A New Era in Roman Healthcare

ROMAN ROADS, public baths and gymnasiums, Hellenistic high culture, the beginnings of democracy, the military muscle to ensure peace—the Roman Empire in the second century after Christ may have looked like a golden age. For the healthy, perhaps it was. But woe unto you if you got sick. Then the shining Roman city showed its dark underbelly.

Compassion was not a well-developed virtue among the pagan Romans; mercy was discouraged, as it only helped those too weak to contribute to society. In the cramped, unsanitary warrens of the typical Roman city, under the miserable cycle of plagues and famines, the sick found no public institutions dedicated to their care and little in the way of sympathy or help. Perhaps a family member would come to their aid, but sometimes even close relatives would leave their own to die.

The Roman Empire in the first centuries of the church ruled over tens of millions. Many no doubt thanked their gods they lived in the “civilized world” found within the empire’s well-defended boundaries and not the “barbarian world” outside. And indeed, in many ways Rome’s material culture was not equaled until the nineteenth century.

The empire’s greatest pride was its cities—more than 5,000 of them. In its eastern half Rome boasted many ancient metropolises: Athens, Corinth, Ephesus, Antioch, Jerusalem, Alexandria. After the conquest of the empire’s western half, Rome also included hundreds of new cities in North Africa, Spain, Gaul, and Britain. These became the chief means of spreading Roman civilization, much of which Rome had borrowed from the illustrious Greeks.

In the second century BC, as in our own day, many people began moving from the countryside to the city in search of jobs and amenities. Once in the cities, however, migrants found themselves living in tenement buildings lacking basic sanitary facilities. The support of family and village now gone, they eked out an often lonely urban existence. In the face of daily alienation or in times of trouble, they could expect no social support beyond occasional free grain and entertainment such as gladiatorial games (“bread and circuses”).

Worse still, should they sicken, no clinics or hospitals existed to provide healing or even basic nursing care. True, one could find physicians. But their fees were too steep for most. Some towns did hire a public physician, but institutional health care was unheard of. So hoi polloi (commoners) were left to rely on folk healers and sellers of herbs, amulets, and quack remedies.

In a world of gods not renowned for their compassion, ­Roman ­culture simply did not en­courage a felt responsibility to assist the destitute, sick, or dying. Individuals were ­expected to care for their own health in any way they could. Many lacked even the safety net of family—discharged soldiers, peasants who had come into the city seeking work, or slaves who had been recently freed. Without a family, you simply had no support system: no one to take care of you when you were sick, no one to help with food or rent when you couldn’t work, no one to bury you when you died.

Destitute families lacking any resources to help sometimes even abandoned the chronically ill to die. In Rome, sick or elderly slaves were routinely left to waste away on Tiber Island. Unwanted children were often left to die of exposure. If a father decided that the family couldn’t afford to feed another child, that child would be abandoned on the steps of a temple or in the public square. Almost without exception defective newborns were exposed in this way.

Female infants were exposed much more often than males because a girl not only added another mouth to feed, but she also couldn’t (according to Roman social customs) work to support the family. Besides, the father knew he would eventually have to bear the added burden of furnishing a dowry for each daughter’s marriage.

The classical world possessed no religious or philosophical basis for the concept of the divine dignity of human persons, and without such support, the right to live was granted or withheld by family or society almost at a whim. As a result, the chronically ill could be seen everywhere in the streets, baths, and forums—many of them homeless and begging. Some turned to the temples of healing gods, such as Isis and Serapis, who were believed to heal supernaturally.

Most famous of these gods was Asclepius, who was worshiped in hundreds of temples and shrines throughout the Roman Empire. The sick would come as pilgrims to the temples. Here they would offer a small sacrifice, so humble that even the poor could ­afford it, then sleep overnight in the abaton, or sacred enclosure, where they believed that the god might appear to them, sometimes in a dream, to heal them. Those who most often sought help were either suffering from chronic or hopeless diseases or were very poor. Some were healed, according to temple inscriptions. By the second century A.D., physicians were available at some temples to offer advice on medical regimens. But pilgrims came for healing, not for long-term medical care, which was not provided. In fact, the dying were not allowed in the temple precincts, since their death would pollute the sanctuary.

A new moral culture

By the first century A.D., however, a new culture began penetrating the classical Roman world: the culture of the Christians, revolutionizing morality and behavior. Palestine couldn’t hold the new faith long, and within a century, it was already spreading rapidly across the empire.

The spread was never easy or unimpeded: starting with Nero’s campaign of brutality in A.D. 64, the supposed unpatriotic beliefs of Christians attracted the hostility of Roman authorities, who responded with local and empire-wide persecutions. Nonetheless, by the middle of the second century, Christian churches had sprung up in most major cities and many smaller ones.

During this time, in spite of great danger to themselves, these churches carried on an active ministry of philanthropy that included the care of the sick. Christian medical philanthropy found its basis in the biblical concept of the imago Dei, the belief that human beings are created in God’s image. At the beginning of ­Genesis, Christians could read: Then God said, “Let us make man in Our ­image, according to Our likeness; let them have dominion over the fish of the sea, over the birds of the air, and over the cattle, over all the earth and over every creeping thing that creeps on the earth.” So God created man in His own image; for in the image of God He created him; male and female He created them. (Genesis 1:26–27, NKJ.) God’s creation of human beings in his image (rationally, spiritually, morally, volitionally) implied that human life is precious and must be protected. In Genesis 9:6 Yahweh tells Noah, “Whoever sheds man’s blood, by man his blood shall be shed; for in the image of God He made man.”

The imago Dei provided the foundation for the Hebrew concept of human personhood, and certain practices common among other ancient Near Eastern societies were forbidden by the Torah: child sacrifice, exposure of infants, infanticide, and castration.

In the New Testament the doctrine of the In­carnation extended and deepened the implications of the imago Dei: “And the Word (logos) became flesh (sarx) and dwelt among us” (John 1:14a). Early Christians believed that the motivation for charity should be God’s self-giving love (agape) to us, which reflected his nature (1 John 4:8). God loved the human race enough to send Christ in human flesh, to die on a cross for our sins (John 3:16).

Agape vs. stoicism

Christians responded by demonstrating Christ’s love to their brothers and sisters, who bore God’s image (John 13:34–35). The weaker and more helpless the neighbor, the greater the need to show them the compassion of Christ. Hence early Christians showed special concern for the protection of unborn and newborn life. This sort of practical morality departed radically from the social ethics of classical paganism and laid the foundation for Christian philanthropy.

The pagan idea of philanthropia (“love of mankind”) not only did not provide an impulse for private charity, but actively discouraged it. In Greek and Roman society beneficence (providing assistance to the needy) existed only on the community level; civic philanthropy was exercised by rulers and the wealthy on behalf of the entire community, rich and poor alike. There was no particular reason to found charitable institutions. The stoic philosophy of many in the ruling class discouraged beneficence motivated by pity because it was based on emotion rather than on reason.

By contrast, God’s love demanded from Christians a response that would demonstrate his love to others, especially the unlovely. James defines “religion that is pure and undefiled before God” in part as caring for “orphans and widows” (James 1:27)—biblical shorthand for all those without protectors and in need.

Christian beneficence went further than Jewish charity, which required only that the Jewish community help its own. To find a new, broader mandate of care Christians needed to look no further than to the parable of the Good Samaritan, Luke 10:25–37. Here Jesus shocked his Jewish hearers when he stated that it was the despised Samaritan who proved himself a neighbor, having compassion on the wounded man and giving him medical aid when even priests and Levites of his own religious community passed him by.

This new ethic also surpassed the Stoic concept of human brotherhood: it was compassionate love (agape), not to the deserving, but to the despised, indeed to enemies. God loved us while we were sinners: Jesus commanded his hearers to “go and do likewise.”

Congregation-based healthcare

Christian theology thus birthed a personal and corporate charity surpassing any previously known. Church leaders encouraged all Christians to visit the sick and help the poor, and each congregation also established an organized ministry of mercy. Presbyters (priests) and deacons added benevolent ministry to their sacramental roles. They collected alms each Sunday, distributed by deacons. Widows and deaconesses provided a ministry of mercy to women. Despite persecution and their small numbers, Christians maintained an extensive ministry to those in need.

By the third century the number of those receiving aid from the hands of the church had grown considerably, especially in large cities. Congregations created additional minor clerical orders, such as subdeacons and acolytes, to assist deacons in benevolence as well as liturgy.

In 251 Cornelius, bishop of Rome, wrote to Fabius, bishop of Antioch, reporting that the church in Rome in that year supported 46 priests, 7 deacons, 7 subdeacons, 42 acolytes, and 52 exorcists, readers, and doorkeepers. The church had divided Rome into seven districts, each of which was under the care of a deacon, who was assisted by one subdeacon and six acolytes.

Altogether the church in Rome ministered to 1,500 widows and others in need. It has been estimated that the Roman church spent annually between 500,000 and 1,000,000 sesterces—an enormous sum—on ­benevolent work.

Grace under pressure

The churches’ program of benevolent care soon expanded, owing to an unfortunate cause. A devasta­ting epidemic began in 250 and spread from Ethiopia across North Africa, then to Italy and the Western Empire. It lasted 15 to 20 years, and at one point in Rome 5,000 people died in one day.

Beyond offering supplications to the gods for relief, public officials did nothing to prevent the spread of the disease, treat the sick, or even bury the dead. This is not surprising, since the pagans believed that nothing effective could be done in a time of plague other than appeasing the gods.

By 251 the plague swept into Carthage in North Africa. Piles of the dead rotted in the streets, where they had been abandoned by their families. The pagans, casting about for causes, fingered the Christians, and a severe empire-wide persecution erupted. The emperor Decius ordered all Christians to sacrifice to the gods on pain of death. Carthage’s bishop, Cyprian, enjoined the city’s Christians to give aid to their persecutors and to care for the sick. He urged the rich to donate funds and the poor to volunteer their service for relief efforts, making no distinction between believers and pagans. Under Cyprian’s direction, Christians buried the dead left in the streets and cared for the sick and dying. For five years he stood in the breach, organizing relief efforts, until he was forced into exile.

The plague of Cyprian, as it has come to be called, marked a new chapter in early Christian medical charity. For the first time, Christians extended their medical care to pagans as well as Christians. To provide even basic care for large numbers of the sick, Cyprian probably hired unemployed men to carry out work that had grown beyond the resources of Christian volunteers. These may have included grave diggers and perhaps an ambulance corps.

Much later, in Alexandria, Egypt, in about 416, the Christian patriarch of that city organized a corps of men recruited from the poor classes to transport and nurse the sick. They were called the parabalani, the “reckless ones,” because they risked their lives by exposing themselves to contagion while assisting the sick. Already in 312, during a widespread plague, Christians in many Eastern cities were performing similar tasks. In the face of epidemics, they seem often to have formed ambulance corps, making up for municipal authorities’ failure to help the sick and dying.

Such large-scale organized emergency efforts did not emerge from nowhere. For centuries Christians had been developing infrastructure in their own churches to help the sick. The diaconal (deacon-led) care that the churches offered the sick was usually palliative, since it was administered for the most part by people with little or no medical training or experience. But we know today that in the absence of professional expertise and even medications, a basic regimen of nursing care ­including food, water, and rest can cut mortality during epidemics by two-thirds or even more.

Christianity did not promise the miraculous healing that the Greek cult of Asclepius did (though such healings were certainly reported throughout the ancient period). But it regularly provided something that was less spectacular and more permanent: care of the sick and the dying by those who demonstrated compassion.

The sick looked to Asclepius, who was called “the most philanthropic of the gods,” for supernatural healing, but not for long-term care. One scholar has termed him a “god of emergencies.” But there was no place for the dying in his sanctuaries. The ministry of medical care in early Christianity began as a church-based diaconal, not professional, ministry. It was provided by unskilled, ordinary people with no medical training. Yet the church created in the first two centuries of its existence the only organization in the Roman world that systematically cared for its destitute sick.

In the early fourth century, lay Christian orders began to appear in the large cities of the Eastern Roman Empire. The two best known were the spoudaioi (“the zealous ones”) and (in Egypt) the philoponoi (“lovers of labor”). The mission of these groups, drawn mostly from the lower classes, was to reach out to the indigent sick in cities such as Alexandria and Antioch. These cities had a large population of homeless sick and dying on the streets. The philoponoi would distribute food and money to them and take them to the public baths, where their basic hygienic needs could be met and they could find warmth in winter. None had medical training, but they were motivated by compassionate concern. Over time they became an intermediate order between clerical orders and laymen, and in the sixth and seventh centuries they were attached to large churches in the major cities of the Byzantine Empire and continued the long tradition of church-centered diaconal care of the sick.

Continuing to bear fruit

Many movements in the history of Christian philanthropy have drawn on the legacy of early Christian medical care. Roman Catholics have excelled in organizing and institutionalizing medical charities, including hospitals, most of them maintained by religious orders of women. The Sisters of Charity, founded by St. Vincent de Paul (1580–1660), became a major force in caring for the sick.

The nineteenth century saw a further explosion of Christian efforts on behalf of the sick poor: In Holland, a Mennonite deaconess movement cared for the ill, and in England the Quaker Elizabeth Fry revolutionized care for prisoners and the sick. Taking cues from both of these, Pastors Theodore Fliedner and Wilhelm Loehe pioneered in their native Germany a Lutheran deaconess movement that soon spread throughout Europe. Among the later trainees at the movement’s base in Kaiserswerth was the famous Florence Nightingale, who took what she learned there to England, where she founded a school of nursing.

Medical missions have constituted another important branch of Christian medical philanthropy. Missionaries to European colonial possessions often established medical facilities where none had previously existed, and much of their work was invested in the founding of hospitals, leprosaria (treatment facilities for lepers), and other health-related institutions. Many of the leading hospitals in cities throughout the world today are the products of Christian medical or missionary charity.

Prominent historian of medicine Henry Sigerist once wrote that Christianity introduced the “most revolutionary and decisive change in the attitude of society toward the sick,” giving sick people a “preferential position” in society that they retain to this day. Christians saw the suffering of others as an opportunity to provide compassionate care in the name of Christ. This was Christianity’s novel contribution to healthcare, providing the foundation for the whole tradition of Western medical philanthropy. By the fourth century it led to the creation of the hospital as a uniquely Christian institution. But the hospital would never have succeeded without an earlier long tradition of medical philanthropy integral to the ministry of the early church. CH

By Gary B. Ferngren

[Christian History originally published this article in Christian History Issue #101 in 2011]

Gary B. Ferngren is professor of history at Oregon State University.
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