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In the midst of the Black Death, Dubrovnik kept its port open with innovations in public health.

Centers of Progress, Pt. 37: Dubrovnik (Public Health)

By Chelsea Follett @Chellivia

Today marks the 37th installment in a series of articles by HumanProgress.org called Centers of Progress. Where does progress happen? The story of civilization is in many ways the story of the city. It is the city that has helped to create and define the modern world. This bi-weekly column will give a short overview of urban centers that were the sites of pivotal advances in culture, economics, politics, technology, etc.

The 37th Center of Progress is now called Dubrovnik, but was known historically as Ragusa. The picturesque port city is nicknamed “the pearl of the Adriatic” for its beauty. But the city has also been called “the Hong Kong of the Mediterranean” for its historic embrace of personal and economic freedom and its maritime trade-based prosperity. Not only was the small city-state of the Republic of Ragusa at the forefront of freedom for its time, being one of the earliest countries to ban slavery, but the glittering merchant city on the sea was also the site of an early milestone in the history of public health: quarantine waiting periods, which were first implemented in 1377. In 1390, Dubrovnik also created the world’s first permanent public health office. Perhaps more than any other city, Dubrovnik can claim to have helped create the idea of public health.

Today, Dubrovnik is best known for its exquisite sights, including many historic buildings and museums. It is located in the southern Croatian region of Dalmatia, best known for the Dalmatian dog breed, which existed as far back as1375. Tourism dominates the economy. Much of the city’s layout remains largely unchanged from the year 1292, with narrow winding stone-paved streets; innumerable medieval monuments, towers, and monasteries; and charming garden-surrounded villas and orange groves. The old city is a designated UNESCO World Heritage Site, boasting well-preserved Gothic, Renaissance, and Baroque architecture in the form of numerous churches and palaces. The city is often considered a major artistic center of Croatia and the site of many cultural activities, theatrical and musical performances, festivals, and museums. The city’s Banje Beach is also popular, and the Gruz Port is now busy with cruise ships.

The Irish playwright George Bernard Shaw (1856–1950) claimed, “Those who seek paradise on Earth should come to Dubrovnik.” Fans of Game of Thrones may recognize Dubrovnik as the set bringing to life the fictional seaside city of King’s Landing. But whereas King’s Landing was the capital of a despotic absolute monarchy, in reality Dubrovnik was devoted to freedom to an unusual degree from its inception, and is proud to have had no king. “The city-republic was liberal in character, affording asylum to refugees of all nations—one of them, according to legend, was King Richard I (the Lionheart) of England, who landed on the offshore island of Lokrum in 1192 on his return from the Crusades,” according to the Encyclopedia Britannica.

Dubrovnik was a tributary city-state under Venetian suzerainty from 1205–1358, retaining substantial independence and growing prosperous as a mercantile power. It was during that period, in 1348, when the bubonic plague first reached the city. Within four years the disease extinguished the lives of perhaps two-thirds of the city’s citizens. And that was just the first wave. During the Black Death pandemic, periodic lulls were often followed by new outbreaks.

In 1358, Hungary pressured Venice to surrender control of Dubrovnik, and the Republic of Ragusa (1358–1808) was born. It was during the republican era that the city created the novel public health measure of quarantine, and practiced it from 1377–1533. While not perfect—outbreaks of plague occurred in 1391 and 1397—the measure was nonetheless revolutionary. Other cities soon implemented similar protocols, such as Geneva in 1467. 

“It should not be a surprise to find Dubrovnik at the heart of quarantine’s origin-story, because the city was a seafaring supernova for much of the medieval era,” notes British journalist Chris Leadbeater. An aristocratic republic with fewer than 10,000 people living within its walls and a constitution resembling Venice’s, Dubrovnik was ruled by a council of merchant princes selected from the patrician families that comprised about a third of the city’s population. Unlike in Venice, the ranks of the nobility were never formally closed, meaning that newly successful merchant families could gain patrician status. Term limits restricted the top government official, the rector, from serving for more than a month, after which he could not seek the role again for two years. Dubrovnik also “never saw an elaborate increase in bureaucratic functions or felt the great weight of government intervention as Venetians did,” opting for relatively limited government interference with the city’s robust trade. 

If you could visit Dubrovnik during its maritime golden years (1350–1575), you would enter a vibrant coastal city filled with stone architecture, diverse travelers speaking languages ranging from German to Turkish to Italian, and awash in art and commerce. You might have glimpsed noblewomen wearing fine jewelry—who were free to trade their jewels without male permission even in that age of extreme gender inequality, thus contributing to a lucrative export market.

The Croatian economic historian Vladimir Stipetić has noted, “Dubrovnik traded like Hong Kong, Singapore, Taiwan . . . but did so some five hundred years before . . . [and like those countries] became prosperous . . . because of [its] adopted economic policy.” As a result of the city’s relative economic freedom, and the resources saved by the city’s disinterest in military expansionism, Dubrovnik’s fleet of hundreds of merchant ships at times outnumbered those of Venice, despite the latter boasting perhaps 10 times the population of Dubrovnik. Dubrovnik’s economic expansion is also, of course, owed to the innovativeness of its people. In the 15th century, a Dubrovnik humanist, merchant, and nobleman named Benedetto Cotrugli (1416–1469) published Della mercatura e del mercante perfetto (Trade and the Perfect Merchant), which is thought to be the first work on bookkeeping in the world. It was also a trade manual advocating for honesty in all dealings.

The republic mediated trade between the Ottoman Empire and what was popularly called Christendom. Located at the intersection of territories practicing Islam, Catholicism, and Orthodox Christianity, Dubrovnik maintained a policy of friendly trade with people of all faiths in an era when religious tensions were high, while internally endorsing Catholicism. The city’s culture was unusually “secular, sophisticated, individualistic,” and cosmopolitan for its time. During its republican era, Dubrovnik became a major center of Slavic literature and art, as well as philosophy, particularly in the 15th, 16th and 17th centuries—earning the city the nickname “the Slavic Athens.” It produced notable writers, such as Cerva (1463–1520), Šiško Menčetić (1457-1527), Marin Držić (1508–1567), and Ivan Gundulić (1589-1638), now regarded as Croatia’s national poet. His most famous poem is the “Hymn to Freedom”:

O liepa, o draga, o slatka slobodo,

dar u kom sva blaga višnji nam Bog je dô,

uzroče istini od naše sve slave,

uresu jedini od ove Dubrave,

 sva srebra, sva zlata, svi ljudcki životi

ne mogu bit plata tvôj čistoj lipoti.

 O beautiful, o precious, o sweet Liberty,

the greatest gift of all the treasures God has given us,

the truth of all our glory,

the decoration of Dubrovnik,

all silver, all gold, all human lives

are not worth as much as your pure beauty.

Despite its lack of military power and its miniscule size, Dubrovnik’s economic freedom and remarkable political and social stability helped the tiny republic to survive for almost half a millennium before Napoleon conquered it in 1808. While Dubrovnik was at times compelled to provide tribute to its more powerful neighbors to maintain political independence, the republic’s citizens were proud of their relative liberty. In fact, the republic’s Latin motto was Non bene pro toto libertas venditur auro, meaning, “Liberty is not sold for all the gold in the world.” The republic’s flag was simply the word Libertas (Latin for “liberty”) in red on a white background. From 1792 to 1795, Dubrovnik also issued silver coins called libertinas, featuring the word Libertas in the design’s central position. Moreover, the republic was among the first European countries to abolish slavery, outlawing the slave trade in 1416. The city’s governing council voted that “none of our nationals or foreigners, and everyone who considers himself or herself from Dubrovnik, can in any way or under any pretext to buy or sell slaves . . . or be a mediator in such trade.”

Recognizing the threat that recurring outbreaks of bubonic plague posed to their city, the people of Dubrovnik took action to preserve their trading prosperity and their very existence. Thanks to Dubrovnik’s public health measures, the city managed to prevent many deaths and even achieve significant mercantile expansion during the plague period.

Bubonic plague is a bacterial disease that, when left untreated, is usually fatal within days of symptoms appearing. The bubonic plague has ravaged humanity many times, and has even been found in human skeletons dating to 3000 BC. Bubonic plague cases still occur even today. The first outbreak of the illness that was widespread enough to be termed a pandemic occurred in the 6th century AD, during the reign of the Byzantine emperor Justinian I. But the bubonic plague pandemic that devastated Asia, Africa, and Europe in the 14th century—named the Black Death or the Great Pestilence—proved to be the most fatal pandemic in recorded history, killing perhaps as many as 200 million people, including up to 60 percent of Europe’s population. 

That outbreak first emerged in western China. In just three years, between 1331 and 1334, bubonic plague killed more than 90 percent of the people in Hebei Province, which covers an area of land slightly bigger than Ireland. Over 5 million Hebeian corpses presented a preview of the deaths to come.

The scale of the devastation is difficult to imagine. The Black Death laid waste to Europe from 1346 to 1353. In 1348, the bacteria wiped out 60 percent of Florence’s population. That same year, the plague reached France, and within four years at least a third of Parisians were in the grave. The following year, the plague arrived in London and halved that city’s populace. In practically every city and town, the tragedy repeated itself.

One firsthand account of the devastation notes: “[T]his mortality devoured such a multitude of both sexes that no one could be found to carry the bodies of the dead to burial, but men and women carried the bodies of their own little ones to church on their shoulders and threw them into mass graves, from which arose such a stink that it was barely possible for anyone to go past a churchyard.”

Survivors were haunted by grief and loneliness. In 1349, the Italian writer Francesco Petrarch, who lost many companions to the plague, including his muse Laura, wrote:

Where are our dear friends now? Where are the beloved faces? Where are the affectionate words, the relaxed and enjoyable conversations? . . . What abyss swallowed them? There was a crowd of us, now we are almost alone. We should make new friends—but how, when the human race is almost wiped out; and why, when it looks to me as if the end of the world is at hand? Why pretend? We are alone indeed.

Despite life’s hardships, survival was nonetheless preferable to death, and people made a great number of innovative attempts to prevent and treat the disease that was decimating humanity. Many of those measures were tragically ineffective, such as bloodletting and avoiding baths. (Bathing was thought to expand the pores and make one vulnerable to disease.) Some measures helped a little in the prevention of illness—such as avoiding foul smells, including rotting corpses, and encouraging better home ventilation. 

Famously, medieval understanding of how disease spread left much to be desired. Many assumed that the Black Death was a divine punishment for mankind’s sins, giving rise to the distressing flagellant movement, and some of the brightest minds of the day at the University of Paris, when commissioned by the king of France to explain the plague, concluded that the movements of Saturn were to blame. Others blamed witchcraft. Reprehensibly, still others violently scapegoated religious minorities: “Hygienic practices limited the spread of plague in Jewish ghettos, leading to the Jews being blamed for the plague’s spread, and widespread massacres, especially in Germany and Central Europe.” 

However, while they may not have grasped the cause of the illness, medieval people did possess the general concept of contagion. They knew that the plague disseminated from one place to another and that transmission was occurring in some way: the suspected vectors ranged from the wind to the gaze of an infected person. 

Fortunately, medieval people did not need to know that the bubonic plague spreads mainly via fleas to figure out that limiting contact with people and objects from known outbreak sites was the most prudent course of action. This idea became widespread in part through the works of various physicians publishing medical pamphlets or tractates throughout Europe that may have represented “the first large-scale effort at popular health instruction in history.” The Catalan doctor Jaume d’Agramont (d. 1350 of plague), for example, advised the public against eating food from “pestilential regions,” and wrote that “association with a sufferer of a pestilential disease” could cause the illness to spread from one person to another “like a wildfire.” The possibility of interpersonal transmission became widely suspected, even if few guessed at the flea’s role as an intermediary. 

Even before the plague, Dubrovnik made several strides toward better public health. While we now take basic hygiene measures for granted, Dubrovnik was something of a medieval outlier when it limited the disposal of garbage and feces in the city in 1272. The city banned swine from city streets in 1336, hired street cleaners in 1415, and created a complete sewage system in the early 15th century. Dubrovnik’s relative prosperity allowed it to offer competitive wages to draw physicians from other cities, such as Salerno, Venice, Padua, and the home of the first university, Bologna. In 1390, Dubrovnik also created the world’s first permanent public health office to enforce its various public health rules.

Economic incentives helped motivate the trade-dependent city’s innovations in public health and sanitation: “Sanitary measures in Dubrovnik were constantly improved because the city was forced to find a way to protect itself from diseases and at the same time retain the lucrative trade relations which formed its economic base.” During the outbreak of 1347, the Dubrovnik writer and nobleman Nikola Ragnina (1494–1582) claimed that people first attempted to banish the plague with fire: “There was no cure and everyone was dying. When people saw that their physicians could not defend them, they decided to . . . purify the air with fire.” The fires may have helped to kill off some of the plague-carrying fleas, but were ultimately a failed experiment. So, they tried something new.

Even a primitive understanding of how the illness spread proved sufficient for the people of Dubrovnik to attempt a radical and historic experiment in disease prevention. In 1374, Venice first put in place waiting periods for ship passengers to enter their city, but this was purely at the discretion of health bureaucrats, thus leading to irrational, selective enforcement. But in 1377, Dubrovnik’s council implemented a much more logical system: all passengers on incoming ships and members of trade caravans arriving from infected areas were to wait for 30 days in the nearby town of Cavtat or the island of Mrkan before entering Dubrovnik’s city walls. The quarantine period was soon expanded to 40 days (the word “quarantine” means “40 days”)—a number likely reached as a result of experience, as the full course of the bubonic plague from contraction to death was typically around 37 days.

“Dubrovnik’s administration arrived at the idea of quarantine as a result of its experience isolating leprosy victims to prevent spread of the disease,” notes historian Ana Bakija-Konsuo. “Historical science has undoubtedly proved Dubrovnik’s priority in the ‘invention’ of quarantine. Isolation, as a concept, had been applied even before 1377, as mentioned in the Statute of the City Dubrovnik, which was written in 1272 and . . . is the first mention of the isolation of the patients with leprosy.” Dubrovnik’s stone seaside quarantine shelters, sometimes considered the first plague hospitals in Europe, were called lazarettos after Lazarus, the patron saint of lepers. Today the city’s lazarettos serve as tourist attractions and concert venues.

Devastating plague outbreaks eventually forced Venice to implement a complete ban on anyone entering its walls, bringing trade and city life to a halt, but Dubrovnik’s limited waiting periods let the republic keep its doors open to people and merchandise from abroad. “Hence, Dubrovnik implemented a method that was not only just and fair, but also very wise and successful, and it [eventually] prevailed around the world,” according to historian Ante Milošević. Quarantine procedures remain the standard policy to this day when dealing with certain contagious diseases.

The Black Death pandemic is sometimes viewed as the end of medieval civilization and the beginning of the Renaissance period. Faced with a disease that would not become treatable until the advent of antibiotics in the 1940s, Dubrovnik certainly underwent a rebirth, recovering from the initial wave of deaths to become the first city to implement a coherent public health response to the bubonic plague. Dubrovnik’s invention of quarantine represents not only perhaps the highest achievement of medieval medicine, but the emergence of one of humanity’s oldest disease-prevention tools and a turning point in the history of public health. With its strong ideals of liberty and devotion to public health, Dubrovnik during its republican era has earned its place as our 37th Center of Progress.

Chelsea Follett is the managing editor of HumanProgress.org and a policy analyst in the Cato Institute’s Center for Global Liberty and Prosperity.

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