century knew that in St. Paul's words, "the greatest virtue is charity" (I Corinthians 13:13). This rubric tries to solve the conundrum that officials faced. The movements of the suspect had to be limited, yet the community had to care for its needy. A careful reader will find this worry is found throughout the "Orders thought meete ...."
Yet interestingly, the most significant rubric of the "Orders thought meete ..." might be its simple requirement that local church officials must inquire into all deaths and report weekly on illnesses and deaths. These are the English Bills of Mortality that allowed Englishmen to recognize the regularities in the course of a disease, its location, its transmission, and its decline. This was, in effect, a sort of epidemiology that allowed the English and indeed all Europeans to track the course of an illness. We recognize the importance of the CDC's Morbidity and Mortality Reports. We see in the Orders an early example public health monitoring. And it has been argued that tracking of this sort was what led to the moderation of plague epidemics in the seventeenth century and to their disappearance in the eighteenth.
These are just a few of the insights the "Orders thought meete ..." offers. In its whole, it allows the thoughtful reader to begin to understand how disease and public health were understood in a world before germ theory or miracle cures.