The Sick Poor and the Origins of Medical Charity

Classical antiquity had no hospitals, foundations or philanthropic charities. Christianity changed all that.

by Gary Ferngren
Terri Scott

Few descriptions of epidemic disease are better known than that of Thucydides. In a well-known passage that became a model for later writers, Thucydides describes the plague of Athens in 430 BC, which he himself had experienced in a city that was overcrowded with citizens of outlying villages who had taken refuge inside the walls of Athens during the Spartan invasion of Attica:

Terrible, too [writes Thucydides], was the sight of people dying like sheep through having caught the disease as a result of nursing others. This indeed caused more deaths than anything else. For when people were afraid to visit the sick then they died with no one to look after them; indeed, there were many houses in which all the inhabitants perished through lack of any attention. ….The bodies of the dying were heaped one on top of the other and half-dead creatures could be seen staggering about in the streets, or flocking around the fountains in their desire for water. The temples in which they took up their quarters were full of the dead bodies of people who had died inside them (Thucydides, History of the Peloponnesian War 2.51–53. Translated by Rex Warner. London, 1974, 154–55).

In the world of classical Athens, responsibility for health was regarded as a private, not a public, concern. In spite of several well-known epidemics in the ancient world, virtually all outbreaks of infectious disease were left to individuals to deal with on a self-help basis. Emergency measures were rarely taken by municipal officials—hence the frequently described scenes in classical literature of corpses lying unburied in the streets during times of plague. Moreover, public officials did not believe they had any responsibility to prevent disease or to treat those who suffered from it. Alex Scobie speaks of “a cynical acceptance of the state’s indifference to the lot of the urban poor.” Traditional attitudes of pessimism and quietism—the feeling that little could be done on a public level to end widespread disease, or to care for the ill—also underlay the inactivity of public officials and their failure to undertake preventative or emergency measures.

There existed in classical antiquity, moreover, little recognition of social responsibility on the part of the individual. Philanthropy among the Greeks did not take the form of private charity, or of a personal concern for those in need, such as orphans, widows, or the sick. There was no religious or ethical impulse for almsgiving. Philanthropic acts were undertaken for the purpose of increasing one’s personal reputation. Philanthropy brought honor to the donor. The classical world, moreover, did not recognize emotion or pity as a desirable response to suffering or as a motive for personal charity. “Broadly speaking,” writes A. R. Hands, “pity for the poor had little place in the normal Greek character; and consequently, for the poor as such, no provision usually existed; the idea of democracy and equality was so strong that anything done must be done for all alike; there was nothing corresponding to our mass or privately organized charities and hospitals.” Hence when donors made gifts or performed services, they intended them for the entire community. No distinction was made between the destitute and others. In fact, the poor were never viewed in the classical world in a separate category that deserved special consideration. The sick poor simply did not have an identity as a defined group. Hence there existed no public or private charitable foundations, clinics, or hospitals for meeting their needs. Any benefaction, endowment, or foundation had to be provided for all members of the city-state, rich and poor alike, a situation that was equally true of the Greek city-states in the fifth century BC and of the large cities of the Roman Empire in late antiquity. Classical society required a new movement, which arose outside the traditional framework of the classical world, to challenge this assumption. That movement was Christianity.


Early Christianity

From the beginning, Christianity displayed a marked philanthropic imperative that manifested itself in both personal and corporate concern for those in physical need. In contrast to the pagan classical world, which had no religious impulse for charity that took the form of personal concern for those in distress, Christians regarded charity as motivated by agape, a self-giving love of one’s fellow human beings that reflected the redemptive love of God in Jesus Christ. At the same time that ordinary Christians were encouraged privately to visit the sick and aid the poor, the early church established forms of organized assistance. The administrative structure of the local church (ecclesia) was simple, but well suited to the supervision of charitable activities that relied on both clerical and lay activity. Each church had a two-tiered clergy composed of priests and deacons, who directed the corporate ministry of the congregation. Deacons, whose main concern was the relief of physical want and suffering, had a special duty to visit the ill and report them to priests. They received collections of alms every Sunday for those who were sick or in want, which were administered by priests and distributed by deacons. Widows who did not need assistance formed a separate class that later developed into the office of deaconess. They were expected to help the poor, especially women who were sick. Although their numbers and resources were often small, Christians were equipped, even in the most adverse of circumstances, to undertake considerable charitable activity on behalf of those who were ill. Owing to a combination of inner motivation, self-discipline, and effective leadership, the local congregation created in the first two centuries of its existence an organization, unique in the classical world, which effectively and systematically cared for its sick.

In the third century the rapid growth of the church, particularly in the large cities of the Roman Empire, led to the organization of benevolent work on a larger scale. Roman cities were crowded, often unsanitary, and, for large numbers of city-dwellers, lonely. As the number of those who benefitted from the church’s charitable activity increased, there came to be too few clergy to deal with the demands made on them. Hence congregations began to create minor clerical orders to assist them. From a letter that is preserved by Eusebius, written in 251 by Cornelius, bishop of Rome, to Fabius, bishop of Antioch, we learn that the church in Rome supported 46 priests, seven deacons, seven subdeacons, and 42 acolytes, as well as 52 exorcists, readers and doorkeepers—altogether a staff of considerable size. Apparently the church in Rome had divided the city into seven districts, each under a deacon, who was assisted by a subdeacon and six acolytes. They cared for 1,500 widows and distressed persons who were supported by the church. Adolf Harnack estimated that the Roman church spent each year from 500,000 to one million sesterces, an enormous sum, on the maintenance of those in need. A century later John Chrysostom writes that the Great Church in Antioch supported 3,000 widows and virgins along with other sick and poor persons and travelers. All this—the establishment of minor orders to assist priests and deacons, the creation of sizable staffs of clergy in large churches, the regular support of considerable numbers of the poor and sick, and the expenditure of large sums of money—suggests that the churches devoted a good deal of attention to corporate philanthropic activity.


The Founding of Hospitals

The perception that the church had an obligation to care for “the poor” was basic to the founding of the earliest hospitals. The hospital was, in origin and conception, a distinctively Christian institution, rooted in Christian concepts of charity and philanthropy. There were no pre-Christian institutions in the ancient world that served the purpose that hospitals were created to serve, namely, the offering of charitable aid, particularly of healthcare, to those in need. Roman infirmaries, called valetudinaria, were indeed maintained by Roman legions and large slaveholders, but they provided medical care to a restricted population of soldiers or slaves, and they were not charitable foundations. The earliest hospitals, called nosokomeia or xenodochia, grew out of the long tradition of diaconal care of the sick in Christian churches. The best known, and the earliest, hospital was the Basileias, which was begun about 369 and completed about 372 by Basil the Great, who became bishop of Caesarea in Cappadocia (Turkey). Basil’s hospital employed a regular live-in medical staff that provided not only aid to the sick, but also medical care in the tradition of Greek medicine. It included a separate section for each of six groups: the poor, the homeless and strangers, orphans and foundlings, lepers, the aged and infirm, and the sick.

Hospitals spread rapidly in the Eastern Roman Empire in the fourth and fifth centuries, with bishops taking the initiative in founding them. They appeared in the Western Empire a generation after they were established in the East, but their growth was much slower in the West owing to economic difficulties. Hospitals were founded specifically to provide care for the poor (Basil called his hospital a ptochotropheion or poorhouse). The pattern of hospitals caring for the poor persisted until the mid-nineteenth century, and hospitals remained for centuries what they had been intended to be from the beginning, namely, institutions for the indigent who were taken off the streets and given a place in which to die. Those who could afford a physician’s care received it in their homes.


Changes in Patterns of Beneficence

As late as the mid-fourth century after Christ the concept of being a “lover of the poor” (philoptôchos) was a novel one in the Greco-Roman world, with no antecedents in classical models of philanthropy. Within the traditional classical pattern of euergetism (public philanthropy), the rich expressed their civic patriotism to the city by sharing their wealth, not with the poor, but with all their fellow citizens. When the sense of community within the city-states was weakened in late antiquity, the old ideological basis for euergetism was replaced by a new ideology of private charity in which one group within society (the poor) was elevated above the rest as recipients of philanthropy. Christians, influenced by biblical texts that spoke of the care of the poor as a duty, rather saw them as especially blessed by God, endued with special grace, and even in their poverty bearing the image of God. They regarded giving to them as giving to Christ, and philanthropy to the poor as demonstrating love for their Savior. The lower classes of the city, given a specific identity and defined for the first time as collectively-deserving the assistance that had previously belonged to all citizens, came over time to replace all citizens as the beneficiaries of assistance. This little-noticed movement marks one of the truly revolutionary changes in human sentiment in Western history and constitutes a significant feature in the transition from classical to a Christian society.


This article was awarded the 2014 Award of Merit for Theological or Scholarly Article by the Associated Church Press.

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