In The Care of Strangers, Charles Rosenberg proposed that hospitals represent microcosms of society at large. The histories, functions, and hierarchies inside hospitals mirror the social and professional relations that exist in their surrounding cultures. Rosenberg argued that the nineteenth-century American hospital was an embodiment of the period’s social hierarchy and reflected its values of charity and altruism. It was the outcome of conflicting and competing professional agendas, and it was the physicians themselves who had the biggest impact on the development of the institution.
As microcosms, hospitals also provide a window into the historical relationship between medicine and religion. In the world of the hospital, physicians negotiated between religious authority and new fields of medical science. For example: in 1793, la Commission de Réforme des Hopitaux, formed in Revolutionary France and composed of medical luminaries such as Pierre-Jean Cabanis, issued a report that criticized the deplorable conditions of hospitals in France, especially of the famous Hôtel Dieu. The Commission attacked the authority of priests and nuns inside the hospitals and condemned the role of the Catholic Church in medical care. It would take another century for a law to evict priests from the boards of hospitals and to replace nuns with lay women in nursing. The ongoing reform efforts, however, reflected distinct chapters in the history of the Revolution and demonstrated the power of the Third Republic’s secularizing and anti-clerical efforts. They were also the outcome of the physicians’ professional project, aimed at transforming the hospital into a legitimate site of medical care and a place for the practice of “scientific medicine.” In each case, the French hospital acted as a cipher for larger societal trends in a combative history of medicine, religion, and professionalization.
If the hospital is a microcosm, and if medicine and religion inside the hospital interacted as they did outside, what reason is there for a history of hospitals? What could a systematic study of this institution add to our knowledge of medicine, or of medicine and religion? When the hospital is examined only as an example of broader social conflicts, then its history adds only a limited—though valuable—perspective on the development of medicine. But the hospital is unique, if for no other reason than it arose as the center of medical power. Studying the hospital provides special insight into the history of medicine and its ongoing—and complex—relationship with religion.
In the medieval Islamicate context, the spread of hospitals necessitated a new kind of practice. Physicians were forced to deal with patients who were uneducated and unable to understand their physicians fully or even express their feelings and bodily experiences in a manner comprehensible to their physicians. While these patients were as reliable witnesses of their bodies as anybody, they were not trustworthy in the eyes of their caretakers. Physicians relied more on their senses and examined, probed, and investigated the patient body to uncover the medical truths that they did not trust the patient to communicate. Coupled with the often impoverished and marginalized status of hospital patients, these collective practices deprived patients of their ability to judge, control, or evaluate their physicians.
Far from being sites of free or charitable care, hospitals are emerging as factories for complicated and technologically sophisticated medical practice.
Instead, physicians, now reigning over collections of sick bodies, became primarily accountable to one another. Categories such as “rare” and “unique” emerged to describe diseases and conditions. Such categories were, by definition, the purview of physicians, as patients had no way of knowing whether their conditions were rare or not. In the hospital, diseases replaced patients as the objects of medical knowledge. Given shorter and shorter periods of time to examine and understand, and fewer and fewer resources and choices of medications and procedures, physicians tended to classify patients based on their diseases. They devised standardized medical recipes and procedures that would cure these conditions but did not necessarily treat their actual patients. Well before works on modern anatomy and physiology appeared, the institutional practices of the medieval hospital gave birth to the culture of modern scientific medicine.
Today, hospital practice continues to be unique, although for different reasons. Far from being sites of free or charitable care, hospitals are emerging as factories for complicated and technologically sophisticated medical practice. The raison d’être of the contemporary hospital is not the socioeconomic condition of its patients or the charitable ethos of its physicians, but rather the space needed for MRI machines and sophisticated operating rooms. In fact, the emergence of family physicians and the emphasis on their role in saving costs and in streamlining medical care further solidifies the hospital as a site of medical technology. Even when physicians and their clinics are located inside hospitals, their primary role is to be gatekeepers of the hospitals’ expensive, elaborate, and futuristic medical innovations. Hospitals continue to develop as investigation and intervention factories that grind only at great expense and are, therefore, meant only as a last resort.
Just as hospitals reveal a unique perspective on the development of medical care, they provide a special perspective for the study of medicine and religion. The hospital offers added dimensions to the historical intersections between medicine and religion—in views about life and death, ethical and unethical practice, and finding care or support at difficult times.
The large, rich, and elaborate medieval institutions were always staffed by learned physicians practicing Humoral medicine, many of whom were not Muslims. Although built and supported by charitable endowments, Islamic hospitals seemed to operate outside of the realm of the authority of religious scholars, a feature that was aided by the lack of a centralized religious authority in the majority of Islamic lands in the medieval period. Islamic hospitals admitted only patients and foregrounded their medical nature and mission. To many, the Islamic hospital seemed to be the epitome of the secularized institution and the forerunner of all modern hospitals.
While the broad strokes of this story stand scrutiny, the overall spirit, the main argument, and the details fail a historical test. In The Medieval Islamic Hospital, I trace the history of Islamic hospitals focusing on a particular institution of the thirteenth century. Far from an arena of conflict between medicine and religion, or a proto-secular space, hospitals were the place where religiously inspired and conditioned ethics and traditions of medical practice were formulated and consolidated. The hospital was a site for charitable care more than anything else. In the Islamicate context, the large and diverse network of charity—including mosques, hostels, kitchens, and so on—allowed hospitals to serve patients almost exclusively. This specialization, however, was not a function of exclusion, whereby hospitals turned away those who were not sick, but one of inclusion, where help-seekers chose the places that could provide them with most help. Physicians perceived their role in the institution as one that was rooted in charity, itself a cornerstone of medical practice.
Patients mobilize religion, as a category that stands in for beliefs, race, and gender, among many other things, to demand respect and force the institution to recognize their individuality and hear their voices.
Similarly, medieval hospitals were a site where religious views were integrated and naturalized within a medical cosmology. Patients entering the Houses of the Crusader Order of the Hospital were asked to give confession and take communion. Amulets, verses from the Quran, and prayers hung from the roofs and adorned the walls of Islamicate hospitals. Embedded in collective practice was a performance of piety that became part and parcel of medical practice. Physicians saw their measly hospital salaries not only as a reflection of the poverty of these institutions but also as part of their own charitable and religious pietistic performance. Hospitals did not function as sites for individual or individualized discussions of life and death or religious meaning-making: they were stages for collective piety and performance of public religion.
Even in the contemporary US, where an ethos of individual religiosity has often reigned supreme, religion and its performance in the hospital continues to be communal, collective, and public. For instance: chaplains are becoming increasingly integrated into the hospital system, adding a religious component to technologized medical practice. Yet the choice of chaplains and the resources dedicated to them are not the result of calls for their services, but rather are the outcome of the overall distribution of resources in medical institutions. Religion in the hospital is a cultural and racial marker that institutions can integrate into cultural competency training, at times, with the perpetuation of stereotypes, or standardized and canned views. Today, for example, in debates over a hospital’s ability or desire to offer contraceptives, religion remains a place for conformity and standardization true to the collective nature of hospital practice.
At the same time, the voices of patients—frequently drowned out to variable degrees based on race, gender, sexuality and socioeconomic status—highlight the importance of religion as a stand-in category for understanding grievances and failures of communication. Patients mobilize religion, as a category that stands in for beliefs, race, and gender, among many other things, to demand respect and force the institution to recognize their individuality and hear their voices. But this strategy also has risks: the mobilization must frame itself in terms familiar to the collective, institutional order to be audible and understandable. As Sherine Hamdy shows in her ethnography Our Bodies Belong to God, patients employed the categories of religion to express their suspicions of and anxiety about a healthcare system that obscured their voices.
Western hospitals are not simply sites for the conflict or collaboration of medicine and religion. These institutions present us with a unique environment where such interactions acquire significantly different and unique meanings and dimensions. Hospitals are not examples of how medicine and religion interact, nor are they instances of how medical knowledge and practice develop. As much as they are connected to these discourses, they are also unique and peculiar cases in which these questions unfold. It is the ubiquitous nature of this institution and its ever increasing importance in an expanding, accelerating, technologized medical paradigm that highlights the importance of analyzing the hospital as a place unique rather than exemplary. Anchored in histories of medicine and religion, hospital history emerges as a subcategory that merits different tools and different hypotheses—a subcategory where the collective plays a central role in forging singular medical and religious discourses.
Ahmed Ragab is Richard T. Watson Professor of Science and Religion at Harvard Divinity School and director of Science, Religion, and Culture. His most recent book is The Medieval Islamic Hospital: Medicine, Religion, and Charity.
Image courtesy of author.