University of Vermont: History Review vol. 6, December 1994

Public Health and Social Medicine: The Historical Legacy of the English Plague Experience

by Nancy Gallagher
The quest to conquer epidemic infectious disease through the discovery and control of the pathogens responsible has been a story of the triumph of science over superstition and testimony to the progress of western civilization. Traditionally historians have placed modern scientific and rational approaches to disease control in the nineteenth century, when Europeans began the quest to understand the material causes of disease and to end its capacity to cause human suffering. Only since the 1960s has public confidence in the humanitarian goals of the scientific establishment been seriously challenged. New diseases, such as AIDS, coupled with the recent assaults on the notion of "progress," have revealed tensions between individual rights and the public interest and inspired the search for the historical origins of western assumptions about the social dimensions of disease.

This paper will trace the history of these tensions and the origin of modern concepts of public health and social medicine in the early modern European experience with bubonic plague. The "Black Death" (1348-51), though devastating, was only a prelude to nearly four centuries of deadly, random, and rapidly-spreading bubonic plague epidemics which helped to shape the context within which European society became "modern." The first section of this paper will examine issues raised in modern epidemiology and current historiography of disease and consider the European plague response in light of those issues. I intend to show how the "principle of segregation" became institutionalized in Renaissance plague control efforts and created an environment in which the plague became an expected, though unpredictable, natural disaster which reinforced inequities in the social order. The second part of the paper will examine how these themes were expressed in early modern England, where the plague was increasingly represented as a problem in social and environmental control. Though the English institutional response to bubonic plague lagged behind those on the Continent, the English experience laid a foundation for liberal democratic understandings of the social dimensions of disease and institutionalized the ethical dilemmas we face presently as new diseases have created post-modern challenges to public health. In England, I argue, the concept of public health evolved within an ideology of the common weal, where personal conduct became a public issue and a matter of civic conscience in the context of government efforts to combat recurring bubonic plague epidemics.

Historiography & Epidemiology

Since 1970, new developments in historiography, combined with a growing ecological consciousness, rejuvenated interest in the role of disease in human history and obscured the distinctions between its biological and cultural aspects. The study of epidemics, such as the Black Death, has been traditionally relegated to the domain of biology, the history of science, or topical histories of antiquarian interest. Prior to 1970, disease histories have emphasized human progress and the conquest of disease through the growth of scientific medicine. Since 1970, historians' renewed interest in cultural history, including the relationship between elite society and the underclasses and the historical deconstruction of modern institutions, has inspired a reexamination of the role of diseases in history. Probably the most significant trend in historical scholarship has been a paradigmatic shift from viewing infectious disease epidemics as natural obstacles to be overcome to a view of human societies and their habitats as parts of an evolving and interactive ecosystem in which human innovation and culture play an integral, rather than dialectical, role. Associated with this changing view of the man-nature dualism has been a growing tendency to view the development of public health strategies as instruments of social control, which protected the security of elite society rather than emancipating the underprivileged classes from the conditions that created disease, famine, and poverty.

The history of the Black Death and the repeated three century assault on European society by bubonic plague have offered historians working within an interdisciplinary approach an opportunity to examine the origin of modern public health institutions and their role in creating modern discourse on the relationship between infectious disease and society. Historians William H. McNeill and Michel Foucault have influenced these trends and established the direction of this particular inquiry.

In an innovative ecological approach to human history, William McNeill's Plagues and Peoples (1976) integrated epidemiology with world history. McNeill proposed a paradigm where infectious disease, or invasion of a population by microparasites, was analogous both biologically and culturally to the exploitive behavior of elites, or "macroparasites." The latter category included the ruling class with its attendant bureaucracy, merchants, and the clergy, who lived off the labor and production of the peasants. Applying principles of immunology to historical change, he advanced the notion of "new diseases" as historical forces and suggested that repeated exposure to either specific forms of macroparasitic or microparasitic invasion resulted in an accommodation of both the parasite and the population - a process whereby the society becomes "disease experienced". [1] McNeill's Law, as some historians have called this theory, has been a point of departure for historians' renewed inquiries into the historical significance of the Black Death and complements socio-economic, biological, and demographic analyses of the history of plague.[2] The AIDS pandemic and the multitude of "new diseases" emerging in the past 15 years have fueled the interest in epidemiological history in general and the history of the Black Death in particular. Concern over the rapid mobility of people and their pathogens within a global, unified disease pool has led world health authorities to stress the importance of early detection and containment of emerging lethal diseases.[3]

Michel Foucault, who challenged Enlightenment assumptions about human progress, studied the means by which Europeans adapted existing institutions to marginalize, segregate and supervise, and ultimately purge society of lifestyles and representations that did not conform to the ideology of elites. He viewed the rationalization of institutions that secured public health and safety as functioning to repress diversity, insure conformity, and ultimately force a policing from within through normative discourse.[4]

His approach has inspired historians of persecution who study how discourse and institutions function to influence official exclusion and popular victimization of minorities. For historians who study the cultural meanings of disease, the Foucault approach has revealed how plague discourse and public disease control strategies became incorporated into a broader political and social control program.[5]

When the biological challenge of the plague encounter and the cultural response are analyzed in terms of one another and when institutions are evaluated in terms of their success or failure to control the plague, one confronts a paradox. While contemporaries' interpretations of the plague were set in a cosmology we no longer recognize as "scientific", the public health policies on which they rested are seen as "surprisingly advanced" and "anticipating" modern scientific epidemiology.[6] Plague historians working from this perspective conclude that observation, necessity, and common sense prevailed over the "windy nothingness" of Renaissance medical theory.[7]

I will inquire instead into how the Black Death and its repeated aftershocks contributed to a Eurocentric standard disease control against which all other cultures, past and present, are evaluated.[8] If we examine how the medical ideology and institutions functioned in Renaissance society to explain the plague and justify social control to mitigate its effects, we discover a continuity between Renaissance and modern epidemiology despite the different beliefs concerning the cause of plague. European society became "disease experienced" from its encounter with the bubonic plague through renegotiating the terms upon which social class and personal conduct determined the harmony of the "body politic". From this perspective it becomes clearer how the plague experience and the official response to it merged to construct a modern view of health and disease as a social problem.[9]

The Novelty of Bubonic Plague in Renaissance Europe: Official Interpretation and Response:

William McNeill defines a "new disease" as one of which a population has no biological, cultural, or institutional memory. Both epidemiologically and immunologically new diseases are devastating in mortality and virulence; the intensity of physiological and social response is proportional to the scope and severity of the disease.[10] The Black Death of 1347-51 produced not only a spectacular mortality, but it also initiated a response of equal intensity in the European mentality and institutions that emerged to manage the recurring crises and prevent future visitations. Though ideology and social customs were in place to explain and contain diseases thought to be contagious, the bubonic plague exceeded the Europeans' capacity to do either successfully.

European experience with leprosy most closely resembles the interpretation and disease control strategy applied to the plague. Leprosy was believed to be a punishment from God for sin, yet it was also believed to be contagious, venereal, and hereditary. Sin, immoral conduct, and rotting flesh merged in belief and elaborated rituals of body inspection, banishment from the community, and, eventually, incarceration in lazar houses.[11] Ritual exclusion not only served to secure the community from infection but also to demonstrate the rejection of the sins believed to have caused the disease. In many ways the bubonic plague resembled leprosy; it produced neurological disorders, a foul stench, and, in the septacaemic variety, black and blue blotches all over the body. All of these provoked revulsion and horror. Unlike leprosy, the bubonic plague caused death rapidly in nearly all of its victims and exceeded all the expected boundaries of status and respectability. The bubonic plague was officially interpreted as divine retribution against entire communities, against all Mankind.[12] The plague held a unique position amid the variety of other diseases affecting Europeans during the period. Special regulations issued during plague epidemics emphasized body inspection for bubos or other plague-specific symptoms, and unique quarantine measures were imposed on families, communities, and ships' crews where plague was diagnosed. Though scholarly debate continues over the extent to which contemporaries discerned bubonic plague from other concurrent epidemic diseases, both discourse and public health policy were plague-specific.[13] The European response during three and a half centuries of recurring epidemics of bubonic plague had a theological basis, despite increasingly practical strategies to control it and natural theories to explain it. Though the strategies suggested to regain God's favor varied regionally and evolved from an emphasis on piety to moral responsibility, the rationale behind plague control strategies, to create a more Godly kingdom on earth, did not. Modern concepts of public health and social medicine were born and well-established before biology replaced God as First Cause.

Carlo Cipolla, one of the leading scholars of Renaissance medicine and public health policy, argues that Galenic medical interpretations of plague, based on miasma were largely ignored in favor of the belief that contagion spread the disease, either through direct or indirect contact with the infected. Renaissance medical scholars felt a combination of factors triggered a plague epidemic, which tended to fall into three categories: 1) general influences (air quality and/or planetary aspects), 2) "miasma" or a "morbid principle" from organic putrefaction or infected people, animals, or objects, and 3) the humoural balance of individuals, making some more susceptible to the disease than others.[14] Most striking in this explanation is its structural similarity to the model used in modern scientific epidemiology, which analyzes disease incidence in terms of the interactions between: 1) the environment, 2) the agent, which may be a microbe, a toxin, or a physical factor such as harmful radiation, and 3) the particular hereditary or behavioral characteristics of the host populations which predispose them to the disease.[15] In both the Renaissance and the modern scientific models, the ability to prevent disease or contain their spread focuses upon the individual (or certain groups), whose physiological constitution or personal conduct potentially endangers himself and the community, and the perceived means of transmission from host to host.

Throughout the Renaissance, tactics targeting the individual became problems of medical authorities, who performed the function of giving advice on disease prevention through proper lifestyle and personal hygiene and regulated licensing of legitimate medical practitioners. Governing officials and their administrative bureaucracies occupied themselves with the problem of disease transmission, the second line of defense against the plague. Through the development of public health policy and the bureaucracy to administrate it, both the environment and the host population were increasingly monitored and managed. What began as a tenuous alliance between recognized medical authority and public health administrators became increasingly collaborative throughout the plague encounter. By the end of the seventeenth century, medical theory and public policy reinforced one another, despite the on-going disagreement over the etiology of the disease.[16] In the Renaissance, as in the twentieth century, strategic measures relied upon quarantine of the afflicted and potential carriers, warning the public of epidemic threats, and educating the people in disease prevention through proper lifestyle and health regimens. As Renaissance authorities proceeded from the articulation of preventative strategies within this paradigm to attempts to enforce them, the plague became a social disease as well as a biological one.[17]

Medicine, Mobility, and Double Standards

The European plague encounter posed a major dilemma, a paradox illustrating the tension between nature and culture that new diseases create. Contemporaries associated the plague with human mobility; subsequent plague epidemics over the next three centuries reinforced this view as they coincided with greater movement of people and goods in expanding trade networks. Italian city-states pioneered formal restrictions on the mobility of people and goods during plague epidemics in the fourteenth century via quarantine of infected communities and the refusal of imports from ships or caravans suspected of carrying the disease. Where restrictions were successfully enforced, economic hardship with its inherent social consequences ensued, making infected communities even less able to handle the burden of disease and death. European communities were economically dependent on, and socially organized around, a system of exchange which facilitated the spread of plague vectors. Those whose livelihood depended on steady production or income from wages could easily slip into economic ruin. The textile industry was hit particularly hard. According to the miasma theory of disease, fleece, cloth, and fur-bearing animals were likely agents of transmission, as the poisonous particles of "corrupted air" were believed to adhere to such materials. Plague regulations of Italian health boards became increasingly systematic in the destruction or impoundment of these economic staples, despite protests and efforts to circumvent the law.[18]

The problem of plague and human mobility created another interesting irony in European society which challenged the fundamental structure of the social order. Freedom, rank, and privilege segregated the ruling and propertied elites from the peasants. workers, and the poor. McNeill's paradigm of the "macroparasites" versus the "producers " provides a useful conceptual model for understanding the double standard within which public health policy and its consequences would be experienced throughout Europe. This social arrangement enabled those with privilege and means to evacuate plague-infected areas and leave the workers and the poor to fend for themselves. The consequences of this behavior provoked controversy at the theological and the practical level. Not only did contemporaries recognize the injustice and lack of Christian charity such behavior demonstrated, but the evacuation of governing officials left infected communities vulnerable to crime and social unrest.[19] Renaissance governments responded to this problem by creating policies and institutions which devised early warning systems for plague outbreaks and a bureaucratic apparatus for crisis management during epidemics by designated authorities. This enabled the elites to escape before a town was placed under quarantine, while damage control would be minimized in their absence. Italian city states were in an excellent position to do this, because they had in place an educated, organized bureaucracy trained in state administration and obedient to central authority.[20]

Italian city-states pioneered the public health policies and institutional organization which served as a model for other European countries to emulate. Ideas for disease containment and control spread through Europe with each new plague epidemic. Collaboration between medical faculties, governments, and religious authorities became formalized and legally articulated in Renaissance plague control efforts. Physicians increasingly stressed hygiene, morality, and moderation in plague prevention advice and increasingly attributed the spread of plague to personal conduct and lifestyle. Theologians, both Catholic and Protestant, interpreted the plague as divine punishment, a theme that was elaborated rather than challenged during the Reformation and Counter-Reformation. Plagues generated a body of religious discourse, in which special prayers, sermons, and rituals during epidemics emphasized personal piety, morality, and obedience to authority. Quarantines and restrictions on public assemblies left the individual more personally responsible for his or her own fate and demonstrated the association between personal conduct and community disaster. While these policies and their attempted implementation met with limited success and created controversy, the efforts to control plague influenced how Europeans experienced the disease, by altering the framework within which they interpreted their own affliction and that of others. The following case study of England's plague control efforts in the sixteenth and seventeenth centuries will examine how continental influences, local concerns, and the problems of mobility and class distinctions created a uniquely English response to the bubonic plague.

Plague Policy in England:

In England, as throughout Europe, plague was a constant threat in the four centuries after the Black Death. Epidemics broke out nearly every year in some part of England. The evolution of plague control measures in the sixteenth and seventeenth centuries provides an interesting contrast to public health policy in other European states and illustrates how epidemiology became integrated into an evolving social and political order. Each epidemic tested the limits and efficacy of official efforts to control the disease. Each new visitation of the plague heightened the sense of failure of previous policies and contributed to a growing discourse on social disorder. Public health policy in early modern England coincided with major religious, political, and socioeconomic changes. The Protestant Reformation, state formation, the Civil War, the Interregnum, and the early stages of the industrial revolution all coincided with plague epidemics and the efforts of authorities to control disease through public health policy [See Appendix I]. Plague control became one theme in the broader debates over local versus central control, the civic and moral responsibilities of elites and common folk, and, ultimately, the principles upon which the national identity rested. Despite the changing interpretations of the etiology of the disease and its social meaning, there was a growing awareness of the relationship between the plague and urban blight and a developing consensus that a co-ordinated effort was required to prevent disease through the amelioration of social ills.

Disease control efforts throughout the sixteenth and seventeenth centuries generated, through reports of mortality and a large body of literature on the subject, a growing archive on the plague which inspired further refinement and elaboration of disease control measures. Both public health policy and disease incidence drew attention to the correlation between dearth and disease. Plague policy helped to heighten suspicion and fear of the growing ranks of mobile, unemployed members of the underclasses, losers in both the biological and socio-economic order. Plague orders articulated the necessity for repression and control of the poor in concrete, epidemiological terms. Their enforcement helped to confine the plague within social boundaries and justify more rigorous moral supervision of the underclasses. This historical process helped to dissolve the supernatural, mystical qualities of the disease and place it within the bounds of social and political control.

England's public health policy developed in the context of a different concept of "the body politic" from that on the continent and of a growing commitment to international commerce which depended on the movement of goods within the nation and without. Together, these factors influenced the character of public health policy and the mechanisms by which it would be enforced. The English concept of "the body politic" rested on the belief that the sovereign and subjects were subordinate to a higher principle of the law of God and the common weal, or the "general good, public welfare, and prosperity of the people." [21] This notion of the body politic was a departure from its meaning in Roman civil law or continental ideology based on the divine right of kings and obedience to central authority. During the sixteenth century political and social discourse increasingly emphasized the "commonwealth", which meant the "whole of the state, functioning as a community, where the people have a voice and an interest."[22] England's political structure expressed this ideology. The sovereign, with the Privy Council and a lean administrative bureaucracy, depended upon Parliament to enact statutes and raise funds for national projects and on the co-operation of local magistrates and justices of the peace to carry them out.[23]

The commonweal became the paradigm within which plague policy was articulated, debated and administered during the plague years and through which the social meaning of disease was constructed. Whereas disobedience and negligence in enforcing restrictions during epidemics were seen as the primary obstacles to plague control in Italy and France, in England such failure was attributed to a lack of co-operation, an inadequate sense of public service, and a shortage of resources. This difference need not obscure the similarities of attitudes about the disease or the theoretical explanation for it among English and other European elites. Rather behavior that was seen as an expression of loyalty and allegiance to authority in Italy was expressed as private conscience and public duty in England.[24]

Beneath the rhetoric of the common weal lay a deep tension that resonated throughout the entire plague encounter and surfaced with every epidemic. A double standard of privilege and wealth segregated royalty, nobility, and gentry from the common people. At the first indication of a plague epidemic, the king and his court, nobles, and magistrates would flee the city or town and leave the common folk unsupervised and at the mercy of the plague. Law and order would break down, as would the municipal services already overburdened with disease and death. The rising ranks of the mobile poor in the Tudor period and their migration into London and other urban areas heightened anxiety and exacerbated social problems. In addition, the poor and middling sort became, in their fear and desperation, the targets of peddlers of miracle medicines and magical charms and supporters of an underground economy. The retreat of magistrates, aldermen, judges, clergymen, and physicians from the plague and civic responsibility became the subject of sermons, moral and medical tracts, and literary satire. Despite the growing awareness of the problem, its solution was never found in a change of behavior in elite society. Flight to the country in fact became more immediate and habitual as improved plague-reporting provided early warning.[25] The solution was found instead in restrictions on entertainment and public assemblies during epidemics, harsher penalties for vagrancy and unlicensed begging, a system of licensing medical practitioners, and educating the poor in preventative medicine.

The development of these themes in the evolution of, and response to, plague policy in the Tudor and Stuart period will be explored in the remainder of this paper. Public health policy in England originated in 1518 and underwent major revisions in 1578, 1631, and 1666. Each revision reflected the concerns of the sovereign and Privy Council over immediate political, social, and economic problems. With the exception of the revisions of 1666, none of the major innovations coincided with severe plague epidemics. Historical research suggests they represent a response to recurring problems of social disorder combined with memories of previous epidemics and anxiety over another visitation.[26]

Thomas More and Cardinal Thomas Wolsey laid the foundation for English public health policy in 1518 in response to a variety of socio-economic problems. Since the Peasant Rebellion of 1381, English elites had been increasingly aware of the connection between rebellion and movement and assembly of large numbers of unemployed, unsupervised poor. Economic depression coupled with population increase in the early sixteenth century gave rise to an increasing number of vagabonds and "sturdy beggars" in towns and cities. Local ordinances for the banishment of unwanted persons accompanied orders for public sanitation; social hygiene was clearly connected to environmental pollution. Thomas More's Utopia (1516) had promoted a paternalistic vision of the commonwealth, which forbade idleness and made necessary provision for the poor relief of the disabled and infirm. Cardinal Wolsey, motivated as much by social problems as he was inspired by the efficiency of Italian administration, laid the foundations for public health and social policy in England. The threat of plague and sweating sickness to London in 1517 coupled with May Day riots inspired a campaign against rogues, vagabonds, and the wandering poor in London and neighboring towns. In 1518, Wolsey founded the Royal College of Physicians under the leadership of humanist physician Thomas Linacre. This marked the beginning of an official alliance between medicine and government through which legitimate medical practice would be defined. With the assistance of More, Wolsey constructed the first set of Plague Orders. Both initiatives adapted Continental models and to English concerns and expressed a desire to overcome a reputation of being a backward and unhealthy country.[27]

Unlike her Continental counterparts, England did not order the quarantine of entire towns and risk the collapse of local economies. Instead the plague orders applied the principle of segregation and the doctrine of contagion to specific households. Infected houses were to be marked and closed for forty days "in sign and token of God's visitation", and healthy members could venture forth only in dire necessity and if they carried a white stick.[28] In this way towns could manage their own disease problems while protecting commercial enterprises. Support of quarantined families was delegated to the local parish.

Unlike Italian city states, whose often unpopular quarantine regulations were backed by the absolute authority of a health officer or health board, English orders depended upon the locally elected aldermen and constables to enforce them. As both agents of the people by custom and servants of the crown by law, the effectiveness of constables to secure infected households against the spread of plague required considerable co- operation of the people. As such, the orders were enforced on an ad-hoc basis as local necessities and sentiments dictated. This produced tremendous regional diversity in methods of segregation; more successful programs would become models for subsequent central policy. In some of the provinces plague victims were removed to pesthouses or sheds outside of town or banished to encampments on the heath. Elsewhere, local prevention strategies emphasized restrictions on public assemblies or levied a tax to support the victims quarantined in their homes.[29] By mid-century local practices expressed acceptance of the principle of segregation throughout England, while population pressure, increased vagrancy and urban migration challenged the efforts of local officials to manage the problems of poverty and disease. Religious war and restructuring of the church produced an additional burden as provisions for charity were renegotiated when monasteries no longer provided refuge for the poor and the sick.[30] Despite universal recognition of the need for expanded medical services, efforts to provide them were inadequate.[31]

A renewed effort to deal with the combined problems of poverty, overcrowding, disease, and public disorder was spearheaded in the 1570s by William Cecil, chief minister to Queen Elizabeth I. The revised public health policy, published in 1578, was a collaborative effort between the Privy Council and the College of Physicians. Its title, Orders though meet by her Majesty and her Privy Council to be executed throughout the Counties of this Realm in such...places as are...infected with the plague with the College of Physicians' appendix, An Advice set the best learned physic within this Realm, containing sundry good rules and easy medicines, formalized the relationship between government and medical authority and emphasized the necessity for medical self help, social hygiene and segregation of plague victims. Orders and Advice set the English standard for public health policy and plague control throughout the next century. While the policy was never fully implemented, its innovations set important precedents which would transform the English consciousness and establish a clear connection between moral decay, poverty, and disease.

Many of the protocols listed in Orders were identical to plague strategies on the Continent. Funerals were to be held after dusk to discourage attendance. Designated "searchers" in each parish were to examine corpses, determine causes of death, and record them on death certificates. Plague cases were to be reported to the Justices of the Peace, who were to meet every three weeks to pool the data and co-ordinate regional efforts to prevent the spread of infection. Clothing and bedding of plague victims was to be burned; infected houses were to be quarantined. Punishment of violators of the orders extended to those who criticized the policy; the principle of segregation was enforced in discourse as well.[32]

The 1578 Orders had two distinctions that expressed both the unique political climate in England and the problems of the poor, both of which would have serious repercussions in the social relations and attitudes of the people. The first of these associated plague with poor relief through the levy of a regular tax for care of the sick and destitute.[33] This extended the economic the burden of the diseased poor from periodic charity through church donations in times of crisis to an on-going social welfare system, where the poor would become a continual reminder of the plague. It furthermore created a breakdown in relations between the central and local governments; many towns and villages were either unwilling or unable to meet the dual economic burden of plague and poverty.[34]

A second English peculiarity in the plague policy was its excessively strict quarantine of plague-infected families. The entire household was incarcerated for six weeks; no healthy member was allowed out nor were visitors allowed in, including clergy or physicians.[35] In some towns, the constable was required to nail shut their doors and windows, allowing only a small opening to deliver food and water, which local authorities were expected to organize and supervise. Peasants were not permitted to tend their fields or flocks unless they lived in a remote, isolated area, creating an added burden for the community with the loss of agricultural productivity. Whereas the taxes may have caused resentment of the poor and the interference of the central government in local affairs, the quarantine of families was viewed as harsh and cruel despite its promotion in the name of the common weal.

The 1578 Plague Orders did not have the power of a legal statute, nor were they issued by royal proclamation. Though royal prerogatives were generally respected, the lack of coherence in their enforcement coupled with continuing plague epidemics in the 1580s and 1590s contributed to the growing rhetoric on "disorder" in Elizabethan England and an infatuation among learned elites with the physical pollution and moral corruption of the common people.[36]

The death of Queen Elizabeth was followed by a particularly severe plague epidemic in 1603-4. Estimates vary, but all regions in the British Isles were involved, and London lost probably one-fourth of its population to the plague.[37] The epidemic delayed the coronation ceremony of James I, while encouraging some to speculate that his entourage brought it to England from Scotland, where it had been raging that year.[38] The 1603 epidemic elicited an unprecedented volume of plague literature. Sermons and homilies, medical tractates, pamphlets, and plays provided a forum to debate the failures of past plague prevention measures, restate the themes of public duty during crises, and attribute the spread of plague to the wandering poor and moral and social pollution in the cities. Medical treatises elaborated methods of plague prevention through proper diet and personal hygiene, while advocating the isolation of the stricken in pesthouses. Thomas Dekker's literary classic, The Vvonderfull Yeare 1603, graphically depicted the horrors of the disease, chastised those who abandoned their communities, lamented the inadequacy of medicine, and emphasized the impotence of rituals and remedies to ward off the plague. The tone of the 1603 discourse resonated with escalated enforcement of plague ordinances; both reflected an awareness of the need for a comprehensive, coherent program of plague control.[39]

Anxiety among magistrates and members of court and parliament over popular unrest during plague outbreaks converged with King James' attitudes of authoritarian control in the Plague Act of 1604.[40] This statute mandated tax collection and distribution of funds to plague-infected communities and surrounding parishes and provided the first penal sanctions for violators of quarantine and mobility restrictions. Being discovered in public with a plague sore was a felony, punishable by death. Healthy individuals leaving quarantined households were to be whipped.[41] While the law did little to change behavior at the local level besides arouse controversy over its severity, the 1604 Act was renewed in nearly every Parliamentary session until 1666 and generally viewed by magistrates and statesmen as "permanent, rational and desirable."[42]

A major outbreak of plague in Cambridge in 1630 coincided with a bad harvest and a European-wide depression. High grain prices, unemployment in the textile industry, public unrest, and the threat of another epidemic were familiar in the living memory of King Charles I and his Privy Council. A massive influx of Irish immigrants and rapid, uncontrolled urban growth in London in the midst of these socio-economic problems inspired the swiftest and most comprehensive public health policy England had yet created. A series of "Books of Orders" was drafted in 1630-31 to address problems of grain prices and distribution, poor relief, unemployment, and uncontrolled urban growth. The third book of orders, known as Orders and Directions, enlarged the scope of restrictions on the movement of people and goods to prevent the spread of disease and elaborated the means by which the central government would co-ordinate and supervise local efforts at enforcement.[43] The major innovation of Orders and Directions was its articulation of the problems of immigration, economic depression, urban blight, and plague as interrelated phenomena requiring a social engineering solution. Like previous Privy Council orders, these were based on a combination of Continental models and successful programs in the English provinces.[44]

One important feature of these orders was their attempt to manage the mobility of goods, people, and information so as to keep the economy functioning while restricting the apparent threat of disease and disorder posed by masses of mobile, masterless men. The orders called for the establishment of a councillor commission and a fleet of deputies to monitor local efforts to enforce the orders and thus solve the problem of grain hoarding, inadequate poor relief, and unemployment that contributed to the urban migration. Together, these measures were expected to prevent the spread of plague.

The revision of the Advice section of the "Book of Orders" by the Royal College of Physicians represents a major departure from their previous role of suggesting medicines and precautions against the plague. Advice clearly linked the problems of urban crowding and poverty to public health and gave tacit support for the doctrine of contagion. The College of Physicians advocated the removal of the sick to hospitals, where they could be receive proper medical care, and recommended their segregation from healthy family members, replacing the practice of household quarantine.[45] This may have been motivated by the controversy and past disasters resulting from the incarceration of infected families; not only was the practice objectionable from a moral viewpoint, but the excessive mortality due to both starvation and infection of entire families had demonstrated its ineffectiveness. The social dimensions of the plague were presented in a special report from the King's Physician, Sir Theodore de Mayerne, immediately following the publication of Orders and Advice. Mayerne recommended strict government control of food supplies to support a healthy population and emphasized the need for expulsion or savage punishment of "unruly base sorte of people," especially Irish immigrants. He advocated urban renewal of London, where slums and alehouses would be replaced by new buildings "fitt for the better sorte of persons of quality to dwell in and live more neatly."[46]

Though the plans to build a plague hospital in London were abandoned when the threat of plague subsided and serious urban renewal was delayed until after the Great Fire in 1666, the preoccupation with the "meaner sort" found immediate expression in restrictions on plays, games and other popular amusements, alehouses, and ballad singing. Morality became fused with health; certain lifestyles posed an epidemiological threat to the health of the body politic.[47] This connection was made explicit in the Royal College of Physicians in 1636, who attributed the spread of the plague to "loose persons and idle assemblies." "Nothing is more complained upon, than the multitude if Rogues and wandering Beggars, that swarm in every place about the City, being a great cause of the spreading of infection."[48]

Plague policy throughout the remainder of the seventeenth century was not altered substantially, despite major political change. After the beheading of Charles I (1649), the offensive policy of central government authorities overseeing the local enforcement of plague regulations was repealed. During the Interregnum the plague orders of 1631 were reissued with each new appearance of plague, and local authorities increasingly relied upon them for crisis prevention and management, while experimenting with various methods of segregating and caring for the sick.[49] Religious tracts continued to relate pestilence to punishment, while increasingly stressing morality and co-operation during epidemics as an expression of Christian charity.[50]

One important trend to which the increasing emphasis in central public health policy gave a tremendous boost was the system of reporting and dissemination of disease and mortality information. The bills of mortality had been initiated in the beginning of the sixteenth century as an early warning system so that the king and his court could take flight at the first appearance of plague. Both the form and function of the bills of mortality evolved throughout the next two centuries, while becoming more systematic, accurate, and efficient. Under Queen Elizabeth the weekly reports of vital statistics became a routine procedure and expanded beyond simple plague death tolls. With the print revolution, the bills were more widely circulated. After 1593 they were printed on broadsides and publicly posted.[51] This practice had benefits and drawbacks. While authorities worried that publicity of disease incidence in England would disrupt trade if circulated abroad, the weekly bills also served to give public warning to the privileged classes. The bills, according to one contemporary, were "a text to talk upon in the next company, and withal in the plague time [to see] how sickness increased, or decreased, so that the rich might judge the necessity of their removal, and tradesmen might conjecture what doings they were like to have in their respective dealings."[52]

The bills of mortality served not only to make the plague into a more regular feature in the social and natural environment but also to render it more humanly manageable, both by escape of the privileged to their country houses and by increased surveillance and restrictions on those who remained behind. Another important sidelight of these statistics was their substantiation and reinforcement of the connection of plague with urban poverty and pollution, as they publicized the apparent preference of the plague for the poorer, dirtier, more crowded city suburbs.[53] Thus the weekly bills of mortality drew geographical and social boundaries around the disease and reinforced the seventeenth century belief in its moral dimensions.[54]

These trends manifested themselves with unprecedented vigor in 1665 during England's final encounter with bubonic plague. Although the "Great Plague" of 1665 produced a lower mortality than had previous epidemics, the explosion of publications it generated helped to inflate its reputation in English history.[55] Contemporaries, however, called it "the poore's plague," and its significance more properly lies in the social meaning given to the plague at this juncture in English history than in its impact on political or socioeconomic trends.

The massive emigration from London of those of "birth, position, and wealth" swelled in the summer as the weekly bills advertised the mounting plague casualties. Except for a few civic leaders, physicians, and clergymen who remained to provide courageous leadership during the crisis, most of those with means left without paying the required "pest-rates." Suspension of commercial activities and the closing of inns concentrated much of the remaining population in the congested, plague-infested, poorer parishes, where the peddling of miracle cures flourished.[56] The response of government was minimal and inconsequential. A bill to reform James I's plague statute failed, due to the obstinacy of the Lords, who demanded immunity from health examinations and quarantine and refused to allow pest hospitals to be built in the better neighborhoods.[57] The enormous death tolls among the poor in this epidemic were frequently attributed to their failure to take recommended precautions to avoid the plague or employ the correct remedies once infected.[58] The social character of the plague was thus confirmed in both the vital statistics and in the medical and moral discourse.

After 1660, natural philosophers and physicians became increasingly involved with issues of public health and social medicine. Two men, John Graunt and William Petty, achieved special recognition in the history of medicine and public health for their scientific analysis of the bills of mortality.

John Graunt (1620-1674) is viewed by historians of medicine as the most influential and important pioneer of the statistical social analysis of disease.[59] In his classic work, Natural and Political Observations...upon the Bills of Mortality (1662), Graunt analyzed the social dimensions of pathology and mortality and demonstrated the correlation between environment and specific diseases. He distinguished between diseases whose incidence is predictable (endemic) and those, such as the plague, smallpox, and measles, "that do not keep that regularity."[60] Graunt statistically linked demography to disease and its social significance. While his quantification of disease was ground-breaking, a contemporary, William Petty would expand such analysis into the realm of public health policy.

William Petty (1623-1687), statistician and founder of the Royal Society, explored the cost and social impact of the plague throughout the better part of his career. Perhaps his desire to champion the cause of public health was inspired by three major epidemics during his lifetime, but more likely his work expressed a Puritan world view that embraced utilitarian natural philosophy as the means to creating a humanitarian, harmonious social order.[61] By subjecting the Bills of Mortality to a statistical, cost-benefit analysis and reverse Malthusian logic, Petty proposed a grand scheme to evacuate London of plague victims at the onset of an epidemic to 10,000 designated houses in the suburbs, whose occupants would be removed to rental properties at government expense. Petty estimated, based on the average value of each person at 70 and estimated plague tolls, that the kingdom would lose 7,000,000 with another severe epidemic. He projected, with his scheme and its probability to save lives, that England could realize a national worth of 600,000,000. Government expenditure for his proposed program, including its administration, he argued, was in the national interest.[62] The evacuation of healthy families and the conversion of their homes to temporary plague hospitals would serve to keep London plague-free, while achieving the humanitarian goal of organizing and supervising the care of the sick. Presumably this was assumed to be a small sacrifice for the common good.

Petty's proposals to secure the English population from death and disease included plans for maternity hospitals to reduce infant mortality, a system of wardship and service to the state for illegitimate children, and studies on health risks to occupational groups responsible for production, such as farmers, manufacturers, sailors, and soldiers. He promoted the education and regulation of medical personnel in sufficient numbers to serve the entire population in order to "cut off and extinguish that infinite swarm of vain pretenders unto, and abusers of that God-like Faculty, which of all Secular Employments our Saviour himself after he began to preach engaged himself upon."[63] For Petty, the power and wealth of the body politic depended on the health and productivity of the individuals, which in turn rested on following the advice of recognized medical authority. The government, he felt, was justified in enforcing any policy to achieve this end.[64] Though Petty's statistics became outdated and his disaster relief plans never materialized, his statistical and demographic approach to social medicine would endure and become the foundation for disease research and public health policy in the nineteenth century during the cholera epidemics.[65] Disease had become a social phenomenon within an economic theoretical framework long before the germ theory of disease appeared or the role of animal vectors and bacteria in plague epidemics was discovered.[66]

After the epidemic of 1665 the plague never visited England again.[67] The English response to a scare in 1720, when an epidemic erupted in Marseilles, illustrates the historical legacy the bubonic plague left behind. Improved communication through newspapers had kept the English people abreast on European developments; rumors or news of plague aroused immediate concern. The Marseilles epidemic prompted swift, reflexive government action. Parliament immediately passed a new Quarantine Act in the winter of 1720-21. Based on the French model, the act restricted shipping from infected ports, provided for the removal of plague victims to hospitals and their family members to special quarters. "Cordons sanitaires," a line of armed guards, would surround any infected town and prevent anyone from escaping. Resistance to regulations would be a capital offense.[68] The recurring themes of past plagues surfaced in sermons, pamphlets, political speeches, and medical self-help literature, only now they were framed in eighteenth century terms. God was punishing Christian society for the deistic leanings of the Church and the greed and corruption of government and commerce. Moralists suggested called for a "Reformation in Manners" of the indigent poor and physicians advocated the miasma theory of the plague, as the analyses of Graunt and Petty supported it.[69] The immediacy of this response can be largely attributed to the enshrinement of past experience and English controversies in recorded history. The reprinting of previous plague tracts, sermons, and pamphlets most likely orchestrated the discourse in a generation that had no direct experience with the plague. The 1721 plague scare inspired Daniel Defoe's The Journal of the Plague Year, in which this resurgence of the English plague history would inform the consciousness of succeeding generations.[70]

As soon as the Quarantine Act was passed, controversy erupted over the legitimacy of excessive police control of public health. English physician John Pye mounted a devastating assault on the Quarantine Act on medical, religious, and humanitarian grounds. Most significantly, he framed the issue in terms of the national identity. Not only were the quarantine regulations a cruel punishment and destructive of the English economy which depended on free movement of goods and people, but, more importantly, they represented "arbitrary power in France...intolerable to a people under a 'free government' in England."[71] This theme reverberated through Parliamentary and public debates over the next year. The Quarantine Act of 1722 repealed all the French features. There would be no cordons sanitaires, no removal of the sick from their homes, and no quarantines of infected towns. England would rely on co-operation and local control.[72]


There has been no mention of bacilli, rats and fleas in this analysis for the simple reason that they are irrelevant to the meaning of the plague for the generations that experienced it or, for that matter, to its historical significance. The coincidence of plague epidemics in early modern England with demographic and economic changes fueled rising anxieties over the migration and concentration of "undeserving poor" in urban areas and fostered an association between epidemic disease and poverty, pollution, and moral degeneration. Policy and practice articulated and demonstrated an inequity between the privileged and wealthy, who were able to escape the plague, and the underclasses, whose mobility was confined by means of health passes, bodily inspection, and quarantine. The responses of ruling elites to bubonic plague created an epidemiological double standard that reflected a social one. Graunt's and Petty's statistics perhaps confirmed what contemporaries saw as a self-evident truth, that certain kinds of people and their social behavior created an environment which welcomed the plague. This raises an important question: to what extent were these men measuring a "natural" phenomenon as opposed to a historically constructed one reflecting the prejudices and policies of an inequitable social order? After the etiology of bubonic plague had been discovered in the 1890s the British government revised its plague policy. A comparison of the 1666 plague orders and the 1902 revision reveals an enduring ideology that implicates immigrants and the poor as sources of the plague [See Appendix 2].

Though historians generally agree that the plague experience did not create new social tensions or direct the course of philosophical or political change, the attempt here has been to demonstrate that public health policy, the ensuing controversies, and their resolution expressed and reinforced latent attitudes of elite society about the morality and vulnerability of the poor to disease. In England, the plague became a matter for public discourse on these underlying tensions and an opportunity to experiment with programs to contain the disease and enforce a social and moral order. The macroparasitic agenda and the microparasitic challenge converged in the plague experience to produce a concept of "public health", which established the social boundaries of disease vulnerability to which the innovations of statistics and natural science could be applied. Both experience and doctrine functioned together to establish symbolic and physiological categories in which "new diseases" could be clinically defined, researched, and fought in terms of social, ethnic, and national boundaries. The alliance of medicine and government was, with the last epidemic, complete.[73]

The plague played a role in the discourse on social problems, the responsibility of the government to the people, and the appropriate constraints on personal freedom when the health of the community is perceived to be in jeopardy. England's experience with plague control left to us the modern dilemmas of epidemiology. To what extent should the government restrict civil liberties for the security of public health? At what point does medical information about an individual become open to the government or the public's right to know? To what extent should private enterprise in a global market economy direct profits to the health care of the people or compromise its growth to prevent the emergence or spread of disease?

In the twentieth century, genes and hormones replaced body humours to explain why some people were more vulnerable to disease than others and microbes and toxins replaced miasmas as agents of disease. However. the history of the European plague encounter as a social and cultural phenomenon continued as new laws backed by scientific studies expressed historically constructed attitudes and legitimized exclusion and persecution in the name of social hygiene and public health. ENDNOTES******************************** 1).William H. McNeill, Plagues and Peoples, (New York: Doubleday, 1976), 5-10. back

2) For the use of the McNeill paradigm in scientific revision, see Neil M. Ampel, "Plagues - What's Past Is Present: Thoughts on the Origin and History of New Infectious Diseases," Reviews of Infectious Diseases 13 (1991): 658-65, Stephen R. Ell, "Immunity as a Factor in the Epidemiology of Medieval Plague," Reviews of Infectious Diseases 6 No.6 (1984): 866-79, and Richard M. Krause, "The Origin of Plagues: Old and New," Science 257 (Aug. 21, 1992): 1073-78.

[3].Mary E. Wilson. M.D., review of Emerging Infections: Microbial Threats to Health in the United States, by Joshua Lederberg, Robert E Shope, and Stanley C. Oaks Jr., and Thomas H Weller, M.D., Review of Emerging Viruses by Stephen S. Morse, Ed., New England Journal of Medicine 329 No.19 (Nov. 4, 1993): 1431-3.

[4].Michel Foucault, Madness and Civilization: A History of Insanity in the Age of Reason, Trans. Richard Howard (New York: Vintage, 1988), 3-7, 38-64, and Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, A.M.Sheridan Smith, trans., (New York: Vintage Books, 1994, c1973), 22-6.

[5].See, for example, Sharon Achinson, "Plagues and Publication: Ballads and Representation of the Disease in the English Renaissance," Criticism 34 No.1 (Winter, 1992): 27-49, and Claudine Herzlich and Janine Pierret, "From Causes to Meaning," in Illness and Self in Society, trans. Elborg Forster (Baltimore: John Hopkins U. Press, 1987), 98-105.

[6].Carlo M. Cipolla, Public Health and the Medical Profession in the Renaissance, (Cambridge: Cambridge U. Press, 1976), 9-10, 33, 115-16. This is a major theme throughout Cipolla's works. See also C.F. Mullett, The Bubonic Plague and England: An Essay in the History of Preventative Medicine (Lexington: U. of Kentucky Press), 3, 5-6, 10-11.

[7].Philip Ziegler, The Black Death, (New York: Harper Torchbooks, 1971), 72.

[8].Cipolla argues that in Italy "a highly organized group of professional had positive results [in controlling plague] by virtue of the fact that their powerful organization prevented medicine from falling completely into the hands of quacks." He contrasts this with China, where such a distinction was never made and where "medicine never rose above the level of quackery." See Cipolla, Public Health, 115.

[9].George Rosen, "Medical Care and Social Policy in Seventeenth Century England," in From Medical Police to Social Medicine: Essays on the History of Health Care, (New York: Science History Publications, 1974), 159-175.

[10].McNeill, 3,8, 147-52.

[11].For an excellent discussion of the merging of leprosy and rituals of exclusion and persecution within a Christian theology see R. I. Moore, The Formation of a Persecuting Society, (Cambridge, MA: Blackwell, 1987), 45-65.

[12].Herzlich and Pierret, 4-7.

[13].Carlo Cipolla, Miasmas and Disease: Public Health and the Environment in the Pre-industrial Age, Elizabeth Potter, Trans., (New Haven: Yale U. Press): 2, and C. F. Mullett, 4-5.

[14].Carlo M. Cipolla, Public Health and the Medical Profession in the Renaissance, (Cambridge: Cambridge U. Press, 1976), 23-4.

[15].The 20th century paradigm presented here is the one used in epidemiology textbooks since World War II and fully developed in the 1960s. See Mervyn Susser, "Epidemiology in the United States after World War II: The Evolution of Technique," Epidemiologic Reviews 7 (1985): 147- 77.

[16].Cipolla, Miasmas and Disease, 1-9, Boris Velimirovic and Helga Velimirovic, "Plague in Vienna," Reviews of Infectious Diseases 11 no. 5 (1989): 808-26.

[17].As Renaissance medical authorities were unable to control comological influences they felt triggered the plague, medical experts today agree that our only line of defense against "new" diseases is early detection and a global warning system. Viruses in particular have eluded the promises of vaccination. See Stephen S. Morse, "Emerging Viruses: Defining the rules for Viral Traffic," Perspectives in Biology & Medicine 34 No.3 (Spring, 1991): 387-409, and Stephen S. Morse and Ann Schluederberg, "Emerging Viruses: The Evolution of Viruses and Viral Diseases," Journal of Infectious Diseases 162 No.1 (1990): 1-7.

[18].Cipolla, Public Health, 24-44, and Cipolla, Miasmas and Disease, 77-78.

[19].This phenomenon was recognized with the first epidemic in 1348 and became increasingly a subject of debate in sermons, legal tracts, and plague literature. See Giovanni Boccaccio, The Decameron of Giovanni Boccaccio, Richard Aldington, Trans., (Garden City, NY: Garden City Books, 1949), 3-7. In sixteenth century England, the problem of "flight" of magistrates, justices of the peace, and constables during plague strikes was the most pressing issue. See Paul Slack, The Impact of Plague in Tudor and Stuart England, (London: Routledge & Kegan Paul, 1985), 36-46.

[20].Cipolla, Public Health, 6-11, Cipolla, Faith, Reason and the Plague in Seventeenth Century Tuscany, (Ithaca: Cornell U. Press, 1977), 11-12, 93-98. Cipolla contends that the Italian public health institutions reflect the organization of Renaissance universities, whose curriculum was divided into theology, medicine, and law. Roman civil law provided an education in state administration, which created a trained bureaucracy to carry out plague regulations. Whether they deserve the reputation Cipolla awards them of being more enlightened and scientific than other European states or more despotic, as English historians suggest, is an on-going scholarly debate. For an analysis of the evolution of theory and policy in response to plague experience, see Ann G. Carmichael, "Plague Legislation in the Italian Renaissance," Bulliten of the History of Medicine 57 (1983): 508-25.

[21]."Common weal," Oxford English Dictionary, 2nd ed. Vol. III, 573.

[22]."Commonwealth," Oxford English Dictionary, 2nd ed. Vol. III, 574. For an extensive discussion of of the expression of this theme in sixteenth and seventeenth century discourse, see Kevin Sharpe, "A commonwealth of meanings," in Politics and Ideas in Early Stuart England, (London: Pinter, 1989): 3-71.

[23].For a discussion of the recent historiography and reconsideration of these relationships in state formation and local political and social concerns, see Joan Kent, The English Village Constable 1580-1642: A Social and Administrative Study, (Oxford: Clarendon Press, 1986), 1-32, and Kevin Sharpe, "Crown, parliament, and locality: government and communication in Early Stuart England," in Politics and Ideas, 76-100.

[24].This is a major theme in seventeenth century English political history. See for example, Keith Thomas, "Cases of Conscience in Seventeenth-Century England," in Public Duty and Private Conscience in Seventeenth Century England, John Morrill, Paul Slack, and Daniel Wolff, Eds., (Oxford: Clarendon Press, 1993), 29-56, and Kevin Sharpe, "Private Conscience and Public Duty in the Writings of James VI and I," in Morrill, Slack, and Wolff, 77-100. In Italy magistrates blamed recurring epidemics on "the people's disobedience nad lack of observance of the proper ordinances which have been generally issued," and increased enforcement efforts. See Cipolla, Faith, Reason, and the Plague, 93-8. For the emphasis on the commonweal and public duty in failure to prevent plague in England, see Paul Slack, Poverty & Policy in Tudor and Stuart England, (London: Longman, 1988), 144-5.

[25].The mass exodus from London in 1665 and the flight of the court is vividly described in Walter George Bell, The Great Plague in London in 1665, (London: Bodley Head, 1951), 53-71. The heroism of the Earl of Craven, who stayed in London, managed the crisis, and contributed both resources and service to the sick is the celebrated exception to the rule.

[26].Paul Slack, The Impact of Plague, 200-201. Most of the history of the English plague policy presented in this paper is indebted to Paul Slack's studies. His work provides the most comprehensive analysis of the English plague experience in relation to social, economic, and political developments. In this paper I attempt to cast some of these changes within McNeill's paradigm of "disease experience" and emphasize the origins of modern concepts of "social medicine" in the English plague encounter.

[27].Slack, Impact of Plague, 201-2, and Paul Slack, Poverty and Policy, 114-117.

[28].Mullett, 44.

[29].Slack, Impact of Plague, 203-4.

[30].Italian states were able to use monasteries and parish clergy in their plague control programs, though this was not without problems. See Cipolla, Faith, Reason, and the Plague, 1-14. For problems encountered in the English Reformation, see Slack, Poverty and Policy, 13, 17-22.

[31].Keith Thomas, Religion and the Decline of Magic, (New York: Charles Scribner's Sons, 1971): 8-13, 178. The Royal College of Physicians were a small, elite fraternity whose membership expanded from twelve in 1518 to forty in 1663. Liscencing of country physicians and surgeons had been a church function; seculization of medicine was gradual and many communities went without "legimate" health care through the entire plague period.

[32].Slack, Impact of Plague, 210. The church was not above the law during plague crises. Clergy who taught "the vanity of resisting pestilence" were forbidden to preach. See Mullett, 88.

[33].Slack, Impact of Plague, 210.

[34].For an analysis of the problems of enforcement and the exacerbation of tensions between central authority and local government, see Slack, "Towns Under Stress," in Impact of Plague, 255-310. For a discussion of the burden of enforcement of plague orders in amid rising demands in the sixteenth and early seventeenth century on local J.P.'s and constables, see Kent, 28-31. Kent effectively destroys the myth of the constable as incompetent, lazy, or corrupt.

[35].Slack, Impact of Plague, 210-11.

[36].Paul Slack, "The Dangerous Poor," in Poverty and Policy, 91-112, and Mullett, 58-90.

[37].J.F.D. Shrewsbury, A History of Bubonic Plague in the British Isles, (Cambridge: Cambridge U. Press, 1970), 267, 284-5.

[38].Shrewsbury, 264.

[39].Mullett, 119-142.

[40].Plague policy in Scotland was strictly and brutally enforced. James I believed in absolute "divine" right of the monarch and a strong central government. See Shrewbury, 185-6 and C.F. Mullett, "Plague Policy in Scotland, 16th-17th centuries," Osiris 9 (1950): 441-5.

[41].Slack, Impact of Plague, 211.

[42].Slack, Impact of Plague, 211.

[43].Paul Slack, "Books of Orders: The Making of English Social Policy,"

Transactions of the Royal History Society 5th ser. XXX (1980): 1-22.

[44].Slack, "Books of Orders," 8-13. Sir Theodore de Mayerne, French Hugenot and physician to the King was the chief architect of the plague policy and utilized the Paris model. The strong central authority reflected in the orders met with intense opposition, however the stricter penalties on vagabonds, idleness, and drunkeness was applauded by most.

[45].Slack, "Books of Orders," 4-5, Shrewsbury, 354-5.

[46].Quoted in Slack, "Books of Orders," 8.

[47].Achinson, 27-8, 32, 42-3

[48].Royal College of Physicians, Certain Necessary Directions, as well for the Cure of the Plague, as for the preventing the infection (London, 1636), quoted in Achinson, 39.

[49].Slack, Impact of Plague, 221.

[50].Slack, Impact of Plague, 242-4.

[51].Slack, Impact of Plague, 148-9.

[52].Slack, Impact of Plague, 149. Quoted from Economic Writings of William Petty, II.

[53].Slack, Impact of Plague, 164-9.

[54].Historians have interpreted this significance of this conjuncture from a variety of perpsectives. Sharon Achinson examines the connection between plague medicine and public health policy and the prohibition of ballad singers as conveyers of both political subversion and disease. George Rosen views the recognition of the social and environmental correlants of plague and their analysis in the seventeenth century as the basis for modern social medicine. See From Medical Police to Social Medicine, 1-2, 159-175. Paul Slack takes a more moderate position, showing it more a change in direction from the long term developments in society, political and religious thought, and the social meaning of disease. See Impact of Plague, 244-54. For an interesting analysis of how this conjuncture encouraged an infatuation in the seventeenth century with country life and its moral and medical virtues, see Andrew Wear, "Making Sense of Health and the Environment in Early Modern England," Medicine in Society: Historical Essays, ed. Andrew Wear (New York: Cambridge U. Press, 1992): 119-47.

[55].The popularity of Daniel Defoe's and Samuel Pepys' accounts of the London plague of 1665 have contributed to the misconception of its severity. For a discussion of Defoe's influence on this historical perception, see Bell, x, 72-4. While the death toll was higher, the London mortality (17.6%) was below that of the epidemics of 1563, 1603, or 1625. See Slack, Impact of Plague, 150-1.

[56].The most detailed and thoroughly documented account of the phenomenon of "flight" and its consequences for the poor is found in W.B. Bell, The Great Plague of London, 1665, 53-99. For demographic evidence of how flight conributed to "social differentials in mortality," see Slack, Impact of Plague, 166-9.

[57].Bell, 304, and Slack, 224. The Privy Council issued revised "Rules and Orders" in 1666 which added the requirement of plague hospitals (See Appendix II, item 10). This was the only major revision from earlier procedures, and the plague had subsided by then. A full text of the 1666 Privy Council "Rules and Orders" may be found in Bell, 328-9.

[58].Bell, 96. For example, L'Estrange, in The Intelligencer, published articles during the plague reporting its concentration in the"sluttish parts of those parishes where the poor are crowded together" and felt they "hastened their own destruction" for consuming cold drinks and going outside before their fever had subsided. He concluded that the absence of plague from the higher social and governmental ranks was God's blessing, ingoring the fact that these people had left London.

[59].Rosen, 163.

[60].John Graunt, Natural and Political Observations on the Bills of Mortality, quoted in Rosen, 164.

[61].Although Petty's political outlook favored Francis Bacon and Thomas Hobbes, he was a member of the group of Puritan intellectual reformers who viewed the new "natural philosophy" as a confirmation of the power of providence and the means to impove social welfare in anticipation of the approaching millenium. See Charles Webster, The Great Instauration, 15-31, and Rosen, 167-8.

[62].Mullett, The Bubonic Plague, 253-9. Petty was also responding to the apparent demographic decline in the late 17th century and associated economic concerns, See Slack, Poverty & Policy , 43-4, 55.

[63].William Petty, Economic Writings, quoted in Rosen, 167.

[64].Rosen, 168. Politically, Petty was a disciple of Francis Bacon and Thomas Hobbes. He was Puritan, however in his religious persuasion.

[65].For an excellent analysis of the significance of Petty's contributions to public health concepts in the eighteenth and nineteenth centuries, see George Rosen, "Economic and Social Policy in the Development of Public Health," in From Medical Police to Social Medicine, 176-200.

[66].Yersinia pestis, the bacillus that causes plague and the role of fleas and rats as vectors was discovered in the 1890s. Throughout most of the nineteenth century the miasma theory of disease predominated, encouraging increased attention to public sanitation and control of air and water pollution. I argue that the substitution of "germs" for miasmas was a minor one in terms of general patterns in health policy and practice.

[67].The disappearnce of plague from Europe and the possible immunity Europeans may have acquired is still a mystery. For recent theories of biological immunity, see J.H. Bayliss, "The Extinction of Bubonic Plague in Britian," Endeavor 4 no. 2 (1980): 58-66, and S.R. Ell, "Immunity as a Factor in the Epidemiology of Medieval Plague," Reviews of Infectious Diseases 6 no. 6 (1984): 866-79.

[68].Slack, Impact of Plague, 326-8. The statute was based on a study by physician Richard Mead, who drew largely on the Mayerne model aof 1631 and policies in France and Italy.

[69].Slack, Impact of Plague, 328-9.

[70].Defoe based his account of the plague on various seventeenth century plague tracts that had been republished during the plague scare of 1720-1721. See J.H. Plumb, "Foreword," in Daniel Defoe, A Journal of the Plague Year, New York: New American Library, 1960, ix-x, and Bell, 71-5. Bell feels it is not historically accurate. Paul Slack argues that while Defoe's account should not be used as a source for the events of 1665, it represents a watershed in historical understanding of the issues and social realities of the plague experience. See Slack, Impact of Plague, 335-7.

[71].Quoted in Slack, Impact of Plague, 331.

[72].Slack, Impact of Plague, 331-5.

[73].Rosen, 171-3, 177. Physicians had become, by the end of the seventeenth century, the recognized authorities and architects of public health policy in England. Their expertise was recognized by Parliament in passing statutes, and they became the leading spokemen for medical and health reform in England.

University of Vermont. History Review vol. 6, December 1994