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Home , Danse Macabre, Danse Macabre (book), Medieval dance

Public Health Then and Now

Social Inequality and as Illustrated in Late-Medieval Death

...... Johatn P. Mack-enbach. MD, PhD Introduction . Switzerland, but not published until 1538 in Lyons, , as a result of The fattest will be putrifiedfirst. the troubles of the Reformation. Hol- Guyot Marchant bein's sequence of still reflected Danse (1485) the social hierarchy of his time: however, During the late , the because he focused more than Marchant " of death" or "danse macabre" was on individual representations his wood- cuts no longer showed a procession of the a favorite theme in Western and Middle living and dead. Therefore, his dance of literature and painting. Origi- European death was no longer medieval in character nally, this may have been a real dance or but anticipated the . Figure 2 procession. but around 1400 developed shows reproductions of some of Holbein's into a literary and pictorial art form, woodcuts.5S usually consisting of a scries of poems The historian Huizinga,2 in his book illustrated by a procession of the living The Watinzg of the Middle Ages, situated and dead. The living were portrayed the theme of the dance of death against according to their social standing and the background of the fierce emotions were accompanied by a corpse or skel- that death generated in times of war and eton. The two most frequent types of pestilence. He wrote: "While it rcminded death dance were those depicted in mural the spectators of the frailty and the vanity paintings (on the walls of a church or of earthly things, the death-dance at the cemetery, with texts underneath) and same time preached social equality as the those published as books illustrated with Middle Ages understood it, Death level- woodcuts. I-' ling the various ranks and professions.' One of the most famous examples is In order to convey this message. the dance the book published in 1485 by the Parisian of death gave an account of social inequal- printer Guyot Marchant; this book repro- ity during life and used the apparent duced one of the first mural paintings of equality of all men before death as a the dance of death, the now lost Danise reminder that a high social rank does not MVacabre of the Saints Innocents cemetery protect against death and may even make in Paris. Table 1 shows the social order in it more difficult for the soul of the this dance of death. Beginning with the deceased to reach heaven. apparently highest social position of the The dance of death was a member of time (i.e.. the ), we descend the a larger family of death themes that also social hierarchy, alternating between reli- included macabre representations on fu- gious and secular "occupations." Well neral monuments, huge scenes of the below the middle level we pass , artes morionedi (manuals physician, and finally we arrive at the verv on how to die properly), and so forth.1(' bottom of the social ladder. represented The popularity of these death themes may bv Franciscan monk. infant, clerk, and hermit. Figure 1 reproduces some of the The author is with the Department of Public woodcuts from this immensely popular Health. Erasmus University. Rotterdam. the of Netherlands. dance death.- Requests for reprints should be sent to This gcnre of book editions reached Johan P. Mackenbach, MD. PhD. Department its artistic apogec in Hans Holbein's of Public Health. Erasmus University. PO Box dance of death, completed in 1525 in 1738. 3000 DR Rotterdam. the Netherlands.

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there would be a collective "last judg- In this paper, I describe the way in TABLE 1 -The Order of Social ment" at the end of history, it was now which the relationship between social Positions in Guyot believed that every individual would be inequality and death was portrayed in Marchant's Danse judged immediately after death.10 In this late-medieval dances of death (i.e., dances of 1485 Macabre new spiritual climate, a good preparation of death painted or published before by the individual for his or her own death 1550). First, I summarize the various No. Social Position became increasingly important. representations of the social hierarchy in Author The dance of death can be seen as an these dances of death. Second, I analyze 1. Pope illustrated sermon that summons the the way in which social inequality was 2. Emperor to do penance for their sins before justified or criticized in the dances. Fi- 3. Cardinal suffering an untimely death (and, in those nally, I discuss whether, indeed, all men 4. King 5. Patriarcha times, many must have been were equal before death in the late 6. Constable untimely!). It was believed by the late- Middle Ages. 7. Archbishop medieval church that an unprepared 8. Knight of being 9. Bishop death greatly increased the risk 10. Squire sent to hell, and so the preaching friars, Social Stratifcation according 11. Abbot such as the Dominicans and Franciscans, to the Late-Medieval Dance 12. Bailiff urged believers to contemplate their sins 13. Man of learningb ofDeath 14. Bourgeois and better their lives before it was too 15. Canon late. The first death dance poem was The representation of various social 16. Merchant probably written in a Dominican monas- positions occupied a central place in the 17. Carthusian sometime in the 14th century, and dances of death. They can be used to 18. Sergeant tery 19. Monk this Latin version was then translated into study social stratification in the late 20. Usurer/poor man German, French, and other languages for Middle Ages or at least to obtain some 21. Physician preaching purposes.4 Throughout its his- insight into the way social stratification 22. Lover was perceived by the commissioners or 23. Parish priest tory, the dance of death remained loosely 24. Laborerc associated with the preaching orders, and executers of these works of art. As 25. Advocate several were actually executed in Domini- previously stated, the commissioners were 26. Minstrel can or Franciscan monasteries. Further- mostly clergymen, often from the Domini- 27. Franciscan more, many of death contained a can and Franciscan orders. Although 28. Infant dances 29. Clerkd representation of a preacher at the start these orders had a critical attitude toward 30. Hermit and/or end ofthe procession. Although in the church establishment, it was certainly Dead king many cases we do not know exactly the in their interest to propagate the church's Master commissioners of these works of art, this conceptions of the organization of soci- link with the preaching orders does give us ety.15 Note. In the second edition, the following were added: Legate (5), Duke (6), some information on their backgrounds This probably explains why the dances Schoolmaster with pupil (19), Man-at- and intentions. of death often retained the scheme of the arms (20), Promotor (prosecutor in eccle- The call to people to contemplate three orders of the feudal society, which siastical court) (31), Gaoler (32), Pilgrim, (33), Shepherd (34), Halberdier (39), their sins and better their lives was was already outdated in the 14th century. and Fool (40). directed at those of all ranks, not only The three orders were the clergy, the Source. Compiled from Kaiser.7 men were but also nobility, and the "third estate," which aOf Constantinople. because all mortal bSometimes interpreted as "astrologer." because, according to the belief of the originally contained only farmers but cFarm laborer. time, higher demands would be made also accommodated the new urban dYoung clergyman. upon higher placed persons when they classes.16'17 Attention has already been were to be judged.714 This line of reason- drawn to Guyot Marchant's alternation of ing can be illustrated with some citations religious and secular personalities (Table from Guyot Marchant. His introduction 1), and although many dances of death partly be related to the ravages of the reads: breached this rigid scheme to some extent great plague epidemics, the first of which (e.g., by including an empress after the see the placed You [the reader] higher emperor), it can surely be referred to as occurred in 1348 and then recurred at persons start [the dance] irregular intervals throughout the 14th for there is nobody who will escape the "classical" version of the representa- and 15th centuries. The death. tion of the social hierarchy in the late- certainly left its mark, not only in the It is sad to think of this: medieval dance of death. The main All is made of one substance [the mortal major art forms of the period1' but also in alternative, which occurred much less flesh]. reli- other aspects of culture such as testa- frequently, was a scheme in which ments, bequests, and other "strategies for And the verse that recounts the answer of gious and secular characters were sepa- the after-life."''213 According to Philippe the patriarch of Constantinople to his rated and represented in two rows.15 Aries, historian of Western attitudes dead companion is as follows: Table 2 gives an overview of the main also late-medieval dances of death and of the toward death, these changes were wise. To rise too highly is not way the social hierarchy was represented. related to a process of individualization of A high estate spoils innumerable people important examples are from France the experience of death. Contrary to but only a few want to acknowledge this. Many and its southern earlier periods, when it was believed that To rise highly makes them succumb.7 and from

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Source. Reproduced with permission from Kaiser.7

FIGURE 1 -A selection of Guyot Marchant's woodcuts: patriarch (5) and constable (6), abbot (11) and bailiff (12).

neighbors, especially Switzerland. The addition of non-Christian ("pagan") char- Other dances of death simply in- most important British example is a mural acters. serted some female characters (e.g., em- painting since lost in a cloister next to St. Guyot Marchant's Danse Macabre of press, abbess, nun, mother) into the Paul's Cathedral in London. A dance of 1485, which was based on the Saints original, male-only order. Notably, this death was painted on the walls of this Innocents wall painting of 1424/25, con- occurred much less frequently in French cloister that closely followed the Danse tained only men. This was clearly unsatis- dances of death than in those from Macabre of the Saints Innocents cemetery factory to many of his potential custom- Germany and other Middle European in Paris. The paintings were destroyed in ers, because a year later a second edition countries (Table 2). 1549, but the poems (translated from the appeared that not only contained an One of the most interesting aspects French by John Lydgate) were preserved. expanded version of the original Danse of the representation of society in dances Lydgate added five characters to the Macabre des hommes but also included a of death concerns the way in which all French original (i.e., lady of great estate, Danse Macabre desfemmes.7 The order in kinds of new occupations were taken into abbess, amorous gentlewoman, juror, and which the women in this dance of death account. In the 14th and 15th centuries, fool). Several manuscripts containing this were represented is given in Table 3. The the archaic scheme of the three orders English "daunce of machabray" have main characteristics of the representation was cracking and slowly falling to pieces.'6 been preserved, some of which incorpo- of the social positions of women are The "third estate" had been growing in rated even further additions to the origi- surprisingly familiar to modem readers. importance for quite some time, but we nal list of characters."-2 Only a limited number of positions (such find only a faint reflection of this in the Table 2 shows that the classical as the abbess, vender, theologian, lady's late-medieval dances of death. The num- version of the representation of social maid, midwife) were defined in terms of ber of overt representatives of the clergy hierarchy was indeed the most frequent. the woman's occupation. Most social and nobility (including military occupa- However, sometimes variations were positions of women were derived either tions derived from the nobility) was brought into this basic order, shedding an from their husband's occupation (e.g., out of proportion to their social promi- interesting light on the perceptions of the wife of the knight, wife of the squire, and, nence. As an example, we may again refer structure of local societies. The main to some extent, queen and duchess) or to Guyot Marchant's Danse Macabre, variations are indicated in Table 2: the from their female social roles in the family which included only a very limited num- insertion of female characters, the inser- and the community at large (widow, ber of representatives of commerce and tion of a number of occupations originat- newlywed, pregnant woman, old lady, trade (bourgeois, merchant, usurer; see ing in the towns of the period, and the witch). Table 1).

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other non-Christian characters. Most dances of death did not include persons who stood outside the mainstream of Christian society. Nevertheless, the mes- sage was also thought to apply to them, and, as a consequence, some of the social orders ended with non-Christian charac- ters such as Jews, Turks, and "heathens" as a general category. The texts concern- ing the Jews frequently had a distinctly anti-Semitic flavor, referring to stereo- types of the Jews' guilt over the death of Christ and of usury and cunning tricks. It is important to note here that plague Quitccuydesimmortel eftrc epidemics not only gave rise to many Par Mortfcrastoftdcpefche4 Tucongnoys bienla maladie dances of death but also led to pogroms, Etcombien que tufoysgrand prcbfire, Pour le panent fecourir, as it was sometimes believed that the VngaultreauratonEudchi. EBc (ine fcais efte eftotirjie, cause of plague was poison spread by the cIR Lemaldont tu deburas mourirn Jews.18 The Spanish dance of death F included not only a rabbi but some Moorish personalities. The non-Christian r I personalities were almost always placed near the end of the row.

Were Death Dances about Social Justice? Superficially, the link between the desire for greater social equality, as manifested during the , and the message of the death dances seems obvious. Many dances of death contained very severejudgments on higher placed persons, and inevitably readers or Peuples foubdain fefleueront Ala fueurde tontdraige spectators were reminded of the rebel- ta tle, lious movements of the time, such as the A lencontre de lsinhumain, Tugaigneras pauure German peasants' revolt of 1524/25.19 For Et lc uioicnt ofteront Apreslongtrauail& ufaige, example, Holbein's image, cut during this DYaucc cuixfansforcedemain. Voicyla iMort qui'te conuic. revolt, of a knight being killed by a rather G i4 ferocious impersonation of death must at Source. Reproduced from Holbein.' least have reminded the reader of these events and may have even been intended to do so (Figure 2).8 Also, many death FIGURE 2-A selection of Hans Holbein's woodcuts: pope (1), physician (26), dances had a peasant or land laborer at knight (31), and peasant (38). the rear of the row, and these characters were usually judged much less negatively than the other personalities. There may even have been some compassion, which Middle of death, in Although an older example was used, a was often conspicuously lacking in the general, included a higher proportion of number of new characters were repre- portrayal of other characters. For ex- these urban occupations (Table 2). The sented, such as herald, sheriff, guardian, ample, Holbein, together with many other dance ofdeath ofthe Dominicans' monas- and cook. As a result of these insertions, authors of death dances, presented death tery in Basel, also called the Grossbaseler the Grossbaseler dance of death appears to the peasant as a redemption from all (in contrast to the Kleinbaseler much more modem overall than the more earthly laboring (Figure 2). Totentanz in the Klingenthal monastery in archaic types such as Guyot Marchant's. Some of the texts seem to be quite Klein-Basle), may serve as an example. It This work was destroyed in 1805, but explicit in their social critique. Guyot was painted to commemorate the plague reproductions were published by Merian Marchant's Danse Macabre was relatively epidemic of 1439, which killed 5000 in 1621. Figure 3 contains some of these mild, but some of the German and Swiss more people, including a number of highly reproductions.7 death dances were considerably placed clergymen who happened to be in The Grossbaseler dance of death was severe with regard to their characters. Der the town for a major church council. also the first to include a Jew and several The Knoblochtzer Druck (also called

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TABLE 2-Overview of the Main Late-Medieval Dances of Death and Their TABLE 3-The Order of Social Representations of the Social Hierarchy Positions in Guyot Marchant's Danse Representation of Macabre des femmes Social Hierarchy of 1486 No. of No. Social Position Country/Locality Yeara Preserved Positions Orderb 1. Queen France 2. Duchess Mural paintings and sculpturesc 3. Governess La Chaise-Dieu ca. 1415? Yes 23 Cw 4. Wife of the knight Paris (Saints Innocents) 1424/25 No 30 C 5. Abbess Kermaria ca. 1430? Yes 25 Cw 6. Wife of the squire Meslay-le-Grenet ca. 1490 Yes 19 C 7. Prioress La Ferte-Loupiere ca. 1500 Yes 19 C 8. Noble lady Kientzheim ca. 1517 No 25 Cw 9. Bourgeoise Rouend 1526 Yes 11 S 10. Widow Manuscripts and books 11. Vender (female) Paris (Marchant) 1485 Yes 30 C 12. Bailiff (female) Paris (Verard) ca. 1485 Yes 30 C 13. Spouse Britain 14. Foster mother Mural paintings and sculpturesc 15. Virgin London (St. Paul) ca. 1430 No 35 Cw 16. Theologian (female) 17. Newlywed woman Germany 18. Pregnant woman Mural paintings and sculpturesc 19. Chambermaid Ulm 1440 No 24 Cw 20. Supplicant (female) Lubeck (Marienkirche) 1466 No 23 Cwu 21. Old lady Berlin ca. 1485 Yes 28 S Sw 22. Franciscan nun Dresdend 1534/37 Yes 23 23. Host (female) Manuscripts and books 24. Novice (female) Codex palatinus ca. 1350? Yes 24 Cw Cw 25. Shepherdess Heidelberger Blockbuch ca. 1465 Yes 25 Woman at the gallows ca. Yes 35 Mwu 26. Handschrift Kassel 1470 27. Knoblochtzer Druck ca. 1485 Yes 38 Mwu Village woman Lubecker Druck 1496 Yes 28 Cwu 28. Old woman Handschrift Zimmern ca. 1520 Yes 38 Swu 29. Trafficker (female) 30. Woman in love Switzerland 31. Midwife Mural paintings and sculpturesc 32. Girl Basle (Dominican's monastery) ca. 1445 No 38 Cwup 33. Nun Basle (Klingenthal) ca. 1475 No 39 Cwu 34. Witch 1516/20 No 41 Mwup Manuscripts and books Source. Compiled from Kaiser.7 Basle (Holbein) 1525 Yes 34 Cwu Austria Mural paintings and sculpturesc Metnitz ca. 1500 Yes 25 Cw Former Yugoslavia (i.e., the love of money). In the introduc- Mural paintings and sculpturesc tion, a dead king speaks the following Beram 1474 Yes 10 Sw words to the reader: Hrastovlje 1490 Yes 11 Cw Let all men think of me Mural paintings and sculpturesc and beware of the temptations of the Carisolo 1519 Yes 17 Sw world. Pinzolo 1539 Yes 18 Sw I was rich and held in high esteem. Gold and silver I could spend, but now I am in the power of worms. Manuscripts and books Danza general de la muerte ca. 1400? Yes 33 Cp The cardinal, after having been criticized by his dead companion, admits: aAccording to Hammerstein.5 I have stuffed myself greedily various orders have been characterized as follows: C = classical order (as with Guyot bThe of this Marchant), sometimes with small variations; S = religious and secular personalities separated; with the goods world, a M = original order mixed up; w = women inserted; u = typically urban professions or social like robber does. positions inserted; p = pagan characters added. cMural paintings unless otherwise indicated. The abbot: dSculptures. I would like to have been a poor monk for all my days.... There will be complaints from the priests Doten Dantz mit Figuren [the death dance with poems consisting of eight lines each]) that I have taken so many gifts, with figures] or Oberdeutscher achtzeiliger is a good example. The emphasis here, as and that I have suppressed the poor Dotentanz [an Upper German death dance so often, was on one particular type of sin with force.

September 1995, Vol. 85, No. 9 American Journal of Public Health 1289 Public Health Then and Now

to pay, sell, loan and bail, but you care only little for your soul. 41* fl*.ew*4110.m. l 0 ".-.w y-W 3neAUd And this death dance ends in the vigorous r. ick re lf r, ito Us4i bcns1uio image of a charnel house: ,^,9Z6twf 4rn3wAit* w.s§*Vu Here lie the bones, large and small. - V - Whether man or woman, knight or E 37-Sp servant, t everybody has the right to lie here. The poor with the rich, the servant with t the gentleman.... Those who are noble and powerful, rich or beautiful, t do not raise yourself above the others.7 4. L I. ..: The Grossbaseler dance of death did g t not even have compassion for the lame beggar (Figure 3). It portrays him as a ti-c -I L leper: he has lost one of his feet, and he t ze'utab has to twist his left arm strangely around A Lrnw . +s, his stick because of his deformed hand. at his beggar's bag T4*"0.:: 1i- The small flask hanging it. f is also a frequent attribute, and it may contain the ointment given to lepers during the last mass, before they were expelled as living dead, or simply his drinking supply (lepers had to carry their own).20 Despite his tragic fate, death says to him: Hop this way with your crutch, death wants to pull you down now. You are worth nothing to the world, come and join my dance too. The beggar answers with the following bitter words: A poor cripple here on earth, as a friend he is not wanted. Death, however, wants to be his friend, he takes him away together with the rich.7 It appears as if the desire for social equality had been subtly transformed into something much closer to the transcenden- tal message of the church. In these dances of death, there were clear reminiscences Source.v Rproce -wherm-is-s-v -f-ro Kaisr.7 of a desire for social equality, but the friars had cleverly integrated Source. Reproduced with permission from Kaiser.7 preaching this desire into the official teachings ofthe church, thereby neutralizing the revolu- FIGURE 3-A selection of Merian's reproductions of the Grossbaseler dance of tionary potential. As so perceptively noted death: empress (3), beggar (21), sheriff (28), and Jew (33). by Kaiser, this form of equality had nothing of a promise to the poor but only threatened the rich.7'2' It was a downward of all that was propagated, and tion to do penance and save one's soul, leveling And, as a final example, the dead compan- because the reward for earthly poverty to him: individual salvation ion of the "official" says thereby emphasizing was admission to heaven, there even was But also it is If you had administered justice to the instead of earthly justice. an element of justification of poverty and poor as you did to the rich, quite clear that no one, perhaps with the social inequality in these dances of death. you would have gone to this dance exception of humble people such as cheerfully.7 peasants or land laborers, escaped these Nevertheless, when reading the texts harsh reproaches. The same Knoblochtzer Were Al Persons Equal before carefully from beginning to end, it be- Druck let the dead companion say to the Death in the Late MiddleAges? comes clear that a desire for greater social artisan: justice cannot have been the main back- The conjunction of social (in)equal- You have the habit of staying awake late dances of ground of death dances. First, all the at night ity and death, as viewed in these reproaches were followed by an exhorta- to make clothes, fur coats and shoes, death, raises the issue ofwhether the risks

1290 American Journal of Public Health September 1995, Vol. 85, No. 9 Public Health Then and Now of dying were indeed equally distributed years and that the life expectancy of the diseases was very limited and inaccurate, throughout the population during these highest occupational class was 36 years.28 so even the rich or mighty must have had times. Of course, the equality of all before Data for other European cities from the difficulty escaping the death risks of death was primarily understood in an 18th century confirm this picture of huge epidemic diseases. Nevertheless, the bet- existential sense, but there was also an differences in mortality rates between ter nutritional status of the rich may have implicit assumption of equality in a more persons with higher and lower social provided some protection. literal sense. Ifthe high clergy and nobility ranks.29 It is less clear whether the same In addition, anecdotal evidence sug- clearly had a higher life expectancy than differences were found in rural areas gests that mortality from the plague was ordinary persons, the whole idea behind because the evidence is much less consis- higher in the lower social classes. This the dance of death would have been less tent.30 disease is especially relevant because the self-evident. It sometimes even appears as It is not certain whether socioeco- popularity of death dances in the 15th if the authors of death dances assumed nomic inequalities in mortality also ex- century has frequently been ascribed to the ravages of the plague epidemics, that higher placed persons had higher isted before the 17th or 18th century. Some believe that these inequalities which appeared to kill rich and poor risks of dying prematurely than ordinary indiscriminately.'8 Reports of health com- people. In Guyot Marchant's Danse Maca- emerged only when the large epidemics started to recede and when the first missions in plague-ridden towns fre- bre, the dead person who summons the quently mentioned that there were large abbot says: improvements in nutrition, housing, and individual and public hygiene began to differences in mortality between rich and You will putrify in a little while. have an impact.31'32 This impression is poor.36 There were probably a number of The fattest will be putrified first.7 based in part on a study of the mortality reasons for these differences. For ex- Currently, the existence of socioeco- experience of the British peerage that ample, the poor had worse housing nomic inequalities in mortality is widely suggests that the life expectancy of this conditions (e.g., crowded houses where acknowledged among public health profes- upper-class group was no different from rats and fleas were common) and fewer sionals, and these inequalities are re- that of the general population until it possibilities for observing hygienic prac- garded by many as a core issue that serves began to diverge after the middle of the tices (e.g., washing and replacing clothes). as a powerful illustration of the impact of 18th century.33'M Attempts by communities to control the social and economic conditions on health. It is nevertheless difficult to believe spread of the plague by isolating (in pest Paradoxically, whereas the obesity of the that higher placed persons did indeed houses) those people who were believed abbot was a sign of his high living have the same survival chances as the to have spread the disease (e.g., the poor, standards, nowadays obesity is more fre- majority of the population in the 14th and wanderers and beggars) probably also quent among the lower social classes and 15th centuries. This was a period charac- tended to increase the death toll among is one of the many factors contributing to terized by frequent mortality crises. There the poor.37 In addition, the very rich had their higher risks of mortality.22'23 were dramatic short-run fluctuations dur- the opportunity to escape from plague- The awareness of socioeconomic in- ing which mortality rose to levels 2 or 3 ridden towns by going to their country equalities in health dates back to the 19th times higher than in "normal" years when houses, thereby undoubtedly reducing century, when great figures in public calculated over wide areas and to levels 10 their risks of infection. Boccaccio used health like Villerme, Chadwick, and Vir- or more times higher when calculated this as a motive in his Decameron: a group chow devoted a large part of their over more restricted areas. These mortal- of young men and women from the upper scientific and practical work to this is- ity crises arose from three frequently classes fled from Florence during the first sue.24-26 This was made possible by the interlinked causes: war, pestilence, and great plague epidemic of 1348 and went to availability of national population statis- . War was a cause of epidemics, as a country estate to kill time with erotic tics, which permitted the calculation of, a result of the circulation of soldiers, and stories.38 for example, mortality rates by occupation also of famine, as a result of pillage and or by city district. the destruction of harvests. Famine, in FinalRemarks The only reliable source of mortality turn, caused epidemics.27 Of the three data in the general population that existed causes, famine, or more generally under- In this paper, I have described the before national population registers were nutrition, provides the most obvious link way in which the relationship between implemented (i.e., generally before the with socioeconomic conditions. This is social inequality and death was portrayed 19th century) was the parish register of clear from the association between mortal- in late-medieval dances of death. Three baptisms and burials. The time at which ity crises and food prices at the aggregate different themes have been discussed: the church registers were first kept varied level,35 but must also have been true at the representation of the social hierarchy, from country to country and from region individual level. The rich certainly had a justification and criticism ofsocial inequal- to region, but most of the earliest parish lower risk of dying from undernutrition ity, and the empirical evidence ofsocioeco- registers date back to the 16th century.27 than the majority of citizens, who were nomic inequalities in mortality at the end Only a very limited number of analyses of probably malnourished even in "normal" of the Middle Ages. socioeconomic inequalities in mortality years. For each of these three themes, even have been made on the basis of data from Whether the risks of dying from the a superficial comparison with the present- these registers. One of the best and most effects of war and epidemics were also day situation reveals the important widely known is a study of socioeconomic unevenly distributed throughout the popu- changes that have taken place during the inequalities in mortality in 17th-century lation is less clear. Perhaps those of 500 years that have passed. Social stratifi- Geneva, in which it was shown that the nobility status were more likely to be cation in present-day Western societies is life expectancy at birth of children born in killed in combat. Furthermore, knowl- primarily based on economic distinctions the lowest occupational class was only 18 edge regarding the spread of infectious such as those between occupational

September 1995, Vol. 85, No. 9 American Journal of Public Health 1291 Public Health Then and Now classes. The clergy and nobility have been those who are socioeconomically disadvan- 18. Bulst N. Der schwarze Tod; demogra- submerged, and it is the "third order" that taged provide one of the strongest pos- phische, wirtschafts- und kulturgeschichtli- arguments in favor of egalitarian che Aspekte der Pestkatastrophe von 1347- has formed the basis for the now domi- sible 1352; Bilanz der neueren Forschung. nant occupational classes. It is likely that values. Remarkably, the "visibility" of Saeculum. 1979;30:45-67. the extent of social inequality has been social inequality provided by this link with 19. Werner J. Im Sterben gleich; die revolu- reduced over time, but such inequality is mortality has never produced powerful tionare Melodie des mittelalterlichen To- images; rather, it has produced only dull tentanzes. DasMunster. 1975;28:189-190. still perceived by many as being unjust. 20. Ackerknecht EH.A History and Geography The solace that the medieval critic of bar diagrams. Perhaps, with some creativ- of the Most Important Diseases. New York, social inequality perhaps found in the ity, this link could be used more to NY: Hafner; 1965. of all before death is no emphasize an important moral message of 21. Kaiser G. Das ; ein Beitrag apparent equality zum sozialgeschichtlichen Verstandnis der longer acceptable to us. For the deeply our time: Would it not be agreed by many who have less Gleichheitsforderung im fruhen Mittelal- Christian medieval mind, death was not that societies in which those ter. Euphorion. 1974;68:337-370. only the end of life but the start of the of everything also die earlier are truly 22. Townsend P, Davidson N, Whitehead M. , and the bitter inequalities during sick? O Inequalities in Health (the Black Report and the Health Divide). Harmondsworth, En- life on earth could, to some extent, be gland: Penguin; 1988. traded off against the equality of life in Acknowledgments 23. Rose G, Marmot MG. Social class and heaven. For the secular 20th-century I thank Professor H. H. W. Hogerzeil, Mrs coronary heart disease. BrHeartJ. 1981;45: mind, it is now or never, and it is the M. E. Noordendorp- 13-19. J. M. van der Kleij, Mrs 24. Coleman W. Death is a Social Disease; awareness that this is the only life we will Poesse, and Dr E. Schuster for their invaluable Public Health and Political Economy in ever have that makes substantial inequal- help in bringing together the documentation on Early Industrial France. Madison, Wis: ity in the length of life so deeply disturb- which this article is based. University ofWisconsin Press; 1982. ing. Finally, we can state more confidently 25. Chave SPW. The origins and development than our medieval forebears that such References of public health. In: Holland WW, Detels 1. Kurtz LP. 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