There is no way of knowing if the recommendations for rations given by the ancient Roman agronomists were widely followed in practice, but even if they were, slaves might still have had an impoverished diet. In his recent discussion of this topic, de Martino concluded that the recommendations of the agronomists would have given slaves a very poor diet:
It can be inferred, based on the sources, that there was without doubt a ¹⁰¹ Florence Nightingale noted how it emerged during a papal visit to the Santo Spirito hospital in Rome in January 1848 that patients were actually only being given half the quantities of drugs prescribed to them in order to save money, in spite of the hospital’s enormous endowments (Keele (1981: 183) ). The fact that drugs were known does not necessarily mean that they were available in the right quantities (and at the right price) to those who needed them. That is why the laws of 1900–3 were so important. Corso (1925) gives the text of these laws. Pope Innocent III founded the Santo Spirito hospital near Castel S.
Angelo in 1198 ( Regula ordinis S. Spiritus in Saxia, ed. Migne, Pat. Lat. vol. 217, cols 1130–57).
¹⁰² De Felice (1965: 96): ‘ Per tutto il Settecento e buona parte dell’Ottocento si può dire che in gran parte del Lazio il bestiame era meglio alimentato della massa dei contadini’.
¹⁰³ Livi-Bacci (1986) on pellagra.
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great scarcity of animal protein, insufficient fats and a lack of very important vitamins, C and D, with A being very rare.¹⁰⁴
A clinical trial in Papua New Guinea concluded that symptomatic episodes of P. falciparum malaria were about 30% less frequent in young children who received vitamin-A supplements than in those who received placebos.¹⁰⁵ Much older writers also raised the question of the importance of nutrition in relation to malaria. Carmichael described one case that was reported in the Necrologi (or death registers) of Milan, in which the death of a fifty-year-old man on 7 August 1479 was attributed by one doctor to ‘simple tertian fever with a bad regimen’. A second doctor who also examined this case concluded that the poor diet must have played a significant role, since tertian fevers alone were usually not fatal.¹⁰⁶
At the end of the eighth century Alcuin gave the following advice to a disciple travelling to Italy:
Italy is an unhealthy country. It provides harmful foods. Consequently exercise extreme caution with regard to what, when, or what sort, or which foods you eat; and above all avoid being constantly drunk, since it is from the heat of wine that intense fevers tend to strike the unwary.¹⁰⁷
The urban poor in Rome in antiquity faced food shortages, certainly from time to time, and perhaps chronic food shortages as well. The ‘Mediterranean diet’, whose health advantages have attracted so much publicity in recent years, is of course a modern invention. As has been seen already, peasants in many parts of early modern Italy relied heavily on foods like maize and prickly pears which were not available in Europe in antiquity.¹⁰⁸ Even aspects of the ancient diet apparently conducive to good health probably made little difference to mortality and morbidity from ¹⁰⁴ De Martino (1993: 422): ‘ Da tutto quel che precede si desume che stando alle fonti, vi era senza dubbio grande scarsità di proteine animali, grassi insufficienti e mancanza di vitamine molto importanti, la C
e la D, scarsissima la A’.
¹⁰⁵ Shankar et al. (1999).
¹⁰⁶ Carmichael (1989: 39).
¹⁰⁷ Alcuin, epistolae 281, ed. Duemmler (1895), Monumenta Germaniae Historica. Epistolae, iv.
439: Italia infirma est patria et escas generat noxias. Idcirco cautissima consideratione videas, quid, quando, vel qualiter, vel quibus utaris cibis; et maxime ebrietatis assiduitatem devita, quia ex vini calore febrium ardor ingruere solet super incautos.
¹⁰⁸ Ferro-Luzzi and Branca (1995) defined ‘the Mediterranean diet’ as the diet of southern Italy in the 1960s. If defined as such, it is of course a legitimate object of research, but it must be recognized that the subject as defined has little relevance to antiquity. Ferro-Luzzi and Branca noted, for example, the importance in ‘the Mediterranean diet’ of the tomato, which was not available in Europe before Columbus.
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infectious diseases like malaria. A good example is emmer ( Triticum dicoccum), the most important type of wheat cultivated in Latium and Tuscany in the Iron Age and the early stages of Roman history, as shown both by palaeobotanical remains and literary sources.
Emmer comprised 58% of the cereals from excavations of the archaic layers of the Roman Forum; einkorn ( T. monococcum) comprised 10%, barley ( Hordeum vulgare 32%), and there was no naked wheat at all. Research at Etruscan sites such as Acquarossa and Podere Tartuchino is producing broadly similar results, sometimes with a greater importance of barley over all types of wheat. Rations of emmer are mentioned in the Twelve Tables, confirming its importance in the fifth century . By the Roman Empire cultivation of emmer in Latium had declined in favour of poulard wheat ( T. turgidum), even though emmer was suitable for the wet conditions of Latium and contains a higher proportion of protein than modern varieties of bread wheat ( T. aestivum), but it continued to be important in more mountainous regions such as Umbria. By the early modern period cultivation of emmer ( farro) had decreased to the point that statistics for its production were not recorded in the documentary investigations into Latin agriculture of that period, such as the Inchiesta Iacini. Nevertheless it continued to be grown by a handful of farmers and data survive for emmer prices on the markets of Rome in the nineteenth century, allowing its price ratio with respect to naked wheats to be firmly established. Within the last twenty years emmer has been rediscovered by Italian botanists being cultivated on a few farms in isolated areas of the Apennines, after it was thought to have become extinct in Italy. It is now sold and marketed as a health food in Italy ( farro perlato) because some research has suggested that consumption of emmer reduces the risks of heart disease and cancer of the colon, perhaps because of its high fibre content. However, these diseases attain their highest frequencies among elderly people. Population age-structures produced by endemic malaria show that most people would have been killed by infectious diseases before they became old enough for intestinal cancers, for example, to become a major cause of death.
Consequently it is unlikely that consumption of emmer in western central Italy in antiquity did significantly improve the health of the population in practice.¹⁰⁹
¹⁰⁹ De Martino (1979); Ampolo (1980: 15–19); Hjelmqvist (1989); Perkins and Attolini (1992); Rendeli (1993: 140); Twelve Tables, 3.4; Pliny, NH 18.19.83–4; Sallares (1991: ch. 3, esp.
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Before leaving the topic of the interaction of malaria and malnutrition in humans, it is important to remember that other parasites may also figure in this equation. For example, the presence of intestinal worms may help to cause malnutrition in cases of malaria. Some research in Madagascar suggests that treatment with antihelminthic drugs considerably reduces the frequency of severe malaria attacks.¹¹⁰
5. 4 C I
E
A fully comprehensive population history of Italy in more recent times, based on local studies (akin to the English parish studies) of both mortality and fertility covering a long period of time from all over the country, has yet to be produced by Italian demographers.
To see how endemic malaria drastically altered demographic patterns at the local level against the background of a historical situation where large parts of the population of a country as a whole were quite healthy, it is necessary to turn to Britain and consider the sort of data that were used in Wrigley and Schofield’s Population History of England 1541–1871 and in subsequent research. Although England is too cold for P. falciparum to have ever become endemic in the past, it is
warm enough for P. vivax. P. vivax only requires a temperature of 15–16°C to complete sporogony inside the mosquito in summer, and many of its strains in temperate climate regions have developed a certain tendency in the direction of avirulence to enable it to survive long, cold winters in northern Europe inside humans.¹¹¹ P. vivax existed in Britain in the past in the Westminster 481 n. 101); Strabo 5.2.10.228C noted the predominance of emmer over naked wheats in the mountains of Umbria in his own time: [Ó ∞Ombrik&] ‹pasa d’ eÛda≤mwn Ó c*ra, mikr‘ d’
øreiotvra, zei9 m$llon ∂ pur‘ toŸß ånqr*pouß trvfousa (the whole of Umbria is prosperous, but rather hilly; it feeds men with emmer rather than wheat); De Felice (1965: 121); ch.
on Movimento dei prezzi delle derrate alimentari, in Monografia (1881: 350, 354–6); Toubert (1973: i.
244) noted references to far in the Statuti della Provincia Romana from the thirteenth and fourteenth centuries ; Perrino and Hammer (1984).
¹¹⁰ Cited by Mutapi et al. (2000), who observed themselves that there appear to be immunological cross-reactions between malaria and schistosomiasis.
¹¹¹ Malaria parasites generally overwinter in human hosts rather than vector mosquitoes (Hackett (1937: 209–12) ) because sporozoites tend to degenerate after about a month inside the salivary glands of mosquitoes (Garnham (1966: 369) ). This traditional view has been confirmed and reinforced by recent research employing the new techniques of molecular biology (e.g. Babiker et al. (1998) and (2000), Hamad et al. (2000) ) which has shown that subclinical asymptomatic infections do persist in some people, during seasons of the year when 152
Demography of malaria
and Lambeth districts of London, in the coastal marshes of Kent and Essex, the East Anglian Fens, parts of the south coast, possibly also Bridgewater in Somerset and the Ribble valley in Lancashire, and probably as far north as the East Lothian area of Scotland.
Robert Hamilton described the course of the typical epidemics of vivax malaria at King’s Lynn in the late eighteenth century.
if a very wet winter and spring are succeeded by a very hot and dry summer, in which the ditches and marshes are nearly dried up, it is generally epidemical, and spreads widely around us. It most commonly appears about the middle of August, and lasts till the ditches are filled with water, the marshes somewhat covered, which, with a frost, usually puts a period to its raging in that form, for that season; for it now generally changes to the type of a genuine intermittent. This is it’s [ sic]common mode of termination, as the winter advances; but when it rages with extensive violence, during the autumnal months, it puts on a variety of morbid degeneracies, many of which, by persons unaccustomed to its Proteus-like changes of type, would be taken for a very different disease.¹¹²
Hamilton’s description illustrates in a historical context the very important conclusion reached in Chapter 2 above about the importance of quotidian fevers. It was only in the final stages of the annual epidemic that the tertian periodicity manifested itself. Until then the fevers of vivax malaria generally took a quotidian form.
Similarly Sydenham stated that epidemical agues in the autumn were at first accompanied by a continual fever.¹¹³ Hamilton emphasized the association of P. vivax malaria with marshes which tended to dry up during the summer, an association also found in Italy. He observed that what he called the ‘marsh remittent fever’
of England was the same disease as the tertian fever of Minorca.
Hamilton also noted that during the epidemic of 1783, a very hot year, many agricultural labourers were attacked during the harvest. In addition, he made interesting observations about the possibility of contagion at a time when the miasmatic theory of ‘bad air’
still prevailed. He commented that the marsh fever was observed to spread through large families, starting with one or two cases, mosquito activity is low, at levels undetectable by microscopic examination of blood smears, not only in the case of P. vivax but also in the case of P. falciparum, even in geographical regions with low levels of transmission of malaria (traditionally thought to be an impediment to the development of acquired immunity). P. falciparum malaria now seems to be in many cases a more chronic disease than generally used to be thought, cf. Garnham (1966: 413).
¹¹² Hamilton (1801: 27–8).
¹¹³ Meynell (1991: 124).
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‘which looked very much like the effects of contagion’. The use of ‘Peruvian bark’ (cinchona) as a treatment was also discussed.
This probably played a major role in the decline of vivax malaria in England.¹¹⁴
The last major epidemic of malaria in England occurred in 1857-9, during two very hot summers, but three-quarters of the population of the Isle of Grain in Kent suffered from malaria in 1876.
Cases of malaria occurred as recently as 1921 in that locality, following the reintroduction of P. vivax by soldiers returning from the campaign in the Balkans in 1916. The possibility of the reintroduction of malaria to the Isle of Grain was a matter of concern to the local public-health authorities in Kent as recently as 1952–4.¹¹⁵
Malaria could have been transmitted in England by Anopheles atroparvus and A. plumbeus.¹¹⁶ P. vivax malaria is generally regarded in modern medical literature as a considerably milder disease than P.
falciparum. It seldom kills well-nourished, otherwise healthy people by itself. The Hippocratic Epidemics noted that tertian fever was not dangerous (see Ch. 2 above). More recent historical evidence from Italy supports this view. For example, Cipolla described the reaction of Alessandra Macinghi Strozzi, who in 1459, upon learning that her son in exile at Naples had tertian fever, ‘took comfort because you do not die of tertian fever, unless other illnesses intervene’. The last four words are crucial, because her son did die after all.¹¹⁷ The evidence from the English parish studies suggests that in historical contexts where it could operate in synergy with other infectious diseases, and where its targets probably suffered from malnutrition, P. vivax malaria produced extraordinary changes in the mortality regimes of human populations.¹¹⁸ Sydenham observed the association in infants of rickets and ‘coughs and other symptoms of being in a consumption’ alongside autumnal ¹¹⁴ Hamilton (1801, 39, 43, 73ff.).
¹¹⁵ Dobson (1997: 320–7, 349); Smith (1956).
¹¹⁶ Snow (1990) described the mosquitoes of England. Shute (1951) described the laboratory culture of A. atroparvus. He noted that to breed it one only needs some grass with some soil attached to the roots in a basin of rainwater about two feet in diameter.
¹¹⁷ Cipolla (1992: 69); Garnham (1966: 139) stated that he had observed fatal cases of P. vivax malaria in young children.
¹¹⁸ Modebe and Jain (1999) described a recent case of severe complications caused by P. vivax malaria. Dobson (1989: 269) concluded that vivax malaria had less effect on colonists in the United States than it did in England because of a relative shortage of other diseases in North America, even though P. vivax malaria was probably imported from England (Kukla (1986) ).
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intermittent fevers, although he noted that ague was more dangerous to the elderly than to infants.¹¹⁹ There is no doubt that P. vivax was indeed responsible for the demographic patterns found in the English marshlands, because the parasites were found in the blood of the last few people to have indigenous English malaria, in the early years of the twentieth century. In addition, quinine, which would not have substantially helped sufferers from other diseases, relieved the symptoms.
Important research by Mary Dobson discovered that before the nineteenth century crude death rates were as low as 20–30 per 1,000 in many rural parishes of south-east England, but in the marshy areas of Kent and Essex crude death rates were over 50–60
per 1,000, sometimes as high as 80 per 1,000. It is very important to appreciate that the excess mortality produced by malaria is not a marginal phenomenon. The differences in overall morta
lity levels between the parishes most severely afflicted by P. vivax malaria and the healthiest parishes in the same area were quite literally of the order of 300–400%. Similarly, comparing fifteen marsh and fifteen non-marsh parishes between 1551 and 1837 in the same parts of England, Dobson found that crude burial rates in the marsh parishes exceeded 100 per 1,000 in about 11% of the years, while such high burial rates were only attained in non-marsh parishes about once every two centuries on average. These staggeringly high mortality rates occurred in the malarial districts at a time when the population of the rest of England was increasing and was quite healthy.
Life expectancy at birth was slashed in the malarial regions.
Dobson reported that in three North Shore malarial parishes in north Kent it was 33 years, compared to no less than 58 years in four parishes in the East Downs where P. vivax was not endemic, in the early nineteenth century.¹²⁰ The difference between the life ¹¹⁹ Meynell (1991: 122, 135).
¹²⁰ Dobson (1997) is fundamental on malaria in England, esp. pp. 133–49 and 172 on local variations in death rates. Many of the results of her long book are summarized in her (1980) and (1994) articles. See also Reiter (2000). One might also compare the situation around Valencia in Spain in the eighteenth century (Palmero (1994) ). Palmero and Vega (1988,: 351) translated and quoted the following comments of Francisco Llansol, written in 1797: ‘the dwellers of the Upper Riverside in certain towns like, for example, Cárcer Valley, Castellón, Alberique and so on, are likely to have poor health. They are pale yellow-skinned, there are many women with swollen bodies, and people living in these areas, in general, are likely to have a short life . . . when people die, they are mostly between forty and fifty years of age’.
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