Historians often demure when asked what concrete lessons can be drawn from the past. Meanwhile, purported irrelevance threatens the place of the humanities in higher education. That crisis of confidence, made more urgent by the COVID-19 pandemic, calls for a renewed engagement with practical questions and public audiences. What lessons can be drawn from the interrelated histories of disease, environment, and medicine? This roundtable invites four scholars of Middle East history to reflect on a series of questions to illuminate the current moment–in the region and beyond–with their research.
How does your research illuminate the current moment? To what extent can we draw lessons from studying the history of humanity’s interaction with disease?
Joelle Abi-Rached: My research broadly rests on three ideas: (i) that the way in which societies deal with disease illuminates underlying assumptions and hidden tensions, (ii) that current understandings of diseases and health are products of specific social, political, cultural, indeed, ethical and economic contexts, and (iii) finally that disease is a major force in historical change. In my forthcoming book ‘Asfuriyyeh: A History of Madness, Modernity and War in the Middle East (MIT Press), I use mental illness and concepts of normality and abnormality as a lens into illuminating questions related to social and public health policy, collective, and individual behaviors, knowledge production, mutations in discourses and practices as well as the process of institution-building and its resilience over time.
The COVID-19 pandemic perfectly illustrates the impact of context on behavior (individual and national). Sweden, for instance, has relied on its citizens’ sense of social responsibility instead of imposing draconian lockdowns as most countries have done in an attempt to contain the spread of the coronavirus. Some countries have seized on the occasion to reinforce authoritarianism, consolidate power, and reinforce surveillance while others have embraced tracking technologies to manage more efficiently the epidemic. Many countries in the Middle East are in the midst of a revolutionary moment (Lebanon, Iraq, and Algeria), the COVID-19 crisis might either stifle these social forces or enable new social contracts to be forged.
Interestingly, epidemics (typhus, cholera, or the plague) were so common in the nineteenth century that some of the descriptions of insanity and mental illness during that period were in reference to contagious diseases. The intelligentsia of the Nahda even spoke of the “germs of insanity” in what it believed was a new epidemic of insanity, suicide, and mental illness that were the products of the civilizational forces that marked the fin de siècle. What is clear is that historically, epidemics have had such dramatic consequences as to become a metaphor for social and political disorder.
A. Tylor Brand: My forthcoming book, Famine Worlds, explores how we as individuals and societies understand and respond to the presence of crisis in our daily lives, using the Syrian famine of World War I as my case study. Certainly, the patterns that we discern in the past can serve as useful analogies as we try to make sense of our current predicament, but it pays to be cautious about how we interpret those similarities. History does not repeat, and sometimes its rhymes are just misleading homonyms.
If we examine the COVID-19 pandemic and the famine of WWI together, this difficulty is apparent. Superficially, the crises shared quite a few features. Both featured an economic crash and widespread unemployment. Both saw scarcity and profiteering. Mortality rates rose and people began to use physical distancing to avoid a deadly disease. But the famine and the pandemic were utterly discrete events and the aforementioned problems arose from complex causes in unique historical contexts. For the historian, the difficulty lies in determining which similarities are trivial and which are not. While economic and medical comparisons may be tenuous, measures of the humane experience may be strikingly relevant. Certain accounts of the boredom, fear, and uncertainty that famine witnesses experienced could have been written yesterday. But when we seek historical parallels, we must do so in good faith, rather than using an example simply because it appears analogous.
Christopher Rose: My monograph in progress discusses the linkage between wartime food policies, hunger, and disease in Egypt during the First World War. An article about the “Spanish” influenza in Egypt will be out next spring in the Journal of World History—ironically, I spun it off into an article because it did not quite fit the trajectory of the book, and now that the topic has become quite popular with the COVID-19 outbreak I have become the “Spanish flu in Egypt guy.”
My particular interest is in the socio-political impact of disease, rather than the epidemiological or virological. Major crises—like the influenza of 1918-1920 or COVID-19—provide study-able moments of social abnormality. They expose social fault lines and exacerbate layers of social difference in ways that lay them bare—in short, the things that people normally put up with, or “grin and bear” become intolerable, and we can use these moments to explore them. This both gives us a glimpse into “normal” life for people who may not have left records of their own—as ninety percent of the Egyptian population during WWI were illiterate—and also into the ways that disease can have broader social and political repercussions.
Seçil Yılmaz: My manuscript in progress, tentatively titled Love in the Time of Syphilis: Medicine, Sex, and Morality in the Ottoman Empire, 1860-1922, analyzes the emergence of syphilis as public and health concern in the late Ottoman and early Republican period. The manuscript traces the impact of syphilis on the varieties of production of medical knowledge and practices, everyday lives of people from all social classes in the empire, and social values and meanings attributed to sexuality, gender, and morality. Different from other contemporaneous diseases such as cholera and plague, syphilis was not nearly as fatal. However, its visible impact on the body through emergence of rashes and boils, loss of tooth, nose, fingers, in addition to general paralysis (which manifests as insanity) as well as its hereditary characteristics transmitted to the future generations were major sources of social anxiety. Syphilis was known to be a sexually transmitted disease (STD), but it had non-STD and endemic forms; one could contract the disease through “innocent” touch—through shared utensils, towels, and even wet nursing. These characteristics of syphilis contributed to enhancement of secrecy as well as fear.
Such features of the disease the legitimate grounds for the medical and political authorities to enact new regulations about hygiene—public and moral—and mobility, of especially workers, sailors, soldiers. In the regions where the disease was most common and endemic, Ottoman authorities sought to require medical examination for marriages, domestic passports indicating syphilis-negative status for long-distance travel, and new forms of hygienic rules and inspections in public places such as barbershops and coffee houses. Such regulations, like in the case of COVID-19, were closely related to the fact that there was no efficient medical method available to treat syphilis and other venereal diseases before Salvarsan (Arsphenamine) became available in the 1910s. In the absence of an effective treatment in the course of the nineteenth century, Ottoman physicians competed with and in fact, were often bested by the techniques of lay healers.
As with COVID-19, there was significant emphasis on and curiosity about the origin of syphilis. Syphilis was a disease attributed to moral and sexual corruption, and therefore, the invocation of its origin served to ward off blame and stigma. It was long known to be French pox to Italians and Italian pox to the French. Among Ottomans, it was called frengi or illet-i efrenciye, meaning the Frankish disease. The supposed origin of any disease contributes to its “racialization” as well as framing based on cultural, religious, and regional lines. At the onset of the pandemic, there had been significant racializing emphasis implicating “Asian” and “Chinese” characteristics of COVID-19 through stigmatization of the selling, buying, and consuming of wild animals.
To what extent (if any) do you view the history of medicine and disease as an environmental question?
Joelle Abi-Rached: Health, wealth, and the environment are intrinsically linked. There is increasing evidence that COVID-19 is not merely a seasonal fluke but the product of the frantic pace of globalization and the way in which this reckless globalization and hyper-modernity have reinforced inequalities and affected in detrimental ways the environment disturbing more specifically the relationship between humans and other animal reservoirs.
But the “environment” should be taken to mean different levels of ecologies and ecosystems; from the very “micro” level—the individual, biological, cellular, or “molecular” as Gilles Deleuze would say that is the level of the body, to the “meso” level of the community and society, to the “macro” level of the planet. The next inevitable question that the world will have to tackle more seriously and with more urgency thanks to COVID-19 is the ecological one, which is at heart an ethical question about our relationship to one another as human beings but also with other living beings with whom we share life on this planet.
A. Tylor Brand: Epidemics are frequently products of disruptions to the ecological balance, perhaps due to a novel pathogen or to catalysts like war, famine, or natural disaster. Retrospectively, disease ecologies have shaped societies and cultures across the globe. Where environments were inhospitable, communities modified their environment or learned how to survive it better. This never worked perfectly. Several early twentieth-century medical sources estimated child mortality rates of up to seventy percent in parts of Greater Syria due largely to malaria and waterborne pathogens. Indeed, among the afflictions listed in Benoit Boyer’s 1897 public health survey of Beirut, eleven of the seventeen most prevalent illnesses could be linked to water, crowding, or sanitation.
Modern medicine and technology have mostly defanged the microscopic monsters of the past, but even today we remain vulnerable to environmental threats that we ourselves create. Terrifying pathogens like plague, HIV, Hantavirus, and Ebola are zoonoses that we acquire through contact with a wild host. Others, like influenza and coronaviruses, can gain virulence through animal mediation, a particular risk posed by industrial meat farms.
We will eventually stumble past this current crisis, but the future of global health will still depend on how well we manage our relationship with our changing planet. This will be even more important as global warming alters vulnerable ecological and social niches. It is worth remembering that some of the greatest global killers continue to be fairly pedestrian and highly preventable intersections of poverty and ecology: contaminated water, malaria, and measles.
Christopher Rose: When crops fail and the land does not produce, people become sick. Mortality rates among malnourished people are substantially higher than they are among those who are well fed. When clean water is not available, people become sick; cholera, in particular, spreads extremely easily through the water supply, and the inability to clean one’s body or clothing contributes to the spread of louse-borne illnesses like typhus, relapsing fever, and trench fever (all of which appeared during World War I in areas that experienced environmental degradation).
It is also probably not a coincidence that we have seen several pandemics emerge from developing parts of the world, where humans are venturing into new territory and environments without a full understanding of what diseases may be endemic to those regions. Bacteriologists and virologists have been sounding the alarm for years about what may be frozen in the tundra and could thaw out due to climate change. The more our environment changes, the more likely I think we are to see new diseases emerge, or old ones return (and that is before we address issues like the loss of herd immunity due to the anti-vaccination movement).
Seçil Yılmaz: Methods of environmental history have contributed immensely to our understanding and analysis of medicine and disease in the past few decades. Historical studies on many diseases including but not limited to plague, cholera, and malaria demonstrated how the human body and human actions are not separate entities or merely an extension of its environment; it is, in fact, embedded into it. Hence, overcoming the binaries between the human body and environment provided us with productive tools to re-think the role of non-human agents in shaping historical experiences. Until now, as historians of medicine and diseases, we have been occupied with people’s mobilities and migration, and often emphasized the implications and causes of human mobility in the spread of diseases. I believe our COVID-19 experience will prompt historians of medicine and disease to analyze the lives of viruses and bacteria more holistically by also studying the history of non-human agents and their migration more closely.
To what extent have class, gender, and other lines of social difference shaped those histories? What imprint/echo of that uneven social and gendered impact can we detect in this current pandemic?
Joelle Abi-Rached: The histories of epidemics and disease have much to offer in terms of lessons as to how societies have used race, class, and gender oftentimes to reinforce discrimination and stigmatization for narrow political and economic gains. As the historian of medicine Charles Rosenberg puts it, epidemics are the perfect “stress test” because they reveal pre-existing tensions in moral, societal, institutional, and political behaviors.
In my own work, I show how class, gender, and race have shaped in profound ways the history of mental illness. Many of those deemed insane were often poor and often rebellious women at the mercy of patriarchal power. Many used to come to ‘Asfuriyyeh—the mental hospital whose history I reconstruct in my forthcoming book—with the stigma of violence marked on their frail bodies: cauterized heads and iron chains. Indeed, one of the constants in history has been to find scapegoats to the ills that befall on humanity. In the Middle Ages, Jews were often targeted for spreading contagious diseases and poisoning wells. In our own century, we have seen the president of the United States of America, directly accusing China of concocting the novel coronavirus in a Wuhan virology lab and/or accidentally releasing it into nature. We have also seen the bodies of migrants being “disinfected” in public places, such as in India, or totally marginalized and living in precarious conditions in so-called labor camps across the Gulf countries. All these examples demonstrate how the notion of the “polluted body” has, alas, never left us.
In contrast to previous epidemics, however, the COVID-19 pandemic is unfolding live on the global theatre of our interconnected world and very visibly to the point of encroaching on other issues and problems propelled by the impactful tools of social media and big data. Never before had a single pandemic drawn all the available resources–intellectual, physical, moral, and institutional–of the entire planet simultaneously, with so much intensity, and with so much at stake.
A. Tylor Brand: Slogans like “we’re all in this together” may be technically correct, but history would indicate that calamities like famines and pandemics are far more likely to sharpen society’s distinctions than to erase them. Epidemics are social phenomena, not just medical ones, and while a virus generally does not discriminate about who it infects, the medical and social effects of epidemics tend to exhibit obvious demographic preferences.
For example, in the typhus epidemics of WWI Syria, poverty and displacement were closely tied to the spread of the disease. Mount Lebanon’s health director, Husni Bey noted that typhus followed famine refugees from the desperation of Mount Lebanon into nearby towns and cities. Without sanitation or proper shelter, the displaced became a feast for body lice carrying the dread disease, which had a recorded case-fatality rate of 19.3 percent in 1917. Along with typhus, poverty encouraged spikes in malaria, trachoma, tuberculosis, and enteric and cutaneous diseases.
COVID-19 has similarly targeted social vulnerabilities. In America, Latinx, Native American, and Black communities suffer higher morbidity and mortality rates due to a cocktail of socioeconomic and geographical factors, including racial disparities in healthcare and the weathering effects of systemic racism.
The pandemic has increased the precarity of vulnerable groups in the MENA region as well. Refugees and IDPs are at high risk in crowded camps, and in the GCC, canceled contracts have left millions of foreign laborers living stranded and destitute in close quarters as infections mount. COVID-19’s secondary social effects are similarly destructive. Following global trends, domestic violence has risen across the region. Moreover, though Lebanon responded well to the virus, lockdowns further debilitated an economy in collapse, adding food insecurity to soaring poverty and a reeling middle class. Not even wealthy states have been spared. Seventy percent of small businesses questioned in one Dubai survey foresaw bankruptcy within six months.
Christopher Rose: The diseases that spread during World War I in Egypt disproportionately impacted the poor. Sometimes it was the urban poor—typhoid fever and relapsing fever appeared in 1915; one is an airborne contagion, the other louse-borne, and both flourished in the poorer, more densely crowded neighborhoods of Egypt’s major cities. And one sees the usual prejudices expressed in the press about the “low and unhealthy habits” of Egyptians. Health and disease were often used as moving benchmarks to justify the continuation of British rule in Egypt, even as the occupation government reneged on plans to run sewer lines or provide clean water in poor neighborhoods.
On top of this, one has to layer the imperial military agenda. When relapsing fever appeared, it was blamed on Egyptian Labour Corps workers returning from service in Gallipoli, even though the time frame does not match up (the disease appeared in Egypt about a week before the first ELC workers could possibly have returned), and this was justified on the idea that the Egyptians practiced poor hygiene in Gallipolis—as if anyone else had access to running water and soap! The idea that the British imperial troops themselves could be carrying the illness was never considered—and one of the hot spots for relapsing fever during the war was Luxor, which has a low population but was a popular destination for troops on R&R.
When the deadliest wave of the “Spanish” influenza struck Egypt in November 1918, it disproportionately impacted poor, rural areas, and the highest death rates were in young people aged fifteen to twenty-five (this was one of the unusual features of the virus). Since agricultural wages had held flat over the war while inflation soared, this means that the young men and young women who were left to keep things running on the farms while fathers and older brothers went to join the ELC or find other work were the ones carried off by the disease after the war ended. And I do think, given the fact that agricultural production held somewhat steady during the war, that there is a gendered component to it—there must have been farms or estates being managed by women during the war, but I do not know where I would even begin researching that.
And we are seeing the same thing happen now. African-Americans and Native Americans seem to have a higher mortality rate from COVID-19 than other demographics. On the one hand, there’s a clear link with the systemic racism that has resulted in more health problems overall among that demographic, and in lower standards of medical care immediately available to them (especially in the South or on reservations); on the other, there are public officials who are either engaged in victim-blaming or ignoring the disparity altogether.
Seçil Yılmaz: Gender and class had been at the center of the debates on syphilis in the late Ottoman context. In a globalizing world in the second half of the nineteenth century, massive infrastructural development in transportation made it possible for people to move around with various obligations and motivations: as newly drafted soldiers to serve in the military, as refugees, and emigrants in search of a new home, as dispossessed peasants to find new jobs in urban areas for a better living. When people moved, syphilis (and of course other diseases) moved with them. In the Western and colonial contexts, syphilis along with other venereal diseases were, what Mary Spongeberg calls, feminized because women’s bodies, and especially the bodies of prostitutes and single working-class women were framed as the source of the disease. What is different in the Ottoman context of syphilis, as I have discussed in my article, “Threats to Public Order and Health,” is that Ottoman authorities both prioritized and stigmatized lower-class men for the spread of syphilis. Lower class men were both the backbone of the military and workforce and the most mobile segment of the Ottoman society in the late nineteenth century. It was essential to control and prevent the spread of disease among and through these men, who were seen as the primary vectors of syphilis by Ottoman medical authorities. Lower class women, even though less frequently than men, also migrated to urban areas to work as domestic servants in service of emerging middle-class households in the late-Ottoman context. As appeared in the mainstream Ottoman newspapers towards the end of the nineteenth century, these women were also framed as a threat to public morality and health due to the possibilities of carrying and transmitting venereal diseases.
When diagnosed with syphilis, patients were often required to go through a demanding treatment process, if done properly, in isolation lasting between six weeks to three months including resting, application of mercury ointment, and bathing. In other words, one would need to have access to a clean source of water, food, and reliable health care as well as income to halt the progress of the disease.
Syphilis and other venereal diseases present a unique case in the analysis of gender and sexuality in relation to the history of medicine. And yet, social class differences intersected with the impact of epidemics when we think about cholera, malaria, and tuberculosis alongside syphilis. Poor living conditions, access to clean water, food, and housing deeply shaped the communities’ experiences of epidemics in the late Ottoman as well as global context. Along with social class, in the global context, there are many examples of discrimination and criminalization of “sickness” based on ethnic, religious, and racial backgrounds of indigenous populations by colonial powers. In other words, it was not only social class and gender but also race and ethnicity that played a significant role in shaping the history of medicine and disease.
In the context of COVID-19, we observe that the requirement of isolation sharpened the differences among different social classes along the lines of access to housing, food, childcare, and health services. It is often working classes (along with health workers) who carry the burden of providing the “essential” services who became more vulnerable to its influence compared to others who had the opportunity to keep their jobs while working from home in isolation.
What does the COVID-19 pandemic reveal about the history of medicine and disease? How, if at all, has it impacted your research agenda?
Joelle Abi-Rached: If there is one thing that this pandemic reveals it is that historians are more than ever needed to prepare the world to tackle with more wisdom and nuance the next pandemic and its challenges. Historians are not oracles but they can anticipate some of the issues that would eventually emerge, they can identify the points of tensions, the hidden assumptions and patterns, they can warn about the dangers and consequences of totalitarian control, they can make the case for the need for science and not superstition or political interests to guide policy without succumbing to the powerful appeal of technology. Historians will be needed to warn societies about the pitfalls of a blind faith in science as well as the dangers of ignoring it entirely.
For me, the COVID-19 pandemic was a wake-up call on the urgent role historians need to play as adjudicators, advocates, and chroniclers of the world to come, given their training as the recipient of a way of thinking about the world that takes into consideration its messiness, complexity, and inter-connectedness but also its incredible potential for reinvention, survival, and adaptation. Besides being a tragic human and social drama, COVID-19 is also an opportunity to rethink the world including the mode of governance of individuals and populations, the role of technology, as well as the values we want to cling to and pass on to future generations. Every major epidemic in history enabled an epistemological rupture and altered the course of history, why should COVID-19 be different? The shift might not come in the very near future, the dramatic change that the black death enabled played out over two centuries. Nevertheless, we should seize this unique opportunity to think about a healthier, more equitable, more peaceful, more innovative, less polluted, and more livable planet before it is too late.
A. Tylor Brand: History teaches us that epidemics are not just about the sick and the dead. Virulent diseases dramatically shape the way that we conceive of the world and those within it.
We make sense of epidemics through constantly evolving disease constructs, which allow us to define both the disease and its social implications. Often, such constructs are framed as narratives that establish the epidemic’s origins and progression while identifying heroes, victims, and villains. Such constructs are not simply innocent ideas since they guide our social interpretations and behaviors. During WWI, the evolving typhus construct infected the contemporary understanding of poverty in destination towns for refugees. As the typhus construct became entwined with poor beggars, the economically secure began to practice an exclusionary form of social distancing that isolated the poor for fear of infection.
In the current pandemic, the disease construct has been complex and highly politicized, featuring several narratives rooted in very different fundamental beliefs about the world. Superficially, the debate has often centered on the application of biopower and the costs-benefit of lifting lockdowns (similar to debates in 1918). However, the uncertainty of the pandemic has also provided fertile ground for fantastical conspiracy theories and bizarre counternarratives, as partisans and self-styled skeptics have sought to shape the perception of the crisis to suit their particular ends. Fringe groups have exploited division for visibility. Militias have occupied statehouses, vandals burned 5G towers, and anti-vaxxers have spread disinformation. Tired anti-Semitic libels and bizarre theories about Bill Gates and vaccine nanochipping have gained traction in the unregulated Thunderdome of social media, often aided by astroturfing. Feeding the discord, public figures across the globe have openly promoted denialism and some leaders have even manipulated data to justify early re-openings.
The chaos of our current discourse reinforces how difficult it can be to understand a complex crisis in real-time, let alone one in historical context. The Lebanese famine of WWI was so rife with rumors and conspiracy theories that one observer wryly wrote that he could believe only three-fourths of what he himself said. We might expect as much. In the uncertainty of crisis, conspiracies offer a reassuring sense of structure and control, even if that belief is wrong. However, this knowledge should certainly make us cautious as we analyze historical sources, wherein people with even less data at their fingertips had to negotiate and interpret their own micro-apocalypses.
Christopher Rose: The COVID-19 pandemic has, ironically, revealed how little things have changed in the century since the “Spanish” influenza pandemic. A colleague in Cairo sent me some newspapers from the period that I had not seen before, and it just keeps hitting me as I read how so much of what was being said then echoes what is said now during the current pandemic. There were constant complaints that the government was either doing too much or not enough (frequently at the same time). Health professionals wrote in to urge everyone to take the threat seriously, not to go out if they felt sick, for citizens to practice what we now call “social distancing,” and to see a doctor if they experienced certain symptoms. Ultimately, that is all that could be done from a medical perspective because then, as now, there was not a vaccine, so the best that could be done was try to treat the symptoms and provide palliative care for those with extreme cases.
The other thing that is not new is people complaining about how the pandemic inconvenienced them personally. Some people wrote in to complain that their lives were upended for “the flu,” that their children were bored being stuck at home on weekends because cinemas had been closed for matinee performances—it is all so, so familiar, and it really has given me an entirely new perspective on the pandemic. I have spent a lot of time wondering how it could have been so severe and yet the suffering seemed to attract so little attention, and now I understand much better how it happened (this is not to say that it actually makes sense).
Seçil Yılmaz: Lack of knowledge about the symptoms and progress of the diseases led to confusion and even denials about the presence and/or destructive impacts of epidemics. As with cholera and syphilis in the past, the absence of sufficient and reliable treatment for COVID-19 translates as social fear and anxiety. Equally, prevention strategies to stop pandemic were seen as barriers to the economy in the past as now. Quarantine practices as well as medical inspections and burial practices in the time of cholera in the nineteenth century were met with resistance from a wide array of social groups including merchants, workers, and pilgrims. Modern forms of quarantine in the days of COVID-19 also led to everyday resistance and protests due to the interruption of economic activities, social gatherings, and even religious rituals.
There had been a significant leap in the making of transnational networks of scientific and medical knowledge production in the age of great pandemics during the nineteenth century. Medicalizing missions intersected with civilizing missions in the search for the etiology of cholera, plague, syphilis, malaria, etc. Louis Pasteur and Robert Koch’s institutionalized initiatives in bacteriology, as well as Alfred Fournier’s research on syphilis in St. Louis Hospital in Paris, became centers for scientific and medical learning in the late nineteenth century. The Ottomans established the Imperial Institute of Bacteriology by inviting Maurice Nicolle as its director from Pasteur Institute in Paris in 1893, which served as both a research center and a school for the instruction of bacteriology. Ottoman physicians and bacteriologists contributed to the making of a vernacular language and methods of medical and scientific practice by adapting Pasteurian science to local circumstances. In other words, there had been a significant circulation and exchange of medical knowledge and practices in the late nineteenth century. The COVID-19 experience displays massive competition as well as collaboration among scientific circles at a global scale in comprehending the symptoms and development of a vaccine, which is the new race against time.
As for differences, social media and the speed of information exchange transformed the experience of pandemic fundamentally. While the quality of the information might be questionable, we have speedy access to everyday life experiences of COVID-19 all over the world exhibiting cultural and social peculiarities as well as commonalities among different social groups. In terms of the changing role of the state, despite uneven access to health services for different social classes, we observe that health sciences and services, public or private, became a fundamental infrastructural element of the state machine in the course of the twentieth and twenty-first centuries. Compared to epidemics in the nineteenth-century context, people have no questions about accepting hospitals as venues for health care. Now, the criticism is rather towards the insufficiency of health care units and personnel as well as the cost because of the absence of welfare state practices to implement health service as a basic human right.