The Black Death and the Transformation of the West

A trio of books on the Black Death and its impact on western civilisation.

Illustration of the Black Death from the Toggenburg Bible (1411)The mobilising and paradoxical power of medicine cannot escape any observer of the contemporary world. We live at a time when we are healthier and live longer than ever before. Yet inequalities remain. Despite increasing healthcare provision those at the bottom of the social ladder continue to be in worse health than those at the top. Moreover, antibiotics, once heralded as the means to eradicate infectious disease, are useless to fight the scourge of increasingly drug-resistant germs. Tuberculosis, once assumed conquered, is also rearing its ugly head again. Furthermore, new lethal diseases, such as AIDS and Ebola fever, threaten to undermine the advance that modern medicine appears to have achieved.

Medical science is a double-edged sword. In today's world life-support machines offer the means to extend survival, but at what cost to the individual and their family? Equally, while genetic engineering offers the possibility of manipulating our genetic make-up, genetic screening allows healthy individuals to discover the alarming news that they will suffer a degenerative disease in the future. Mass screening programmes for cervical and breast cancer have also generated panic among healthy women without conclusive evidence that such screening will reduce these diseases. Thus, while we have greater medical knowledge about the body and disease than ever before, this information has increased our ethical and moral dilemmas. Spiralling costs in medical provision and technology add to the difficulties. Who has the right to such care, and can society afford to pay for it? TO what extent can societies risk their reputation in not providing good healthcare for all? Can medicine and its experts really provide the solution to the illsof society as they promise?

Such questions are vast as well as emotive. Yet, they are not new. Examining the history of disease and medicine from different historical perspectives, the books by Herlihy, Porter and Watts indicate that the legitimacy of medicine has always been an ambiguous one and cannot be divorced from the wider relationship between disease, economics and society.

Originally written in 1985, when the fear of the spread of AIDS was at its peak, Herlihy's collection of essays provide some interesting thoughts about the relationship between disease and the power of experts. Focusing on the Black Death (1348) which reduced the population in some European cities by 80 per cent, Herlihy draws some powerful parallels between the plague and AIDS. He compares the ways in which each disease generated hostility, not only towards the victims of the disease and social outsiders, but also undermined the authority of the experts. just as AIDS crushed the optimism that medicine could conquer infectious diseases, so the medieval plague called into question the expertise and skill of medical practitioners. Increasing entry of untrained and unlicensed medical practitioners in the wake of the death and migration of large numbers of physicians meant many feared that the skill of the profession was at threat. Even those who had the expertise seemed helpless in curing the disease.

While powerless to stop the suffering caused by the plague, medical practitioners nonetheless rapidly learnt from the devastation. For Herlihy the plague represents a major turning point in the history of medical knowledge about contagion and the use of quarantine measures to prevent the spread of disease. The havoc caused by the disease also sent many medical practitioners to review their own methodological tradition and ways of handling disease. This was signified by the heightened priority of anatomical investigation in medicine during this period. Leading to the development of modern pathological theory, Herlihy points to this period as the catalyst for the rise of modern medicine.

While it is debatable that the Black Death was as radical in its impact on medical knowledge as Herlihy suggests, his argument is a provocative one which will lead other historians to re-examine not only the period of the Black Death but the foundations to medieval and modern medicine. Herlihy's focus on one disease in the fourteenth century stands in stark contrast to that of Watts, who surveys not only the plague, but leprosy, smallpox, syphilis, cholera, yellow fever and malaria over the past six centuries. Synthesising the work of many other historians, Watts shows the numerous ways in which populations have been affected by specific diseases and political and medical responses. Taking imperialism and colonisation as the focus, Watts highlights the ways in which disease spread around the world and was used for strengthening empires. Like many other historians Watts asserts that it was disease, more than military strength which was the tool of conquest to many lands. While providing a rich description of this process, Watt's argument is weakened by an overpreponderance of detail. This is not helped by the fact the author tends to glamourise pre-colonial societies in the relationship between society and medicine. Many of the problems caused by disease Watts attributes to the colonial powers, without examining the complexities of hierarchy, medicine and culture that prevailed before their arrival.

While Watts oversimplifies his argument, Porter provides intelligent analysis. Some reviewers, like the one in The Economist (February 14th, 1998) have argued that Porter's book is merely 'an old fashioned Whig interpretation' of the history of medicine, in which the rise in medical knowledge can be seen as an advance from ignorance to enlightenment. To suggest this, however, is to miss the book's most important message. As Porter stresses at the beginning, and reiterates powerfully throughout his lengthy but captivating text, the authority and legitimacy of scientific medicine in Western society has lain only in small measure in its ability to cure the sick. He is quick to point out that scientific medicine has never been the only view of disease and the body, nor have all medical practitioners agreed with its doctrines. Throughout the book Porter shows that experts constantly competed over the ways the body functioned and what caused disease. Moreover, Porter points out that it would be a mistake to 'represent modern medicine as a monolith'.

One of the most interesting aspects to Porter's book is his examination of the way in which medicine has gradually asserted itself in more and more aspects of human life. whether it be the workplace, home, law court, schools or even state policy, medicine has increasingly being seen to have a critical role. 'The more medicine seemed scientific and effective the more the public became beguiled by the allure of medical beneficence, regarding the healing arts as a therapeutic cornucopia showering benefits on all, or, like a fairy godmother, potentially granting everybody's wishes' (p.630). Not only has medicine come to play a role in almost every aspect of society, it is intricately tied to the fashions and consumption of the modern world. Individuals can thus fantasise that they have the right to change their body f through cosmetic surgery and other services. Statesmen and - social reformers have also bought into the ethic that medicine is crucial to national efficiency and can resolve social differentials in health. Like many politicians and social observers of today, Porter is sceptical whether medicine can ever match up to people's expectations or resolve what are social, economic and cultural questions and not medical issues.

Porter ends his book with a provocative challenge to the medical profession and health policy-makers. He points out that much of the research and practice of medical practitioners has been off target, disproportionately investing in 'a form of medicine ("Band Aid" salvage) whose benefits often come late... buy little time, and... are easily nullified by external, countervailing factors' (p.714). His final warning is that in its most successful hour medicine faces its most critical dilemma. 'For centuries medicine was impotent and thus unproblematic. From the Greeks to the First World War, its tasks were simple: to grapple with lethal diseases and gross disabilities, to ensure live births and manage pain. It performed these with meagre success. Today, with mission accomplished, its triumphs are dissolving in disorientation. Medicine has led to inflated expectations, which the public eagerly swallowed. Yet if those expectations become unlimited, they are unfulfillable: medicine will have to redefine its limits even as it extends its capacities. (p.719).

About the Author

Lara Marks is the co-editor of Migrants, Minorities and Health (Routledge, 1997).

The Black Death and the Transformation of the West

Harvard University Press 117 pp. £17.95 (hb), £7.95 (pb). ISBN 0-674-07613-3,

Epidemics and History: Disease, Power and Imperialism

Yale University Press, xvi + 400 pp. £30. ISBN 0-300_07015-2

The Greatest Benefir to Mankind: A Medical History of Humanity from Antiquity to the Present

Harper Collins, xvi + 831 pp. £24.99. ISBN 0-00215173-1

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