Students of Europe in the early modern period claimed that the major context of health care provision in the early modern period was poor relief. Studies of Europe claim that the richer classes donated funds to medical relief, yet never drew on it themselves. The rich made their own medical arrangements in their homes and rarely attended hospitals as patients.49
The Ottoman sources mention the “poor,” the “miserable,” the
“needy,” and the “weak” as the entitled benefi ciaries of endowed institutions. The separation of patients according to social class is an old tradition in many medical systems. As today in our Western society, so in the early modern Middle East, those with means had more medical options. In many studies, hospitals have been portrayed as reinforcing/emphasizing this separation. It is almost a common-place to assert that (only) those who could not afford private medical
treatment at home went to hospitals. Hospitals were thus associated with poverty, poor medical attention, and death, seen as a fi nal option or last resort. When people of means (the richer) did eventually enter hospitals in the twentieth century, a second form of separation occurred:
now patients were separated within the buildings according to social class (which included also race). A patient’s ability to pay for service and his or her insurance coverage became factors that determined the nature of care: the particular hospital, and even the wing, ward, and room in which a patient was placed.50
On the surface it seems Ottoman reality is yet another example of separation of patients according to social class. Patients of means were treated at home by physicians who came to them; they did not visit physicians at their clinics, let alone undergo hospitalization. The story of a sick person who is cared for at home by his loving fam-ily and close friends is a literary topos popular also in the genre of biographical dictionaries. Hospitals as a place of care are but rarely mentioned in biographies of Ottoman dignitaries even as an option.
Evliya Çelebi included in his book on his extensive travels in the Ottoman Empire in the middle of the seventeenth century the biogra-phy of his relative and patron, Melek Ahmet Paƒa, a senior Ottoman offi cial. In the winter of 1656, while serving as the governor of the province of Özü to the northwest of the Black Sea, Melek Ahmed’s neck swelled up and he fell sick. A pustule developed, and after fi ve to ten days his neck became red and as thick as a loaf of bread. Many physicians, surgeons, and phlebotomists were brought to the paƒa’s bed, and although each of them prescribed a different treatment, the paƒa’s condition deteriorated: he lost his voice and could only hum like a bee. Many in his household believed his end was near. Some offi cers in his entourage left to look for a new patron. Melek Ahmet Paƒa himself was sure his time had come: he dictated his last will and his funeral arrangements using sign language (Evliya does not elaborate about the signs). However, Evliya Çelebi, the faithful com-panion, dreamed a dream whose interpretation gave the paƒa new hope. Once again a surgeon was summoned. The surgeon opened the paƒa’s collar, drained the pus, and removed the rotten fl esh. New medications were sent to Melek Ahmet Paƒa from the imperial palace, and within two months he had fully recovered.51
From these and other pieces of evidence one could deduce that poor people were admitted into hospitals where medical care was distributed free, whereas the well-to-do contracted private doctors and were treated in the privacy of their own homes. Many studies make this deduction, but I believe the reality was different. It is true
that hospitals offered medical treatment free of charge, and thus prob-ably were quite attractive to the materially poor, but in the Ottoman context the word “poor,” which refers today primarily to those who have little money and as a result may not be able to obtain the neces-sities of life, may have several possible meanings. In cases where it is possible to determine the identity of Ottoman hospital patients, it is clear that a considerable percentage of them were actually well-off. They may not have been the richest people in town, but they were not in need of free medical service. The social status ascribed to them placed them higher up, toward the middle of the social lad-der. But still they were accepted into hospitals free of charge. There were other, nonfi nancial, circumstances that could bring someone to a state of neediness. Hospital patients, rather then being fi nancially needy, were perceived as deserving help and sympathy due to their merits, social status, and specifi c circumstances.52
The identity of hospital patients is not unlike the identity of those granted permission to dine at the Ottoman soup kitchens. It is clear that a considerable percentage of them actually belonged to elite groups. The categories of those entitled to a free meal were many and varied, whether such entitlement was based on religion, social standing, or vocational activity. Religious scholars, employees of the institution, Sufi s, poor people and those retired from military or palace service might all dine side by side in a soup kitchen, although the imaret meals were very hierarchical and they did not necessar-ily dine together at the same table, dine at the same time, or eat the same amounts and dishes.53 However, it is interesting to note that being entitled to medical and food support was expressed in terms referring to economic, social, and physical hardships.
Sultan Süleyman expected that people carrying with them money and goods would be admitted into his Istanbul hospital, and instructed what should be done in such cases: he ordered the clerk (katip) in the hospital to record in detail the belongings that patients brought with them when admitted; special attention was to be given to recording money and other valuables. The clerk’s duty was to return to the patients leaving the institution whatever they had brought with them according to his records.54 A special area in the hospital was reserved for the treasury (bayt-lü-mal or hazine), which no one was allowed to enter except the head physician. The hospital funds and the patients’
valuables were kept there.55
The attraction of affl uent patients, therefore, was not only the expectation of the donors about who the future benefi ciaries would be.
The affl uent actually came. We have already mentioned one A±mad
b. Mu±ammad from Damascus, known by his nickname Ibn al-Munqår (d. 1623). According to his biographer, Mu±ammad Am¥n b. Fa∂lallah Mu±ibb¥ (d. 1700), a family member of a later generation, Ibn al-Munqår, became famous as a poet before he was twenty years old.
He was renowned for his expertise in both science and the Arabic language. After his father’s death in Istanbul, where he had held the position of a judge, Ahmad traveled to the Ottoman capital to claim his inheritance. His fame spread in the capital as well, and the head mufti of the empire made him his assistant. But soon A±mad suc-cumbed to melancholy and lost his reason, and his speech became slurred. He was fi rst put in the hospital but later was sent back to his hometown, accompanied by some other Damascene notables return-ing from Istanbul. In Damascus a house was rented for him where he was under constant care and supervision. He was allowed only to leave the house when accompanied by a guard and for limited periods of time. He never regained his reason and after thirty years died, still a madman.56
In sum, a simplistic explanation of who was entitled to free medical services based solely on the social and economic standing of poor hospital patients versus rich people treated at home does not refl ect the realities of the early modern Middle East. Neediness was decided upon the establishment of poverty, which was described as the lack of something crucial. That could include the lack of mate-rial objects, but when it came to entitlement to free medical services it seems the second category was at least as important: the lack of social objects, like skills or family that allow one to rise from one’s position. Need may result from circumstances imposed from outside or from a choice to live in an ascetic way (like the Sufi s). Poverty can be structural—that is, it could be the result of a long social and economic process that affects groups; poverty can also be a temporary situation, a specifi c case that can be easily remedied and from which recovery is possible.
Who, then, were the majority of patients in hospitals? We should remember that the sources used here are the product of urban Otto-man elite groups, and therefore it should not come as a surprise that the “heroes” of these sources are members of these same groups.
The wretched and the miserable, whether socially or fi nancially, are anonymous and invisible in sources of this type. However, although the sources provide almost no direct evidence on the identity of hospital patients, they do speak to us and reveal who were deemed worthy of medical support in early modern Ottoman society. Unlike in our modern hospitals, in early modern Ottoman hospitals social
status determined acceptance, rather than medical diagnosis. And in contrast to the popular image of premodern hospitals as almshouses, those who could expect care in Ottoman hospitals did so on social grounds, not economic ones.57
The Nonpoor Foreigner as Entitled to Medical Help
The specifi c mission of Ottoman hospitals was to help the sick, the injured, and those suffering from mutilations and pain. In this sense, hospitals were part of a group of institutions to which imarets, hos-pices (tabhane), and hostels and inns for the wayfarers in towns and along commercial routes (han and karavan-seray) also belonged. This group of institutions had two aspects in common. The fi rst is that all distributed physical help. The second is that this group of insti-tutions was intended to serve people who for a number of reasons could not take care of themselves. They might have lacked fi nancial means, health, and strength (physical and mental), or supportive fam-ily (through accident or physical or emotional distance). But it was not necessarily because of a continuous poor situation, that a person availed himself or herself of charitable medical services. Under certain circumstances even a member of a famous and well-off family could use free medical services.
Medical treatment and care were usually distributed within the family. If the family was the prime agent in distributing health and medical care, hospitalization, then, signaled the absence or the dysfunc-tion of a family. Here “family” is understood in a wide context. Family here is more than blood or marriage ties. It encompasses also those who are close, which allows also us to consider also “strangers” like friends, companions, and associates from work or a religious order, as providing care and affection to a patient and taking responsibility for him or her in times of medical need.58 The function of the hospital institution together with, or in addition to, the family exemplifi es the balance (and sometimes rivalry) between different supportive agents:
family, the neighborhood, and the community at large.59 People of means were patients in hospital if they had no family close by to support them. They may have had no family at all or they may have been strangers in a faraway place.
“If travelers and wayfarers are sick, they come to the hospital of Sultan Mehmet the Conqueror and they treat them.”60 This was the description by Evliya Çelebi—a traveler himself—of the patient population in the hospital established in Istanbul by Mehmet II.
The English traveler George Sandys described the hospitals in the
capital at the beginning of the seventeenth century as a place where foreigners were entertained.61 In Istanbul, the Ottoman capital, there were many foreigners, who came there for many different reasons:
they included merchants, immigrants from the provinces, scholars, adventurers, and others.
Strangers to Istanbul who owned property were among the patients in the hospitals in town. When patients died in hospitals, as in other cases of deaths of people of means, the kadi (judge) was asked to manage the estate. He would write down a detailed list of the estate of the deceased (metrukat defteri), record who the rightful heirs were and what their share in the inheritance would be after set-tling debts (including sums owed to the spouse, like the remainder of the bride price), and pay for burial costs. These lists were included in the Muslim court registers, and indicated where people died, whether peacefully at home or in special circumstances, such as during the pilgrimage of Mecca. The very fact that people who died in hospitals appear on such lists testifi es that they left some property when they died, otherwise the kadi would not have been asked to intervene in his capacity as settler of inheritances. Yet the estates of such hospital patients were rather modest.
In the deceased lists from seventeenth-century Istanbul, four people are recorded as having passed away in hospitals in town. Their property was composed of movables only. One of them was Ahmed Efendi bin Hasan Beƒe, who died in the hospital of Mehmed II. He owned three male slaves (ghulam). This hints at his being a man of wealth, but apparently their quality was mediocre at best: their value in January 1617 was estimated at 11,450 silver coins. It was a mod-est sum in comparison to the prices of other slaves recorded in these lists. He also left behind several unsettled debts, in the amount of 1,150 silver coins. Osman Efendi bin Mehmed Bey, a religious scholar (‘alim), passed away in the Süleymaniye hospital. The head physician tried to gain control over his estate, but his riding animals and beasts of burden amounted in December 1649 to the humble sum of 3,400 silver coins. He owed 640 coins to a man who had loaned them to him previously. The estate of Façli Beƒe, who also died in the Süleymaniye, was settled in the summer of 1656. It included cash in the amount of 1,100 silver coins and merchandise worth an additional 905 coins.62
Two of the four patients who died in Istanbul hospitals during the seventeenth century left no heirs. One of the two who did leave heirs was survived by fi ve family relatives, including a wife, two daughters, and two brothers, but the head physician tried nonetheless to gain control over the inheritance.63 Could it be that he thought he
could get away with it because these relatives were not present? It is telling that the possessions of all four of the patients who died in the hospitals included no immoveable property; rather, their assets were all moveable items: cash, slaves, and merchandise. Perhaps this is evidence of their identity as visitors to the city.
In addition to the capital there were other urban centers that were magnets for foreigners. The Holy Cities, Mecca and Medina, attracted thousands of Muslims from all corners of the world. They fl ocked there both to fulfi ll the duty of the hajj and to study. The long road and its hardships proved too diffi cult for many, and they fell sick or died along the way, or else arrived sick and died there.
Rapacious local governors and leaders of caravans certainly tried to seize the belongings of people who died along the way.
This was the context of a complaint sent by ‘Umar, the caretaker of the holy sites in Medina, to the sultan about certain leaders of hajj caravans. According to him, they had taken charge of the property of dying pilgrims and embezzled it. Instead of taking only the outstanding share for expenses of the convoy and transferring the rest to the imperial treasury, the leaders had taken an extra share for themselves, robbing widows, orphans, and other heirs who should have benefi ted from these funds. The sultan sent a decree to the provincial governor and head judge in Damascus to investigate this alleged crime. The decree says that if ‘Umar’s complaint proves to be valid, the culprits should be removed from their posts in the hajj caravan; all excess charges levied by them be recovered and transferred to the treasury.64
Those lucky pilgrims who reached Mecca and Medina unharmed were obviously exhausted. Even the healthiest and strongest among the pilgrims and travelers were foreigners in town, and when they fell sick some of them had to seek help at the local hospitals. They did not know the physicians there and could not rely on supportive friends and relatives. Thus, the patients in the hospitals in these cities might be rich people who would have contracted a private physician in their hometown—they certainly could have afforded one—but on their travels to foreign lands used hospital services that were given free of charge. Several hospitals existed in Mecca and Medina, which were founded in the pre-Ottoman periods. The hospital founded by
‘Imåd al-D¥n Zang¥ (d. 1174)—who also erected medical institutions in Syria, his seat of power—functioned as a hospital in the sixteenth century as well, despite financial hardships as the endowment supporting it shrank.65 To these were added Ottoman institutions, like the hospitals of Sokullu Mehmet Paƒa and Gülnüƒ Sultan, men-tioned above.
It is conceivable that there were also wealthy foreigners among those who died in the Meccan hospital, deaths that became the sub-ject of two identical decrees. In March 1568 two decrees were sent to the Ottoman judge in Mecca at an interval of two weeks. The sul-tan ordered the judge to inform him in detail about who had taken charge of the personal effects of dead patients in the hospital there.
The judge was to explain what had been done with them, how and to whom they were sold, how much was received for them, and how that amount was spent.66
The palace pages in Topkapı Palace who were treated in the hospital there, which served only members of the palace service, shared some characteristics of the travelers. The pages did not have immediate family close at hand, since they were the product of the periodic levy (devƒirme) of Christian youngsters from the conquered lands. Despite being far away from their biological families, they were not alone in their illness. In contrast to foreigners admitted to hospitals who found themselves in a strange land in their time of
The palace pages in Topkapı Palace who were treated in the hospital there, which served only members of the palace service, shared some characteristics of the travelers. The pages did not have immediate family close at hand, since they were the product of the periodic levy (devƒirme) of Christian youngsters from the conquered lands. Despite being far away from their biological families, they were not alone in their illness. In contrast to foreigners admitted to hospitals who found themselves in a strange land in their time of