WHERE WERE THE DOCTORS WHEN THE ROMAN EMPIRE DIED?

The notion that inadequate health services might have been one of the reasons for the fall of the Roman Empire is investigated. Despite many factors preventing the early development of an adequate public health service, the Romans had achieved much by the 5 th century AD. Apart from many laws promoting public health, various official measures were taken by the Roman government, for example the appointment of state physicians and free medical services for the poor. But the greatest contribution of the Romans was the provision of facilities which served as an indispensable infra- structure for public health care, such as the provision of an ample supply of pure water, public baths, advanced measures for the disposal of sewage, and somewhat later under the influence of Christianity, hospitals for the general public. Although there were still deficiencies, the Roman government cannot be criticised for laxity as far as the provision of health services was concerned. Inasmuch as they were in default, it was because of lack of scientific medical knowledge which only evolved c. 1 500 years later.


INTRODUCTION
Several cogent arguments can be advanced to support the view that inadequate health services might have been one of the underlying reasons for the fall of the Roman Empire. The first and most obvious is the Romans' total ignorance of the scientific bases of health. Also the fact that there were social barriers barring the way to a good health service: there was no driving force or organisation to put existing knowledge to practical use. Another stumbling block was the negative attitude of the Greeks and the early Romans toward the ill: the ideal man was noble, beautiful and harmonious. Disease made man an inferior being and thus a disgrace. There was thus no conception of organised, long-term medical care of the sick or disabled. Yet another barrier to the early development of health services was superstition and primitive religious beliefs and practices. The early Romans were content with traditional folk medicine, prayers, expiations and magical practices.
Greek medicine was eventually introduced into Rome, but it took long to be assimilated in Roman thought and practice -even in the highly developed Roman Imperial society one finds that alongside excellent 64 Where were the doctors when the Roman Empire died?

Foreign aid
A good illustration of Rome's attitude to public health can be found very early in her history: a great epidemic broke out in Rome in the year 293 BC. The senate consulted the Sibylline books, as was traditional in times of crises. The recommendation was that they should import the cult of Asclepius, the Greek god of medicine, from its chief centre in Epidaurus. It is related that a serpent (the symbol of the god) boarded the ship at Epidaurus of its own accord, and when the mission arrived in Rome, it swam ashore to an islet in the Tiber. After the epidemic had subsided, the grateful Romans built a temple on the island in honour of the god whom they named Aesculapius in Latin. There is a very prosaic explanation of this myth: Roman medicine was still very unsophisticated in the 3 rd century BC and thus the state had to seek outside assistance against the disease. The priests in Epidaurus advised that it would be more hygienic to have ill people outside the built-up area of the city. Therefore the temple to Aesculapius where the afflicted could seek healing was built on an island in the Tiber, outside the city precincts.

Public physicians
Another instance of an advance in health care is the story told by an early historian about the first physician to come to Rome, namely Archagathus, who migrated from the Peloponnesus in the year 219 BC. He was granted the rights of citizenship and a shop was purchased at public expense for his use. Initially Archagathus enjoyed great popularity as a "wound specialist" (vulnerarius), but he was soon called carnifex because of his savage use of the knife and cautery. The result was that he returned home to his former obscurity, and his profession as well as all physicians fell from favour. Apart from giving us a glimpse of the Romans' antagonism toward Greek physicians, the main significance of this story is to be found in the fact that Rome had done what Greek communities had been doing for centuries -the still rather backward but rising city had in the late 3 rd century BC hired a doctor from abroad to be a resident civic physician.
This practice of hiring a physician to care for the public health of a city was regularly followed by the Greeks from the earliest times 66 Where were the doctors when the Roman Empire died? satisfied the authorities as to their knowledge and skill. In private, however, anyone could still practise medicine.

The Hippocratic Oath
The question may arise why the Hippocratic Oath could not ensure at least some kind of ethical standard amongst physicians. The reason is that this document had no legal force and that most physicians in the pre-Christian era were probably not aware of its existence. It is doubted nowadays whether this so-called Hippocratic Oath was actually written by Hippocrates. It is now regarded as an esoteric ethical document, partly of Pythagorean origin, compiled by a handful of Greek philosophers in the 5 th or 4 th century BC and having as aim to mutually bind teacher to pupil, to keep the soul of the physician in accord with the essential Pythagorean values, and to designate proper moral duties between physician and patient. After a period of relative obscurity, the Oath's high ethical code came to be admired with the advent of Christianity, and since then it has become known more widely.

Rewards and privileges
There were, of course, also good doctors in antiquity, as is proved by the numerous laws granting privileges to physicians in gratitude for services rendered. There had been enormous antagonism against all Greek physicians in the 3 rd and 2 nd centuries BC and humiliation by the snobbery of the ruling class even down to the 1 st century BC, but their position in Rome was definitely established when in 46 BC Julius Caesar granted citizenship to all physicians practising in Rome (even in the 1 st century AD medicine in Rome was still practised largely by Greeks). In the Imperial period the status of physicians greatly improved -there is evidence that the royal physicians at the courts of Augustus and Tiberius received handsome salaries. Augustus further improved their position when, in gratitude to his freedman Antonius Musa who cured him of a disease, he gave to him and all his fellow practitioners freedom from public taxes then and forever. 68 Where were the doctors when the Roman Empire died?

ABORTION
An age-old issue which is still being hotly debated today but which apparently attracted the minimum attention in antiquity until the advent of Christianity, is abortion. For the Greeks and Romans child exposure was a relatively common practice, and infanticide was still practiced by the rich during the highly civilised Roman Imperial period. In excavations infant skeletons were often found under floors and even in rubbish pits -one must remember that the paterfamilias had power of life and death over his whole household. It is therefore hardly surprising that Greek and Roman law did not protect the unborn child, and that the act of aborting the fetus -provided the mother was not harmed -tended to be viewed as morally permissible. Since in classical Roman law there was no prohibition on abortion, it was practised without embarrassment by the upper-class Romans to limit their families (although contraceptives were also widely known and commonly used in antiquity). The first legal measures of the Roman State against abortion was only taken in c. AD 200. But the motivation behind these sanctions is revealing: the point at issue was still not the protection of the unborn infant, but the right of the father which had been impinged upon, or the interest of the state which had lost a potential citizen, or the life of the mother which had been endangered because drugs had been taken. One can, however, trace an increasingly negative attitude towards abortion in all kinds of sources from the earliest times on. This reflects a growing conviction that the fetus as a living being has the right to live. This conviction grew stronger with the advent of Christianity: Christian writers condemned abortion as being incompatible with and forbidden by the fundamental Christian teaching of love which forbade the taking of a life. 70 Where were the doctors when the Roman Empire died?
Empire -c. AD 100 -this number had grown to ten. About half of the water went to the public baths and street fountains; this left about 50 gallons or 225 litres per person per day for a population of around 1.5 million. This figure compares well with modern conditions: the inner city of Bloemfontein e.g. has approximately 265 000 inhabitants; the daily water supply of 101 000 000 litres gives us 384 litres per person per day. But back to Rome: it appears that very little of this immense supply of water found its way to private houses. A private supply could only be obtained by imperial grant on payment of a fee, which meant that only leading, prosperous citizens would qualify; others had to employ water carriers or had to fetch their own water from street fountains or basins. Nevertheless, water was available and of reasonably good quality.

Sanitary measures
Sanitary measures were a source of great civic pride to the Romans. In James Joyce's Ulysses one of the characters says that when the Greeks moved into an area, they would say: "Ah, this is a meet place, let us build a temple!" whereas the Romans would say: "Ah, this is a meet place, let us build a sewer!" A landmark in the field of public hygiene was the Cloaca Maxima, originally constructed by the Etruscans in the 6th century BC to drain the marsh where the Forum Romanum was later situated. Later it acquired all the functions of a modern sewer, and it was so solidly built that it is still used for that purpose today -2 500 years and many millions of litres later! The sewers were continually extended and improved during the Republic and Empire until they formed a network under the city. Most of these cloacae were constructed on such a grand scale -about 3 metres wide and 4 in height -that in certain places a wagon laden with hay could be driven through them with ease. Yet, looking at the reverse of the coin, it appears that by no means all the houses in Rome were connected with the public system of sewers -especially not the upstairs apartments in flat buildings. Therefore the majority of private people -even at the height of the Empire -still had to use the public latrines in the streets, or the (in)famous marble building equipped with urinals, constructed by that very practical-minded emperor Vespasian. The masses were therefore not always able to share in the available hygienic facilities: in the poorer quarters passers-by could count themselves lucky if it was only the con-tical people who, in their belief that prevention is better than cure, made provision for facilities promoting public health care, such as the supply of ample pure water for public and private use, advanced measures for sewage disposal, public baths, etc. In fact, the ready availability of baths is one of the clearest indications of the Romans' positive attitude to hygiene and health. Even more important was the Romans' organisation of medical services. Reference can be made here firstly to the appointment since the 4 th century AD of public physicians in the various towns and institutions, and to the laws regulating the appointment and services of these municipal physicians. And to this may be added that the Romans' talent for organisation also comes to the fore in the creation, since the time of Augustus, of numerous boards and commissions, such as the Water Board, the Health Commission and various commissions of aediles who, as part of their cura urbis, supervised the public baths, the cleaning of the streets, the food supply, the markets, etc. The development of these basic health services into an effective administrative system, together with Rome's most important contribution to organised medical care, namely the development of public hospitals, are legacies that endured even after the Empire decayed and disintegrated.