Advocacy and Community: The Social Roles of Physicians in the Last 1000 Years. Part I in a 3-Part Series.

Karen E. Geraghty, PhD (c), Matthew K. Wynia, MD, MPH

In This Article

From Hospitality to Criminality (1500-1600 AD):

Figure 2. Harriet Tainted by Disease goes into a Workhouse, (London:Carington Bowles,1780) Image courtesy of the National Library of Medicine.

As the state assumed more control of public health matters and issues of economic necessity became increasingly important, there was a gradual but distinct shift in the perception of the poor and a recasting of their role in society. Throughout the Middle Ages, the poor were viewed charitably and their poverty fulfilled a necessary role for the well-to-do, whose beneficent works on their behalf were believed to secure favor with God. By the 16th century, however, tremendous growth in population coupled with outbreaks of pestilence and famine cast suspicion on itinerant vagabonds as carriers of disease and immoral behavior, which threatened the general populace.[10] Support for care of the poor waned among private benefactors.

As care of the poor could no longer effectively be managed by individual charity or ecclesiastical organizations, it too became a regional governmental responsibility. At the same time, economic utility and productivity increasingly became the means by which communities defined the worth of their citizens and the poor came under stricter regulation. Workhouses were established to contain the criminal element, and local towns organized new controls and instituted "poor laws" which provided support of services for the poor, ill, and infirm by levying a tax on members of each parish. Importantly, these laws typically categorized both the sick and the poor according to their ability to work as the goals of organized poor relief were not only to control criminals and provide basic care to the deserving indigent (widows and the elderly), but also to reform the able-bodied poor through enforced labor.[11] Those who were not contributing to social productivity were consigned to institutions for "rehabilitation."

Lumping together the sick and the poor and shifting treatment of the poor and destitute into increasingly organized social structures signaled a change in the interpretation of illness. Whereas it had been formerly perceived as a metaphysical, spiritual affliction, it was now considered a physical and social problem. Institutions such as workhouses and charity hospitals began to seek therapeutic solutions from surgeons and physicians, who played ever larger roles in the treatment of a variety of ailments. Treatments, however, continued to follow the regimen prescribed by the humoralist understanding of the body and policies of moral reform, particularly for those deemed criminal, dangerous, or lazy, were drawn from the influence of the church. It would not be until the 17th century, when a major philosophical shift would reconceptualize the meaning of disease and illness in physical terms, that the groundwork would be laid for real advances in therapeutic measures.