Notes on health policies and hospitals in the Islamic Orient up to the 13 th Century PDF

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Notes on health policies and hospitals in the Islamic Orient up to the 13th Century Dr. Bertrand THIERRY des EPESSES When tackling the issue of public health policy in the early centuries of the Islamic Orient, it is by no means anachronistic to refer to modern-day terminology. Indeed, a rational pu...

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Notes on health policies and hospitals in the Islamic Orient up to the 13th Century Dr. Bertrand THIERRY des EPESSES When tackling the issue of public health policy in the early centuries of the Islamic Orient, it is by no means anachronistic to refer to modern-day terminology. Indeed, a rational public health policy must consider three objectives: Primary prevention (anticipating emerging risks), Secondary prevention (ensuring healthcare services), and Tertiary prevention (providing for the needs of dependent persons). The ruler must therefore ensure that the population under his authority is kept safe from any potential health dangers; that it can be treated in the event of illness; and that when ill health has left individuals unable to meet their needs, everything possible is done to ensure a decent existence for them. The ruler’s duties are very clear: they must respect a code of ethics; comply with the mission of a ruler as defined by the Koran; and reflect the influence of the Sassanid ideal of justice. When you read the Counsel for Kings by al-Ġazālī (d. AD 1111) or the Treatise on Government by Nizām alMulūk (d. AD 1092), this convergence becomes very clear1. As for administrative efficiency, the assimilation of the Byzantine model by the Umayyads in Damas provided a strong framework for an ideology which clearly called for what may be likened to the notion of the Public Weal. When implementing his health policies, the ruler, in keeping with these treatises on good governance, must surround himself with competent advisers. Thus, in book X, chapter V of Metaphysics of the Healing, Avicenna specifies those who, along with the sovereign, constitute the strength of the state; these are the administrators, the expert technicians and the guardians. This tri-partition of the missions is extremely pertinent. Doctors, astrologers2 and engineers are at the very top of the list of expert technicians. The court physician is the expert technician who advises the sovereign; he is responsible for overseeing the health professions and is required to be a medical writer on any subject which may be of concern to the prince. Most medical treatises were commissioned by the prince; however, the dedicated texts written by these doctors are more than mere acts of allegiance, they are acts of health policy intended to be works of reference in the field of policy and procedures. Medical writers expect the ruler to read their works and take note of their recommendations.

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Thus, for both Al-Gazali and Nizam, whose Muslim wisdom cannot be called into question, the Sassanid Khosrow Anushirvan (Nūširvān-e Dādgar) (A.D. 521-579) was the ideal sovereign. 2 Astrologers participated in the risk prevention policy; see Appendix V in Bos (G.) and Burnett (Ch.), Scientific Weather Forecasting in the Middles Ages, The Writings of al Kindī, Keagan International, London & N-York. See also Sbath (P.), Le Livre des Temps (The Book on Weather) by Ibn Massawaïh, a famous Christian doctor who died in 857, in Bulletin de l’Institut d’Egypte (the Egyptian Institute’s Newsletter), volume XV, 1933, 235257.

Primary prevention: anticipating risks Primary prevention focuses on the most frequent illnesses in terms of prevalence and impact, that is to say, not on chronic illnesses (heart diseases, cancers, diabetes...) but on infectious diseases, which are omnipresent. These are defined by ‘Alī ibn ‘Abbās al-Maĝūsī (d. between AD 992 and 995) as: epidemic diseases, indeed pestilent diseases (al-ʾamrāḍ al-wāfida); endemic diseases (al-ʾamrāḍ al-baladiyya); and contagious diseases (al-ʾamrāḍ almu’diyya)3. It was infectious diseases which, by virtue of their scale and scope, prompted the ruler to take action. The first step was to identify the infectious menace. Hence, the energy put into translating the ancient Greek medical texts4, just like the appeal made to the doctors of Gundishapur in the province of Fars, was prompted not by purely intellectual zeal, but by a far more practical reason: to eradicate epidemic diseases by getting to know them. The epidemic was an “object” to be analysed, its emergence and development to be dissected in order to define the course of action required to avert waves of increased mortality.

Indeed, starting with the Plague of Justinian (541-542), the Eastern Mediterranean has been the stage for violent waves of plagues (veritable plague Yersinia pestis and epidemic typhus). The Syrian Plague of 638-639, the so-called Amwas Plague, ended with the death of 25,00030,000 soldiers of the Islamic army. Leaders of the Prophet’s tribe decided on the course of action to take under Hadith: “If you learn that the plague is in a land, do not go there, and if the plague breaks out in the place you are, do not leave that place. Avoid lands affected by plague, for contamination brings death”. The fight against epidemics could not be reduced to this type of directive (the implementation of an absolute quarantine); it was imperative to be proactive by taking early preventative measures at the first signs of danger. On the other hand, it was of course necessary to find a prophylactic solution for those who were maintained in the confined area. The population could not be exposed to the risk of being totally exterminated through an abusive interpretation of God’s will; it was by letting things run their course, as did the governor Abu Ubayd, that the death rate was so high in Amwas. That is why Ya’qūb ibn Isḥāq al-Kindī (A.D. 801-873) came up with a treatise on fumigations in the event of contaminated air which was dedicated to, and probably requested by the Abbāsid prince Aḥmad ibn al-Mu’tasim. This lost treatise, cited by al-Tamīmī, was a compilation of original fumigation recipes, including some from India. The very strong-smelling fumigations used to purify the air which were advocated by qu’al-Kindi (frankincense, laurel seed, yellow sandal, blue bdelium, ruta graveolens) no doubt had a marked effect on the population’s morale, for want of real effectiveness5. The fumigation of urban spaces would become a routine occurrence in times of pestilence. 3

This classification, derived from the galenic summary of the Hippocratic Corpus, is obviously inconsistent with our modern-day classification since the way viruses, bacteria and other micro-organisms are transmitted were of course unknown then. 4 Pormann (Peter E.), Epidemics in Context, Greek Commentaries on Hippocrates in the Arabic Tradition, De Gruyter, Berlin, 2012. 5 Levey (M.), The Medical Formularys or Aqrābāḏīn of al Kindī, Wisconsin Press, 1966, p. 214, 276, 304 & 309.

Pestilent diseases (al-ʾamrāḍ al-wāfida) are understood to be diseases caused by “contaminated” air or water. Endemic diseases (al-ʾamrāḍ al-baladiyya) have a different profile; although they also affect large populations, they have the particular characteristic of being inherent to a specific place and, unlike an epidemic, they are not due to an accidental cause. Prototypes of these are leprosy, malaria and trachoma. Primary prevention is therefore a matter of individual hygiene. Medical treatises abound with inadequate or irrelevant advice such as that given by d’Īsmā'īl Jurjānī (approx. A.H. 435/A.D. 1042 - approx. A.H. 531 A.D./1136) in the Ḏaḫīrah-ye Ḫwārazmšāhī in which he indicates the risk of getting leprosy by walking barefoot in places where lepers live. While individuals are responsible for their own personal hygiene, it is the ruler who is responsible for collective hygiene. Urban planning6, including sewage and garbage disposal, together with the management of rendering and the monitoring of water purity are the prerogatives of a rational preventative health authority. It is implicit wherever the State functions without coming up against inertia or a loss of authority. The muhtasib7 is the strong arm of a controlled health policy; in Muslim cities, its role is to verify that the standards (whether scientifically substantiated or not) are applied and that offenders are punished. The penalty for poor primary health prevention is depopulation which, as Nizām al-Mulūk crudely notes, results in a loss of tax revenue.

Secondary Prevention, health care In the field of secondary prevention, that is to say ensuring health care for the population, the ruler’s responsibility is dependent upon the doctors’ medical training; the monitoring of their practice and of the health care professionals who act by prescription (apothecaries and surgeons); and on access to health care, starting with the hospital.

I The hospital (bīmāristān) Hospitals are founded within the framework of a strong and structured state, even if the initiative behind their foundation is a private one. In this respect, The Umayyads, the Abbasids, and the Buwayhid and Saljuq Dynasties were oviously builders of hospitals. According to the expression used by Al-Gazali to describe the ideal sovereign who cares about peoples’ well-being, they were “builders of mosques, bridges and hospitals”. Hospitals in particular appear to be the prerogative of the Eastern Caliphate, so we can understand Ibn 6

In Al-Wulāh wa al-Quḍāh, Al-Kindī relates that, following the plague of 689, ’Abd al-‘Azīz ibn Marwān (d. 705) created a new neighbourhood in Cairo (Ḥulwān) to protect himself, his court and his army. This was town planning which did not of course take public interest into account. Conversely, the practice of segregating contagious persons can – very rarely – be noted (Faubourg des Malades, Rabaḍ al-Marḍā, de Cordoue). 7 The muḥtasib and his lieutenants appeared in the early days of the Abbasid period ; their mission was to forbid evil and promote good (the Hisba), in all its forms ; see Laoust (H.), Ibn Taymiyya, Traité sur la Ḥisba, in Revue des Etudes Islamiques, LII, 1984.

Ğubayr’s surprise during his journey to Syria in AH 580/AD 1184 on noting that the town of Homs did not have a hospital, when “in those countries” every town has one. Hospitals (bīmāristān) are not an innovation of the Islamic world; the historian al-Maqrīzī credits the concept of hospitals to the Pharaoh Manaqius and mentions Hippocrate’s hospital in Kos. However, their development and growth can undoubtedly be attributed to the Islamic Civilisation. It was probably at the initiative of the 6th Caliph ‘umayyad ʾAbū Al-ʿAbbās AlWalīd ibn ʿAbd Al-Malik (died in AH 96/AD 714) that the first bīmāristān of the Islamic World – in Damas – was founded. This establishment is a policlinic8 because the bīmāristān is open to the city, it does not keep its patients, and the hospital stay is short; in the Al-Tuluni bīmāristān in Cairo (built in AD 872), a patient was considered fit for discharge from hospital if he or she was able to eat a chick and a loaf of bread; such was the criteria used to judge whether someone was cured or not. For prolonged hospital stays, you went to the tīmāristān, which we will look later in the document. In the account of his visit to the East – around AH 736-740/AD 1336-40 – H̱ālid ibn ‘Isa al-Balawī mentions that at the dawn of the 14th Century (Hegira 8th Century), up to 4,000 people were entering and leaving the Mansuri bīmāristān in Cairo every day; this detail confirms that hospital stays, even short ones, were far from the norm. There were various forms of mobile (mahmul) bīmāristān, with the equipment mounted on camels, which have a long history dating back to the Prophet’s lifetime; these were the bīmāristān of military campaigns or epidemics. They were essentially mobile dispensaries. Indeed, the dispensary was at the heart of the bīmāristān, and this dispensary was open to the city; hence, the nāẓīr (director) of the Mansuri Hospital in Cairo was responsible for having medicine delivered to patients in town who were unable to go to the bīmāristān. It is no coincidence therefore that the bīmāristān was often called dārūhānah9. Moreover, much of the pharmacopoeia produced by medical authors is in fact codex for use in the bīmāristān. This was the case when al-Sadīd Ibn Abī al-Bayān (b.AD 1184), Egypt’s Chief Medical Officer and doctor at the Al-Nasiri bīmāristān in Cairo, wrote the pharmacopoeia Al-Dustūr al-Bīmāristānī, which grouped together medical recipes used in the hospitals of Egypt and the Mashreq (as well as in town dispensaries); this book would be followed by the Manual for the Dispensary by Abū al-Munā al-Kūḥīn al-‘Aṭṭār – Minḥāĝ al-Dukkān (AD 1260) – which met with considerable success, going on to become a universal vade mecum. The basic principal of the bīmāristān is that the patient goes there to see a doctor and once the diagnosis has been made, he or she gets given remedies. Surgery was indeed performed there, but only minor surgical procedures for treating wounds and fractures, the most complex operations being in ophthalmology (removing cataracts). There were no serious operations, and Avicenne notes that nephrectomy was out of the question; technical gestures are performed at the patient’s bedside according to medical prescriptions: bleedings, 8

There is often confusion, even in WHO texts, between «policlinic», «town clinic» and «polyclinic», «clinic where all medical disciplines are practised». 9 Dārūḫānah, «medicine house » (persian). Isma’il Jurjānī (died at Marv in the year AD 1136 or 1140) was the head physician of a dārūḫānah in Khwarazm.

examinations or the evacuation of ascites10. Midwives attended to the female patients in both obstetrics and gynecology, also on medical prescription, as was the case in the Al-Muqtadir bīmāristān11 in Bagdad Hospitals fulfilled multiple social functions; over and above providing health care for the poor and needy, it was a way of showcasing the sovereign’s desire to look after his people; of mobilising the rich to be charitable through waqf-s; and of bonding together the religious community by getting them to overcome their selfishness. Ibn Ğubayr thus exclaimed in the 6th/12th Century: “These hospitals are among Islam’s finest claims to fame”. When the patients were discharged from the bīmāristān, they received something to wear and enough alms to cover their basic, immediate needs; that was the rule at the Mansuri Hospital in Cairo. Charity is indeed at the forefront of the hospital: the bīmāristān is not simply a hospital providing health care; it is tangible proof of the spirit of charity. The interior design of a bīmāristān is functional and the scale of its premises depends on the scope of the tasks that it takes on; these range from the most basic to the most sophisticated. Thus, musicotherapy can be provided in well-equipped bīmāristā-s. Therapy through music is included in the doctor’s legitimate therapeutic arsenal and is recommended by Ibn Hindū (H. 4th-5th/10th-11th Century)12: “Of course, that doesn’t mean that the doctor starts playing the trumpet or the flute, or starts dancing. A doctor needs aids, in the same way as he works in association with an apothecary, a man capable of “bleeding”, or yet another who knows how to use suckers; they serve medicine, and medicine is indebted to these techniques. This also applies to musicians who must be summoned in these situations.” Women and men must be treated in separate quarters. According to Ibn Ğubayr’s description of the Mansuri Hospital in Cairo, the women’s sector is separated to such an extent so as to become a separate building. The organisation of the bīmāristān hinges on the medical and paramedical staff, the stewardship staff, and the administrative staff. Its management is entrusted to a mutawallī, the head physician, along with an executive directorate which, in prestigious establishments, is headed by a high dignitary. These important people – the nāzīr of the bīmāristān – are appointed by the ruler and characterised by their ambition for their hospital; this is exemplified by the nāẓīr Badr al-Dīn in Damas, which put all its energy into making the AlNuri bīmāristān a model of its kind by securing funding, installing running water, and extending the buildings by purchasing the surrounding grounds and building on them13. Ibn Hindū specified that the hierarchy was organised in a functional manner: nurses are under the supervision of the mušrif, or head nurse, who organises the distribution of medicine and oversees the prescription of specific foods for each ailment (diet is part of the treatment since, 10

Ibn Abī Uṣaybi'a, Uyūn al-anbāʼ fī ṭabaqāt al-aṭibbā, Cairo, I-179. Rāzī mentions that in the bīmāristān where he practised, a midwife removed uterine fibroids (Meyerhof (M.), Thirty-three clinical observations by Rhazes, Isis, 23, Cambridge, 1935, p. 344). 12 Ibn Hindū, Miftāḥ al-ṭibb wa minhāĝ al-ṭullāb, presented by Moḥaqeq (M.) and Dānīšpajūh, Mac Gill University, Institute of Islamic Studies, Tehran, 1989. It should be noted that the call for musicotherapy in the bīmāristān is not a phenomenon of a later date. 13 Ibn Abī Uṣaybi'a, op. cit., Beirut, II-260. 11

according to Galenic theory, food is a medicine of the first order). The doctors assigned to the wards (līwān) work under the authority of the head doctor. These practitioners are divided into four categories, each one in their specific līwān: the internists (ṭaba’iyyūn), the surgeons (ĝarā’iḥiyyūn), the ophthalmologists (kaḥḥalūn), and the orthopaedists-traumatologists (muĝabbirūn). The pot handlers work in the dispensary under the supervision of the head pharmacist (šayḫ ṣaydalānī) since a dedicated place is required for the preparations. The stewardship staff, who take their orders directly from the bīmāristān’s management, are responsible for bed linen, patients’ clothing and for providing and serving food, which implies stock management on a very large scale. The bīmāristān’s directorates were therefore assisted by a large number of personnel whose tasks were linked to the establishment’s activity. In terms of investment and running costs, funding is secured through donations from the religious community and it is managed in waqf-s. The long-term funding of these pious foundations was particularly dependent on property annuities which, with time, waned with the income from the rented properties, and this is what caused the bīmāristān’s decline. It should be noted that the bīmāristān plays an important role in the field of education and indeed in the research and progression of medical sciences. The bīmāristān is the ideal place for passing on knowledge from master to student and from practioner to practioner. The chief physician, who has the title of “šayḫ”, gives courses, and for this reason he receives a double salary (this was the case at the Al-Nuri bīmāristān in Damas and at the Manuri Hospital in Cairo). Medical students were not the only ones who could sit in on the conferences; in fact, the public lectures (maĝlis) were open to anyone interested in medical sciences. Thus, caliphs would attend talks given by professors in medicine, and in so doing, judge the service provided and confirm by their presence the religious and political connotations of the bīmāristān. The experiments were related to the pharmacopoeia, as well as to any behaviour which appeared to be altered; practioners had the time and opportunity to improve their technique. As al-Buḫarī (4th/10th Century), who was in charge of a lycanthrope (qotrob), wrote: “I bound his hands and feet and I made an instrument out of a cow’s horn to put the food and medicine into his mouth, and this is how I rid him of his illness.”14 In conclusion, we can say that the hospital is an integral part of the ruler’s governing policy in Islam. The concerns of a sovereign such as `Adud al-Dawla Fannā Hosrow (died in AH 373/AD 983) sums up a characteristic profile: he founded and governed the Chiraz bīmāristān in the Fars, and founded another one west of Bagdad, which was completed in AH 371/AD982 (the famous al-`Aḍudī bīmāristān). His concern for the public good extended to other domains, notably to improving irrigation. He was the dedicatee to Kitāb al-Malikī d’’Alī ibn al-‘Abbās (died 982-994). It should be noted that `Adud al-Dawla was a student of the scholar and mathematician Abū Ğa’far al-H̱āzin; there is therefore continuity in this type of governing personality who is driven to do good both by «Adab » (cul...