By Anthony J. Cagle. Published on Egyptological, Journal Articles. Edition 6, 1st October 2012
Most studies of health and illness in ancient Egypt concentrate on disease and other maladies affecting individuals and the medical treatments administered to individuals. However, the concept of public health has received comparatively little attention, largely because the practice of public health has been seen as a fairly modern phenomenon tied to purely scientific notions of the sources and causes of illness and disease and their prevention. Nevertheless, even in the absence of a true germ theory of disease, the ancient Egyptians did possess an understanding of the social context in which many disease conditions occurred and took steps to prevent and alleviate certain conditions at a group level. From fairly basic public health practices, such as the removal of trash to peripheral locations, to reasonably sophisticated theories on the origin of disease and the widespread promulgation of preventive practices, ancient Egypt shows that even in pre-scientific complex societies an awareness of the social context of health and disease existed. Egypt and other ancient societies developed strategies to deal with health and wellness on a community and national level and thus are amenable to study using modern public health theory.
A great deal of knowledge has been gained regarding both the bodily afflictions of the ancient Egyptians and the practice of medicine that sought to alleviate them. Our principal sources for health information are documents that describe various conditions and their treatments – the so-called medical papyri (e.g., the Ebers and Hearst papyri) – and the skeletal and mummified remains of the Egyptians themselves which have allowed paleopathologists to diagnose many of the common maladies afflicting Egyptians of many socioeconomic strata (e.g., Rose 2006, Nerlich et al. 2000). This array of data on the personal health of the ancient Egyptians has proven invaluable from a nutritional, epidemiological, medical historical, and in some cases social perspective.
There is, however, another aspect that has remained relatively neglected in the overall study of health in ancient Egypt: public health. Compared to the analysis of what may be termed ‘personal health’ the study of health from a public perspective takes a more inclusive approach by deriving health data from larger units (groups of people) and examining the strategies and behaviors that affect the health of the overall population rather than at the individual level. This involves more than statistically summarizing data from individuals, though much of the data necessarily derives from the study of individuals. It is also not the simple application of epidemiological methods to the Egyptian population, though epidemiology is certainly an important aspect of public health research. But by dealing with groups rather than individuals and the cultural practices that affect the health of the population, a public health analysis is able to bring these various health-related threads together with social, cultural, economic, and even evolutionary factors to produce descriptions of overall health that are not only more far-reaching in scope, but also produce explanations for why and how societal structures developed to deal with issues affecting the health of the population. In a sense, public health becomes the operative mode of analysis when individual behaviors are translated into collective social action.
Consequently, I will first describe what constitutes an analysis from a public health perspective and provide the general scope of inquiry that such an analysis entails; i.e., those aspects of community health that are typically part of general public health research. Second, I will provide examples from the Egyptian archaeological and philological records that are relevant to these. In this context it is important to note that, even though the ancient Egyptians had no concept of the germ theory of disease and in many cases only a poor understanding of the causes of various conditions affecting groups of people, they were still able to implement various public measures to improve sanitary conditions and improve the health of much of the population. Finally, I will show how an analysis from a public health perspective can provide new insights into the origin and elaboration of certain behavioral and social traits and how they can affect the evolutionary trajectory of Egyptian society.
Like many fields that developed in the absence of a single unifying theory, public health has been defined many times by many different practitioners. Perhaps the most widely cited definition is that of C.E. Winslow which I reproduce here in its entirety:
Public health is the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health. (Winslow 1920:34; italics added)
Often shortened to the highlighted portion, Winslow’s definition has provided the basic template for the public health sector in succeeding decades with modifications generally occurring by adding additional responsibilities as scientific awareness or political needs dictate (Rothstein 2002). In broad outline, however, this definition ultimately derives from the mercantilist and sanitarian movements of the 18th and 19th centuries that placed the health and welfare of the population as an obligation of society via a state-sponsored apparatus (Rosen 1993). Though modern public health touches on a number of areas, its primary function tends to be preventive in nature, either preventing disease conditions from occurring in the first place or preventing the spread of existing infectious agents from ill to healthy individuals. Thus, much of the remaining discussion will center on preventive public health measures.
Deriving as it does from within the context of a modern western state structure, this definition effectively incorporates desired goals into the definition and assumes a certain level of social and political organization with at least part of the organization’s duties directed at achieving those goals. This goal-directedness presents something of a liability when attempting to apply the definition to non-western societies with simpler socio-political structures, or those with no explicit – or in some cases no concept of – community health goals. It is also problematic from an analytical perspective since explicitly embodying goal-seeking motives within the very definition of the area of inquiry presents something of a tautology.
Consequently, while I will use much of modern public health theory as a framework for examining those aspects of Egyptian society that impact community or group health, a somewhat less value-laden definition will have to be utilized in order to provide relevance for this study. Thus, following a long line of anthropological precedent, I now provide my own definition of public health: Any learned behavior that impacts, directly or indirectly, the health of more than the individual. This definition is not only simpler, but avoids many of the interpretive pitfalls of the above definition. It incorporates the social aspects of public health by requiring that any behavior be transmissible to others and thus is amenable to cultural selection and evolution. By doing so it necessarily provides a social underpinning without demanding a particular organizational structure. It also restricts the analytic sphere to those behaviors that affect more than the individual which further allows for the incorporation of various forms of social and group theory. Finally, by avoiding any particular goal of said behaviors, it allows for explanation without reference to any particular end product of health, whether positive or negative, and is therefore more analytic than prescriptive.
Finally, the question of “Why public health?” naturally arises. From a selection standpoint, the health of the population naturally affects the reproductive fitness of the population and thus informs on the viability of the group in relation to its own history and relative to others. Further, the group’s response to matters of the health of its members says much about its overall motivations, ideology, and other socio-cultural aspects of a given population.
The Scope of Public Health
Since many factors influence the health of individuals, the scope of public health is necessarily broad and defining its scope may be easier by simply denoting those areas where it does not apply. Nevertheless, several broad areas of particular interest to public health researchers and practitioners are generally recognized (Detels 2009): Communicable and chronic diseases, environmental/occupational health, nutrition, and sanitation and hygiene. As with other maturing disciplines undergoing specialization, other areas are noted today as being almost distinct sub-fields of the discipline. These include but are not limited to maternal and child health, interpersonal violence, and health disparities. However, for my purposes these can be usefully subsumed under the broad categories defined above, and provide a useful baseline for examining health indicators across a wide spectrum of socio-political organizations.
Communicable and chronic diseases include infectious diseases transmissible either directly from person-to-person or via an animal vector (e.g., plague), organism-based diseases acquired from the environment (e.g., schistosomiasis), and conditions resulting from genetic or lifestyle/aging related processes (e.g., arthritis). Many of these conditions, especially infectious disease, are highly dependent on settlement patterns and population densities and are thus directly conditioned by social, political, and subsistence organization. Chronic conditions are often intimately bound up with both subsistence and demographic factors though they may involve environmental factors as well. These include the sorts of normal wear and tear on the body typical of the daily activities in a population and nutritional deficits (chronic or recurring) resulting from the subsistence regime. The age and demographic structure of the population will also affect both types of disease since susceptibility to each changes with age and can differ between genders.
Environmental and occupational health is often closely related to chronic disease, but also segments society based on occupation and includes traumatic in addition to chronic conditions. Miners will, for example, experience safety hazards of both a traumatic (e.g., cave-ins) and chronic (e.g., hypovitaminosis D) nature that differ from those experienced by farmers. Populations occupying different environmental regimes will also experience different sets of chronic and traumatic hazards, such as excessive heat, cold, and/or aridity, and different sets of parasites.
Adequate nutrition is essential to individual health, both chronically and traumatically, and includes both overall caloric amounts and nutritional adequacy in terms of vitamin and mineral content. Nutritional quality not only affects the individual at any given time, but can also determine lifelong quality of life outcomes: inadequate nutrition in childhood can lead to chronic problems later in life such as stunted growth, musculo-skeletal deformities and diminished cognitive abilities. This becomes especially important while a developing infant is either wholly (i.e., in the womb) or largely (i.e., while nursing) dependent on its mother for its nutritional needs. Again, much of the nutritional quality and quantity people experience is highly dependent on environmental factors, especially for hunter-gatherers, but also for agriculturalists since the environment often determines the types of plants and animals available for domestication. Social, cultural and political factors also carry considerable weight in the form of differential access to amounts and types of food, and also to a somewhat lesser degree in the form of food taboos either culture-wide or within certain segments based on status and/or ideology (e.g., priestly food taboos).
Sanitation and hygiene are perhaps the most crucial factors affecting public health in sedentary societies and include the quality of drinking water, contamination of food products, and the elimination of waste material from the local environment. Most of these factors affect the frequency and intensity of gastrointestinal maladies which tend to be endemic in settled populations in the absence of modern controls on food and water safety and sewage and trash removal systems. While mobile hunter-gatherers do maintain parasite loads (Neel et al. 1968), many helminth and other parasites tend to concentrate and transfer to new hosts via fecal contamination, either through contamination of food and water or via direct contact. Compared to hunter-gatherers who often consume food and excrete waste in different, scattered locations, sedentary peoples concentrate both activities in often very restricted spaces. Consequently, sedentary populations are often in close proximity to sewage unless it is transported away for disposal elsewhere, which generally requires a high degree of cooperation and/or civil engineering and central control. Sanitation and hygiene may be thought of as the development of systems to bring uncontaminated resources into the habitation areas and the removal of waste products while keeping both systems as physically separate as possible.
As mentioned earlier, there are other areas that have received special attention from public health researchers. Since the health of mothers and their children are intimately related early in life, and an individual’s health status in infancy and childhood can profoundly affect the morbidity and mortality of the individual for their entire life, maternal and child health are often treated separately from others. Similarly, trauma related to interpersonal conflict (as opposed to that resulting from accidents) is often recorded differently from occupational injuries due to the intentional and often organized nature of the trauma. Mental and emotional health has also recently assumed more importance in public health circles. Nevertheless, I subsume these within other areas for the purposes of this analysis, although in the case of mental health issues there is often little direct evidence for it apart from written descriptions.
Similarly, it should be apparent that these different areas cannot be considered in isolation from one another since they all affect one another to some degree. The presence of certain parasites, for example, can drastically affect the absorption of some nutrients from food and can also degrade sanitation when diarrhea is a consequence of parasitic infection. All are interrelated to one degree or another, yet for analytic purposes, it is often useful to examine one or another area in some detail as a system unto itself. Also, in a survey article such as this, a certain amount of compartmentalization is useful for clarifying the interpretive issues associated with each system.
Public Health in Ancient Egypt
Egyptians, like every other society, had their own notions of what constituted health and disease and the role of society and the individual in causing and treating disease conditions — in other words, the social determinants of health. Also like others, Egyptian society developed mechanisms, both formal and traditional, individual and social, to prevent the occurrence of disease among the population generally and treat individuals who became ill. The individual both derives his or her view of health and illness from society and also contributes to the creation and maintenance of that view through participation in the various social, religious, and economic systems that affect health at a group level.
The Egyptian Concept of Disease and Health
The various papyri dealing with medicine and disease make clear that the ancient Egyptians had a fairly sophisticated understanding of at least some aspects of disease and human physiology. The Edwin Smith surgical papyrus, for example, is very mechanistic in both its diagnostics and treatments indicating that, at least in those areas of ill-health where the cause is readily visible, treatment takes the form of practical, replicable procedures with expected outcomes. For other difficulties, such as infectious or bacteriological diseases where the ultimate cause of the condition is not readily observable, Egyptian physicians were forced to make more of a theoretical diagnosis involving more ideational concepts of disease and health and the internal workings of the human body.
The ancient Egyptians had a sense of health (snb) that was worthy of being maintained (snb nch wḏ3, “may he live, have salvation, and be healthy”) and conversely that “disease” (mḥr(t)) may result in a state of physical illness, pain, or mental illness (Pommerening 2009). Perhaps the closest they came to developing an overarching theory of illness is embodied in the concept of wḫdw, a basic etiological principle related to fecal matter (ḥś), an excess of which under certain physiological conditions could cause such symptoms as swelling or abscesses (sfwt) as in the Hearst Papyrus (Leake 1952:61) or heat/fever (hȜb) as in the Ebers Papyrus (Steuer 1959:39). Based on these concepts treatments were devised that attempted to address the underlying cause of the condition usually by way of emetics, purgatives, and other methods of removing or “drawing out” disease-causing material.
Infectious diseases were conceived differently. There was a recognition that certain conditions were indeed caused by some foreign agent, though the specific mechanism was unknown. There was at least some recognition that certain widespread health problems were cyclical, sometimes annual, in nature and that the ultimate source of these disease epidemics came from the gods (often Sekhmet) via some other mechanism such as the wind (Brier 2004). However, in at least one instance, a plague or plague-like epidemic (perhaps tularemia or Francisella tularensis) was attributed to “Asiatics” (t3nt ‘3mw) and in some way connected to both Seth and Ra (Trevisanato 2004). Treatments for such diseases generally addressed some of the symptoms and offered magical incantations meant to inoculate against the disease and to drive out the spiritual cause.
Nevertheless, despite having a somewhat flawed theory of disease, the ancient Egyptians were still able to engage in several types of behaviors, both of a cultural sort and by formal policy means, that were more or less effective in preventing certain types of diseases and minimizing the effects of others. As shown by the effectiveness of the sanitarian movement, it is not strictly necessary to have a formal germ theory of disease to be able to make significant inroads into protecting the health of the public (Rosen 1993, Porter 1999). I will now present these measures following the general public health categories outlined above.
Sanitation and Hygiene
Since water is essential to nearly all aspects of life, it is perhaps the most critical element in any public health system. Even today, approximately 1.5 million deaths annually are related to water-borne diseases (Prüss-Üstün et al. 2008). The fact that water tends to flow and carry contaminants over potentially large areas makes contaminated water especially hazardous to large numbers of people. Conversely, these characteristics of water also predispose it to socially controlled management since the actions of one or a group of people on a water source can affect others accessing the same resource. Even apart from its direct health impacts, water used for irrigation often is managed through various social arrangements — sometimes centrally, other times collectively — in order to maintain a reliable food supply, for which Egypt presents an exceptional case (Butzer 1976).
Water is contacted in numerous ways, including drinking, cooking, bathing, washing clothes, fishing, and swimming. The primary water-related diseases in ancient Egypt probably mirror quite closely those found today: generally enteric pathogens transmitted via the oral-fecal route, including various viruses, bacteria, and protozoans. Many of these pathogens may occur naturally in the environment, but may also be introduced into a water system through sewage or the disposal of trash and other biological waste such as carcasses of either people or animals. The symptoms of these diseases are usually gastrointestinal distress and can result in severe and often fatal diarrhea which has the further effect of retransmitting the disease-causing pathogen.
More specific to Egypt is the parasite causing schistosomiasis (Schistosoma sp.) a species of trematode worm. This parasite relies upon both a natural intermediate host, snails of the genus Bulinus, and fecal contamination of snail habitats. The snail vector prefers shallow, slow-moving waters and finds the irrigation canals in Egypt an ideal habitat. The disease may be acquired through consumption of contaminated water, or simply contact with the skin which can be effected through any number of activities involving water including swimming , bathing, or laundering of clothing. Evidence from both tomb and mummy studies indicates that schistosomiasis was present in all classes of ancient Egyptians (Kloos and David 2002).
Sources for water in Egypt were varied depending on both intended use and access. Drinking water could be obtained directly from the Nile, its various canals, or from private and public wells. Several wells are known from Amarna (e.g., Kemp 1986) and wells are known from desert regions by at least the 11th Dynasty with many of the latter placed so as to be used by travelers obtaining various resources from the Eastern and Western desert regions – a public resource (Murray 1955). Wells, especially on the margins of the Nile and in the Delta have the advantage of being relatively free from organic contamination. Nevertheless, it is unclear to what extent wells were used as primary sources of water in ancient times and whether any clear connection was made between health and the consumption of water from various sources. Kloos (1983) for example, studied modern water usage in the village of El Ayaisha in upper Egypt and the extent of contamination by the Schistosoma haematobium parasite and found that well water in that location is considered hard and/or bitter and many residents preferred Nile water for drinking. Kloos also notes, however, that other wells closer to the Nile produce “sweet” water which may be preferred. Consequently, even socially and culturally mediated taste preferences may influence the transmission of disease in certain areas.
Perhaps the most basic of hygiene procedures is the removal of “personal waste” from living areas. In mobile societies this is relatively easily accomplished: simply carry out toilet procedures in a location that is not being immediately occupied. Once sedentism sets in, however, this becomes more difficult, particularly so in dense urban environments. Human fecal matter may contain a number of organisms that can affect human health adversely including several phyla of helminth worms, protozoa, bacteria, and viruses, all of which spend at least part of their life cycle within the human digestive tract. When fecal matter is contacted, it can infect or re-infect others who then ingest contaminated food, water, or through direct fecal-oral transmission. Diseases caused by fecal contamination include cholera, typhus, shigellosis, giardiasis, and various forms of infectious diarrhea, among many others.
For most of the population, toilet practices probably involved little more than going outside to find a somewhat isolated spot for deposition, presumably in a more or less common “latrine” area. While this may seem unsanitary, it is thought that leaving feces to dry in the hot sun may, to an extent, sanitize them (Dixon 1989) and, in fact, is a practice observed in modern times in outlying villages.
Herodotus, however, notes that the Egyptians “ease themselves in their houses” (Herodotus 2004: 90). Indeed, many “bathrooms” have been found in private houses, though these seem to be primarily designed for bathing rather than as lavatories, but the two were often combined (e.g., Amarna House T.35.9 in Frankfort et al 1972:41). The lavatory itself could be a large pot sunken into the floor or drained to the outside via ceramic, stone or metal pipes emptying into a brick structure or a ceramic pot again sunk into the ground. At Sahoure’s temple at Saqqara, however, a series of beaten copper pipes carried wastewater away for some 400 meters, and at Illahoun wastewater was drained out into an open gutter running along the middle of the street (Ghaliongui 1963, Gräzer-O’Hara 2009). Otherwise, stored waste was presumably dumped in a common area, in the Nile, or one of the many canals, though liquid wastewater may have been allowed to seep into the ground to decompose there. It is possible, perhaps even likely, that in larger urban areas waste was simply deposited into the streets where flocks of pigs would be driven through regularly to consume the offal, thus cleaning the streets and creating another source of protein (Miller 1990, Cagle 2002). This role for pigs may also have contributed to their status as ritually unclean and taboo, at least among the priestly and elite classes.
Several other aspects of personal hygiene were culturally mediated as well. It is well known that certain members of the upper classes practiced various forms of personal hygiene, such as the shaving of body hair, daily bathing, and the administration of purgatives and emetics for three days every month. Much of this undoubtedly had health implications. Certainly, the removal of body hair made lice much less of a problem, not only for the individual but for the group as well since each individual could not then spread the parasite. Certain adornment practices, such as lead-based eyeliner have recently been suggested to have some protective effect in terms of its antibiotic effect with regard to eye infections (Tapsoba et al. 2010).
Also of recent interest is the practice of male circumcision which seems to have been practiced by at least some members of the elite classes and perhaps also extended down at least into the warrior class. Circumcision of the male foreskin, qrn.t, is known from several Egyptian documents such as a stela from Naga ed-Der (Pritchard 1969:236), several Old Kingdom reliefs from Saqqara (Jonckheere 1951), the Middle Kingdom (Sethe 1935:34), and perhaps somewhat dubiously from the New Kingdom’s “Tale of Two Brothers” (Lichtheim 1976:206). Circumcision seems to have occurred as more of a rite of passage into adulthood rather than in infancy, although Ghalioungui suggests that it could have taken place anytime between the ages of six and twelve (1963:150). Research into the transmission of HIV has shown that male circumcision can significantly reduce the risk of contracting the virus (Weiss et al. 2000, Auvert et al. 2005). Circumcision probably dates back to prehistoric times (Sasson 1966) and is widespread globally (Silverman 2004), yet it remains unclear as to whether a reduced risk of infection of sexually transmitted diseases was known by its practitioners or whether its effect in this regard is sufficient enough to noticeably increase the reproductive fitness of those populations practicing it. Herodotus does note that the Egyptians “circumcise themselves for cleanliness’ sake” so perhaps there was some recognition of a sanitary, if not strictly a disease, aspect to the practice.
Environmental health is related to personal hygiene in that it often involves removing wastes of various types from inhabited areas or limiting certain pollutive activities to restricted areas. This may be as simple as removing household food debris to an outside trash pit to creating industrial areas separate from residential areas. Such restrictions may be developed due to simple discomfort from the waste products of certain activities – tanners, for example, can often create a great stench – but there is often recognition that these waste products are unhealthy, such as polluting potential drinking water. In public health terms, such actions must have an impact at more than the personal level; everybody throwing their trash into their neighbor’s yard, for example, would not constitute a true public health activity except perhaps in a negative sense. In many ways, this may be thought of as control over the waste stream: directing the flow of waste material from domestic and industrial activities through the settlement areas for eventual disposal.
At a household level, food remains and other trash were generally collected and disposed of in nearby pits, courtyards, or abandoned buildings (Dixon 1989, Cagle 2003), and often in natural or artificial low-lying areas outside of the village (though see Hoffman 1974). At the Amarna workmen’s village, for example, marl quarries south of the village were filled with trash which eventually spilled out onto neighboring ground when the original pit was completely filled (Kemp 1987). Also at Amarna, “the houses behind the road were built first, the area behind them being common ground, used mainly for rubbish pits” (Frankfort et al. 1972:3). At Kom el-Hisn, abandoned buildings, including tombs to a certain extent, were used for trash disposal as well as natural low-lying areas within the village (Cagle 2003). These were often, but not always, located at the outer edges of the habitations due to the tendency of trash heaps to attract scavengers.
There is evidence that trash disposal was stratified along socioeconomic lines. Both Hoffman (1974) at Hierakonpolis and Newton (1924) at Amarna note that elite residences often had much less detritus on their floor surfaces and in the immediate vicinity, suggesting that trash removal and discard away from elite habitation areas was more regular and complete perhaps due to elites employing servants to do that work. There is also at least one instance where trash may have been incinerated in mud brick “furnaces” within the courtyard of a residence (House Q 44; Newton 1924:290).
There is also evidence that there was some form of occupational health knowledge, though the source document must be treated with some caution. The Satire of the Trades describes some eighteen occupations and the attendant ills visited upon the practitioners of each. While probably satirical in nature, the text still gives some impression of the nature of physical problems faced by different occupations, both in the long and short term. For example, the reed cutter:
. . .travels to the Delta to get arrows;
When he has done more than his arms can do,
Mosquitoes have slain him,
Gnats have slaughtered him,
He is quite worn out (Lichtheim 1975:186)
Similarly, the gardener:
. . .carries a yoke,
His shoulders are bent as with age;
There’s a swelling on his neck
And it festers (Lichtheim 1975:187)
Other trades have different ailments, such as the “stoker” with his irritated eyes (Lichtheim 1975:188) and the cobbler who “suffers much among his vats of oil” (Lichtheim 1975:188). Clearly there is at least some recognition that different trades present different risks to those employed in them. Given the probable close nature of his own work as a scribe it is perhaps not surprising that the author conveniently ignores the likely ills afflicting his own profession – eye strain and lower back pain, for example. Elsewhere, Old Kingdom depictions of various sorts of laborers suggests ascites and hernia (Ghaliounguli 1963, Miller 1991).
Nor is the literature entirely devoid of potential strategies that employers could utilize to create a more worker-friendly environment. Corvée and other labor forces were provided with special physicians (wr sinw or sinw sā) to attend to the particular needs of large groups of laborers (Miller 1991:3) and calculations of the food rations provided to workers seem to be adequate to the work being performed (Menu 1982). As Miller (1991) has noted, while a certain degree of on the job mortality would certainly be tolerated, it would not have been in the interest of the administrative officials to lose too many of their working population.
Control of insect pests is important in any public health regime and some of the earliest documents dealing with insect control are from Egypt. Many of these deal with typical household pests and those associated with grain storage. The health impact of the latter is immediately obvious, while household insect pests – fleas, mosquitoes, biting flies, etc. – were probably thought of more as a nuisance than as disease vectors, though the connection between an insect bite and local infection would certainly have been made. Additionally, some connection between flies and disease is strongly suggested by the Smith papyrus’ “Incantation for a man who has swallowed a fly” (XIX, 14-18, No. 16).
The Ebers Papyrus suggests a preparation of ‘natron water’ sprinkled around the house to dispel fleas and burned gazelle dung mixed with water to eliminate grain weevils (Ebbers 1937, Panagiotakopulu et al. 1995). Miller (1987) has also noted that ash was often found spread around the base of querns (metates) presumably as an insect repellant; this may also have resulted from periodical burning of the occupation surface to kill surface and subsurface insects. Herodotus also mentions that Egyptians would, in places, sleep on raised platforms to protect themselves from gnats, and also nets to discourage, presumably, mosquitoes (though these were also said to double as fishing nets, so the veracity of the assertion may be held in some suspicion).
Nutrition and Diet
Food and nutrition is such a vital and extensive component of health that treatment in a survey paper such as this is necessarily limited. The manner of food procurement affects nearly every aspect of society, from the division of labor and wealth disparities to the vitamin and mineral content of the diet. The transition from hunting and gathering to an agricultural economy had, in Egypt as elsewhere, profound effects on the health of the population (Cohen and Armelagos 1984) and the Egyptian diet has been much discussed elsewhere (e.g. Ruffer 1919). Consequently, this discussion will primarily center on several issues more directly relating to the practice of public health.
By most accounts, the diet of the Egyptians in general was quite varied with various types of animal protein available (cattle, sheep/goats, fish, and fowl), along with a wide variety of fruits, vegetables, pulses, and grains. However, food was not evenly distributed throughout the population due either to social and economic class or through cultural means, such as food taboos. The upper classes had access to a wider variety of food and drink and this undoubtedly impacted their health as a group. Tomb paintings and reliefs show wealthier individuals provided with virtual banquets for the afterlife, including various meats, vegetables, a variety of breads and cakes, and jugs of wine or beer (e.g., Emery 1962). While such scenes are undoubtedly idealized to some extent, we have depictions of high-ranking officials with fairly rotund appearances contrasting with far slimmer workers (Ghalioungui 1963:74). Recently, some have argued that the high saturated fat and carbohydrate diet of Egyptian elites – heavy on red meat, breads, and cakes – may have predisposed them to developing atherosclerosis (David et al. 2010). However, since the incidence of disease is biased to only those who were mummified – primarily the elites – these findings are difficult to generalize to the Egyptian public as a whole. Nevertheless, if recent research linking diet and obesity to various disease conditions is indeed valid (e.g., Must et al. 1999), then it is reasonable to hypothesize that the elites minimally presented a greater risk of obesity-related morbidities than the rest of the population.
Diet may have also played a significant role in the dental health of the ancient Egyptian population. Various investigators since Ruffer’s (1920) classic study have noted that the Egyptians suffered from considerable wear on tooth cusps leading to a high degree of abscesses and cysts. This contrasts somewhat with the general pattern of agricultural peoples suffering more from dental caries than excessive wear (Cohen and Armelagos 1984). The possible reasons for this are many. Leek (1972), for example, posited the Egyptian penchant for bread in their diet as a contributing factor. Having found a high degree of inorganic components in samples of offering bread, the majority of it desert sand grains – as one might expect – but others of a more angular character perhaps resulting from storage or grinding apparatus (Leek 1972:131-132). Based on experimental studies, Leek (1972) suggests that much of the sand resulted from deliberate inclusion in the grinding process in order to more effectively abrade the outer husks of the grains. However, both Dixon (1972) and Puech et al. (1983) have suggested that perhaps the Egyptian practice of chewing vegetable masticatories mentioned in, ironically, the tooth therapy section of the Ebers papyrus could be a contributing factor. Indeed, Puech et al. note that a common masticatory, the papyrus plant (Cyperus papyrus) are particularly rich in silica phytoliths and that these can account for many of the wear patterns seen in their sample of Egyptian teeth (Puech et al. 1983).
The other major dietary staple with consequence for public health is beer. While the exact nature of the brewing process and ingredients of ancient Egyptian beer is not entirely well known, its place of honor at the Egyptian table is not in doubt (Helck 1971). The brewing of beer was probably connected in some way to the baking of bread (Samuel 1996) and the two processes could well have developed together. Beer is an fairly ideal beverage – calling it a ‘food’ would be just as appropriate – as it provides a relatively compact source of carbohydrates and calories and, because of its alcohol content, usually presents a safer beverage alternative to often contaminated water sources.
Nevertheless, the social and health effects of its widespread consumption can have both negative and positive consequences. Drunkenness (from both beer and wine) was referred to in several texts in a decidedly negative tone not only for its short-term effects (i.e., the hangover) but also its long-term influences. An example of the former is found in the Insinger papyrus which refers to the usual results from over-imbibing:
He who with wine overfills himself, By aching hair to his bed will he be kept (Ghaliounguli 1963:74)
Similarly, the long term effects are captured in poetry form as “Beer, when it invades a man, masters his soul” (Ghaliounguli 1963:74).
Besides beer’s antiseptic effects, it could have antibiotic properties as well. Beer was prescribed for a variety of ailments, including treatment of the gums and teeth and dressing wounds (Darby et al. 1977). Recent paleopathological work on Egyptian and Nubian populations has shown histologic use of tetracycline in skeletal populations dating to the 4th to 6th centuries AD (Nelson et al. 2010), and similar results were obtained from late Roman samples in Dakhleh Oasis (Cook et al. 1989). The former results were linked to the production and consumption of beer brewed with Actinomycete bacteria in doses that suggested deliberate inoculation during the brewing process, which further indicates that the populations knew of the health benefits of including tetracycline-laced beer in their diet. The health effects of tetracycline ingestion include the blocking of the effects of osteoarthritis, rheumatoid arthritis, periodontal disease, and osteoporosis, the latter of which was demonstrated in Nubian populations regularly consuming tetracycline-laced beer (Armelagos et al. 2001). While the use of such a beer has not been demonstrated yet in Egypt proper during Dynastic times, it is not inconceivable that its use predated the late Roman period and that the medical benefits of beer consumption were not overstated.
Various food taboos have been linked to health concerns, notably the prohibition on pork practiced by several major religions even today and apparently prohibited by at least some sections of Egyptian society, notably the priest and elite classes. Tomb depictions rarely include pigs and tomb offerings are similarly devoid of pork products. The main reason cited for this absence of evidence is mythological in nature: the male pig was often a manifestation of the evil god Seth and was thus considered a ritually unclean or impure animal. Many explanations have been offered for this apparent lack of interest in the pig by Egypt’s elite and the pig’s association with a generally distasteful god (Seth). Certainly, the proclivity of pigs to eat human fecal matter as well as much of the garbage disposed by people in urban settings contributed to this rather negative view. Certain disease organisms, notably Trichinella and Taenia, have often been associated with pork consumption and have been found in the bodies of ancient Egyptians (Miller 1990, Cockburn and Cockburn 1983). However, it is doubtful that the ancient Egyptians made the connection between, specifically, pork and these diseases, and in any case, pigs were raised and eaten by at least some of the population throughout Dynastic times.
Communicable and Chronic Diseases
Several infectious diseases have been identified in ancient Egypt, either through paleopathological analyses of skeletal material and mummies or through textual references. Paleopathological and microbiological analyses have identified tuberculosis (Zink et al. 2001, Nerlich et al. 1995), leprosy (Dzierzykray-Rogalski 1980), malaria (Massa et al. 2000), and possibly smallpox (Ruffer and Ferguson 1911, Lewin 1982) though these diagnoses remain controversial. Some form of plague is mentioned in several of the Egyptian medical papyri, including the Ebers (papyrus 39), Hearst (H XI 12–15), and London (15, 8-10) [Panagiotakopulu 2004].
There is some evidence that person-to-person transmission of disease was, at least in some form, known to occur. The non-Egyptian “Plague Letters” of the Hittite King Mursili II describe some form of highly virulent disease that was transmitted to the Hittites from Egyptian prisoners (Panagiotakopulu 2004:273). From the Egyptian perspective, this disease – probably occurring in the late 18th century BC – was referred to in the Hearst and London papyri as t3nt ‘3mw or of Asiatic origin (Trevisanato 2004). However, the nature of this transmission is unclear and the ancient Egyptians do not appear to have developed any theory of disease that would have required some form of quarantine.
Nevertheless, some form of ‘infectious agency’ did inform Egyptian biomedical practice. Plague was generally thought to arise through the work of “Demons of Disease” or “Malignant Spirits” (Brier 2004: 25) often through the agency of Sekhmet (e.g., Lichtheim 1975:225), though the 18th century plague referenced earlier (possibly tularemia) seems to have been viewed as originating with Ra and Seth (Trevisanato 2004). Because of this spiritual connection, plague was often treated through magical incantations directed at the source deity or to one that could deflect the actions of the causal deity. However, some natural component was also recognized. The verso of the Edwin Smith papyrus contains several incantations referring to an annual disease and describes the source as a “wind” and possibly connected with water as well, which Brier (2004) suggests may have had to do with the annual inundation and malarial outbreaks due to intensified mosquito activity.
Sexually transmitted diseases are relatively rarely referred to or known paleopathologically. Sexual dalliances were frowned upon and cause for legal action in some cases, although these tended to center around adultery rather than simple licentiousness (Eyre 1984). Syphillis, gonorrhoea, and chlamydia are all hinted at in various texts but not directly (Morton 1995) and there is little indication that the Egyptians were aware of the transmissibility of these diseases through sexual or other contact.
Many if not most discussions of the health of ancient populations on an aggregate level stop at the delineation of health problems and descriptions of treatments. However, even very early and organizationally simple societies practiced some active forms of public health maintenance, even in the absence of a rigorously defined theory of health and healthy behavior. For many diseases there would be at least an intuitive linkage between certain behaviors or phenomena and disease. Lim and Wallace (2004), for example, note that the link between human sewage and disease was made early on with attempts to segregate latrine areas from habitation areas in the earliest civilizations with written records. Further, even in the simplest hunter-gather societies, both ancient (e.g., Rhode 2003) and modern (e.g., O’Connell et al. 1991), efforts are often made to segregate defecation areas from other living spaces. Indeed, even the method of disposal of food waste, while often culturally moderated (Galanidou 2000) is generally either burned or discarded outside of main habitation areas, presumably to prevent the accumulation of foul-smelling waste and to keep from attracting various scavenging pests. While these activities may, at an individual level, be a result of basic instinctual avoidance of foul-smelling materials, at a group level they exhibit some degree of cooperation in ridding the immediate area of non-healthful material for all inhabitants rather than for each individual.
In the case of simple societies, these sorts of public health behaviors are moderated by group consensus and passed on through person-to-person learning and acculturation. In larger and more complex groups with some form of hierarchical power structure, public activities may be codified and promulgated through more formal channels in the form of written laws or religious proscriptions having the force of at least some level of coercion behind them. Some of the earliest Biblical texts, for example, deal with the siting of latrines and the social treatment of diseased individuals (Lim and Wallace 2004). These are often couched in the religious language of cleanliness of a spiritual sort, which may or may not be directly analogizing physical cleanliness. However, caution must be exercised when attempting to attribute various religious edicts to specific health issues or, in a larger sense, selective behaviors. As many have found to their peril, relating apparently arbitrary religious behaviors to a supposed selective or adaptive function can be fraught with internal contradiction (Miller 1990, Cagle 2002).
Because people organized into groups can take specific actions that either improve or degrade their collective health, any adequate description of the public health status of a group must contain three basic elements. First, there are those behaviors that the participants themselves believe will result in maintaining, improving, or degrading health. These are necessarily closely bound up with the group’s concept of what constitutes “health”, their concept of the causes and manifestations of disease, and what type and amount of control they can exert over both. Second, there are those actions that are, from the perspective of the participants, entirely unrelated to the health of the group, but have an effect on it. These may take the form of active prescriptions or proscriptions such as food taboos, wealth and status disparities that affect access to food, medicines and other necessary resources, settlement patterns, etc. Third, there are the basics of the local environment that may be thought of as orthogonal to group behavior; culturally mediated behaviors may affect the group’s interactions with certain environmental factors, but their very presence is not culturally determined. These factors include the local climate, parasite loads, available food and water resources, etc.
All of these elements are present in the above examination of the public health practices of ancient Egyptians. The socially moderated disposal of waste in communal areas outside of active habitation areas is likely a cooperative effort aimed at creating a more sanitary and healthful local environment for all inhabitants. Certainly the recognition of various occupation-related injuries and conditions as well as the provision of specialized physicians for major public works projects presupposes a concern – whether originating in some moral source or for purely economic reasons – for the health and well-being of workers. The ancient Egyptians rightfully had a reputation for excellent physicians and creating generally salubrious conditions within their local environment, all to attain and maintain a state of health (snb) and avoid illness (mḥr). In a sense, much of the Egyptian system of training physicians and disseminating medical knowledge via the various medical papyri would indeed fall under the modern rubric of public health even though there was little central administrative control involved. The fact that most of the known papyri are probably copies of much older manuscripts testifies to the long-term interest in retaining and sharing information on disease and injury conditions and the effectiveness of treatments. That certain physicians specialized in the health of workforces also indicates at least a heuristic interest in the health of large groups of people.
We have also examined facets of the ancient Egyptian worldview that can affect health in dramatic ways even when the connection between certain culturally moderated activities and health are neither anticipated nor examined by contemporary actors. Food taboos among the priestly classes and other behaviors, such as the shaving of body hair and daily bathing, potentially impact health, but are often couched in a language of spiritual cleanliness and absolution. These often explicitly proscribed behaviors may or may not have their origin in physical observations of their consequent health impacts but may nevertheless be treated as such from an analytic point of view as an active component of public health. Certainly other daily activities and food and drink preferences — such as the taste of well-derived vs. Nile water — can affect large portions of the population even apart from social and religious structures.
Finally, the basic aspects of the environment of Egypt can affect the overall health of the population. The distribution of the schistosomiasis parasite with respect to the local environment, together with water usage behaviors, will expose certain groups to more or less risk of infection and increase morbidity and mortality accordingly. Overall climate, vegetation, and available water determine in large part the number and kinds of parasites present for exposure, the type and quantities of both wild and domesticated plants and animals accessible for consumption, and the general salubrity of the environment. Egypt is blessed in many ways in that it combines a generally well-watered ribbon of life in an otherwise exceptionally arid setting thus limiting to some extent to number of disease-causing parasites that can exist outside of the human body. Add to that a very moderate Mediterranean climate — albeit with very hot summers — and the ability to produce an enormous quantity and variety of agricultural produce, and the reputation Egypt maintained of a healthy environment until comparatively recent times is entirely sensible, even expected.
Even today, accurately gauging the “state of public health” of a given society is difficult. Simply diagnosing some condition as a “disease” requires a value judgment as to what constitutes “normal”, what specific symptoms constitute the diagnosis of the disease condition, and delineating a cause or causes of the illness such that treatments can be applied and/or preventive measures taken in advance. These hurdles must be overcome before creating adequate measures of the health of a population in terms of the burden and costs that disease places on the society as a whole and its members.
Further, this process is only a first analytical step; the concept of “health” and “illness” are often culturally defined and can mean different things to different portions of society. Individuals will assign their own meanings to their state of health — what their suffering signifies in a larger sense — the cause(s) both proximate and ultimate (e.g., spiritual), and their role as a sick person in society. Even in the absence of any specific disease condition, the behavior of individuals is strongly conditioned, not only by their own personal experiences regarding healthy behavior, but by the norms and mores that society as a whole have developed and transmitted to its members through formal teachings or folk knowledge. For example, the cup of tea and apple that I have consumed while writing this paragraph were chosen in part out of personal preference, but also by the supposed health benefits that I believe may accrue from their consumption: polyphenols and antioxidants in the tea, and well, ‘an apple a day’ as ‘they’ say regarding the latter. Both health and disease need to be seen as not only individual conditions but as ‘deeply social’ processes (Jones et al. 2012) that condition our experiences of and responses to matters of health.
These difficulties are further enhanced archaeologically when our ability to diagnose disease conditions afflicting a past population is severely limited and our access to the belief systems related to health and disease are absent or only obtained with much difficulty and potential pitfalls. Nevertheless, doing so can enhance our knowledge of the causes of the success and/or failure societies experience along their evolutionary trajectories. Health and well-being are intimately connected with fertility and reproductive success and thus can directly affect the very survival of a population. Given the depth of time archaeologists have to work with — especially in the case of Egypt — and the numbers of different societies and environments available to us, we have the ability to examine the results of different strategies for dealing with the consequences of public health-related behaviors both in absolute — survival or extinction — and relative terms through comparative analyses. Consequently, with the above survey I hope, at a minimum, to have created the basis for a template to measure the social and biological determinants of health in at least one population.
It is also possible that research into the public health practices of our forebears may have some import for our modern world. Many populations outside of the developed world continue to live in environments — both natural and artificial — that are not so different from those experienced by our technologically simpler ancestors. By studying the public health successes of these ancient populations, we could potentially devise solutions to public health problems that are relatively uncomplicated technologically yet still provide significant improvements in morbidity and mortality. That many of these solutions were successful in the absence of rigorous scientific knowledge on the part of the participants could also assist in developing programs that promote healthy behaviors that are both readily understandable and culturally meaningful to the population. Further, the time depth that archaeology provides could allow us to implement solutions that produce positive results over the short term without sacrificing the long term viability of the population or their environment.
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