Since its publication in 1986, Alex Scobie’s “Slums, Sanitation, and Mortality in the Roman World,” has dominated discussion of Roman public health and sanitation. While Scobie acknowledges that the Romans “achieved a remarkable standardization… [and] some degree of progress in the sphere of public hygiene,” his vision of Rome is at times as gripping and revolting as the Chicago of Upton Sinclair’s The Jungle. Scobie’s clout has not been limited to the field of Roman history; authors of more general surveys of health and sanitation also frequently turn to Scobie (and often Scobie alone) when they have occasion to make reference to the Roman period. Though thirty years old, Scobie’s bleak vision of Roman health and sanitation prevails both in and outside the field of Roman history.
This was not always the case. To the Victorian-era pioneers of sanitary engineering in the Western world, Rome was a paragon of public health. In an 1850 editorial article summarizing Edwin Chadwick's recent Report of the Sanitary Commission to Parliament, the Edinburgh Review cited ancient Rome as the supreme example of a state that cared about the health of its citizens. As science advanced over the course of the late 19th and, especially, the 20th century, however, Rome lost its status as the ultimate model of public health.
While they paint drastically different pictures of the health conditions of ancient Rome, Scobie and the Victorian sanitarians share a conception of what it means to write the history of Roman public health. Both organize instances of public action related to health into narratives of sanitary progress, always with modern standards in mind. Rome is understood to be either an admirable early forerunner of modern public sanitation, or — after Scobie — another example of how wrong-headed all pre-modern people were with regard to their own collective health. Such an approach necessarily simplifies the historical context of each period included in order to emphasize the narrative leading to the achievements of modern medicine. What is left out from such assessments of ancient public health is how Romans themselves understood the role of the state in their collective health. Specifically, how did Romans understand their own collective health and the role of the state in safeguarding it?
Central to this line of inquiry is Salus, the divine Roman personification of a complex concept often translated as “welfare” or “salvation,” but that became increasingly associated with physical health over the first two centuries of the Roman empire. The importance of Salus to the Roman state has been highlighted by two major recent studies of imperial ideology, both of which identify Salus as one of the most commonly attested values or benefits advertised on imperial coinage, alongside more obvious personified concepts like Victoria, Felicitas, Pax, and Concordia. In order to illustrate the changing importance of Salus to the Roman government, and the variety of methods used in its interest, I synthesize three relatively well-worn subfields of Roman history that have so far remained discrete: first, the history of Roman hydraulic and sanitary engineering; second, Roman medical history, including especially the history of disease; and third, Roman political history. In particular, I rely on three separate threads of evidence: first, state responses to epidemic disease, second, the construction and maintenance of aqueducts, and, third, the relationship between the Roman state and medical authorities.
Each of these threads provides a different perspective on the question of Roman public health, and my findings for each suggest that Roman ideas of what could and should be done in the interest of public health were more intimately connected to political climates than they were to the state of scientific knowledge, such as it was. My examination of state responses to epidemic disease reveals a major disjunction: first, the decline and fall of the Republic saw the end of a centuries-old practice of interpreting certain large-scale outbreaks of disease in Rome as portents from the state gods requiring interpretation and expiation by senator-priests. While there is no evidence that the prevalence of epidemic diseases decreased and supernatural explanations for diseases persisted throughout antiquity, the Roman government treated no epidemic as an official portent requiring state intervention after 142 BCE — with the possible and fascinating exception of the Cyprianic Plague in the mid-3rd century.
The state management of Rome’s water infrastructure, too, changed dramatically with the fall of the Republic, and specifically with Augustus’s creation of the office of the curator aquarum. Previously, the construction of new water conduits had been a political minefield: because of their huge expense, the individual senators who built Rome’s first aqueducts gained popular approval and lasting fame, but risked reprisals from their political opponents. On the other hand, the maintenance required to keep existing ones in working order was largely neglected, resulting in periodic water crises. Aqueduct technology itself did not change in any meaningful way over the course of the first century BCE. Rather, the highly erratic nature of the expansion and upkeep of Rome’s early aqueduct system was an organizational problem that arose from the competitive, suspicious, and jealous nature of Roman Republican politics. Likewise, the orderly and stable form of aqueduct management instituted by Augustus was only possible because of the contemporary political situation: the water system, like all of Rome’s infrastructure, was now presented as a beneficence from the emperor.
While major changes in the relationships of the Roman state with epidemic disease and water management are clearly connected to the fall of the Republic and the creation of imperial ideology, the state’s relationship with medical authorities is somewhat more complicated. Because of their close ties and self-proclaimed cooperation, I include both professional physicians and their patron god Asclepius here. Both doctors and Asclepius were in many ways defined in the Roman world by their Greekness: Cato the Elder famously declared that professional medicine was a Greek conspiracy against the Roman state, and Asclepius was said to have been literally brought from Epidaurus to Rome by a special senatorial embassy in response to a state crisis. As such, medicine’s relationship with the state was largely shaped by the official position of Rome’s government toward Greek culture. Starting in the Principate, the profession of medicine itself gained a political meaning as the body of the emperor became a metonym for the state itself.
Like modern public health, my research is a step removed from medicine per se. One reason for this is that, then as now, the state of knowledge about the human body is only one among many factors that influence health policy. There is no record of a professional physician being involved with the construction of any aqueduct or sewer, for example, but there is abundant evidence that Romans — including Romans who were part of imperial administrations — believed that good water management improved urban health. Physicians are also absent from Republican narratives of epidemic disease, though for a different reason: because of the politico-religious meaning attributed to epidemics in the capital, medicine does not seem to have been considered useful or relevant in such cases.
Some historians of Roman medicine, such as Ralph Jackson and, especially, Vivian Nutton, have long paid attention to the social and cultural aspects of medicine. Given the relatively circumscribed role of professional physicians in the Classical world, however, medical history can only tell us so much about ancient conceptions of public health. Coming up against the same problem in their own period, a group of medieval historians led primarily by Guy Geltner and Carole Rawcliffe have proposed a new approach to writing the history of pre-modern public health in a way that neither relies on modern narratives of progress, nor diminishes political and cultural contexts. First, Geltner and Rawcliffe hold that the intention to improve health and reduce disease in a population should be divorced from the efficacy of those programs, and the inefficacy of a program should not negate the historical importance of the social and political conditions that led to its implementation. Second, they contend that the tendency of public-health historians to use only medical texts and legislation as evidence when studying pre-modern public health is misguided. Instead of these ‘prescriptive and normative’ sources, which give a skewed and incomplete picture of the ‘healthscape’ of a particular time, they argue that historians must incorporate ‘descriptive and practical’ sources like diaries, letters, court documents, and contemporary histories or chronicles in order to understand what people and governments actually did in response to disease. Such sources may be scarce in ancient Mediterranean contexts, but other types of evidence do abound, including inscriptions, iconography appearing on coinage, and literature. These also have much to teach us about health and healthcare in ancient societies, if we ask them the right questions.
Dr. Caroline Wazer recently defended her dissertation, on the concept of public health in Republican and early Imperial Rome, in the Department of History at Columbia University.
 As of February 5, 2017, Google Scholar records 264 citations of the article.
 Alex Scobie, 1986 “Slums, Sanitation, and Mortality in the Roman World,” Klio 68.2.
 Recent examples include V.A. Curtis (2007), “Dirt, disgust and disease: a natural history of hygiene,” Journal of Epidemiology and Community Health 61.8: 660-664., which interestingly cites Scobie as evidence for how much the Romans cared about hygiene, Michael McCormick (2003), “Rats, communications, and plague: Toward an ecological history,” Journal of Interdisciplinary History 34.1: 1-25., and Nikola Koepke (2016), "The Biological Standard of Living in Europe from the Late Iron Age to the Little Ice Age." The Oxford Handbook of Economics and Human Biology. Oxford University Press, 70.
 Edinburgh Review 1850; this narrative was reprinted the same year in the “Shattuck Report” of the Massachusetts Sanitary Commission, which resulted in the creation of first state health department in the United States.
 On changes in the meaning of Salus over time, see Martin A. Marwood, The Roman Cult of Salus. B.A.R., 1988 and Lorenz Winkler, Salus-vom Staatskult zur politischen Idee. Verlag Archäologie und Geschichte, 1995.
 On the prevalence of Salus in imperial coinage, see Carlos F. Noreña, Imperial Ideals in the Roman West : Representation, Circulation, Power. Cambridge University Press, 2011 and Erika Manders, Coining Images of Power : Patterns in the Representation of Roman Emperors on Imperial Coinage, A.D. 193-284, Brill, 2012.
 A version of my findings for this section has been published as “Between Popular Medicine and Public Health: Senatorial Responses to Epidemic Disease in the Roman Republic” in William Harris, Popular Medicine in Graeco-Roman Antiquity: Explorations, Brill (2016).
 On the likely connection of the Decian persecutions to the Cyprianic plague, see Kyle Harper, "Pandemics and passages to late antiquity: rethinking the plague of c. 249–270 described by Cyprian." Journal of Roman Archaeology 28 (2015) and “Another Eye-witness to the Plague Described by Cyprian and Notes on the ‘Persecution of Decius’”. Journal of Roman Archaeology 29 (2016). On the treatment of epidemics by the Byzantine emperors, see Dionysios Ch. Stathakopoulos, Famine and pestilence in the late Roman and early Byzantine Empire: A Systematic Survey of Subsistence Crises and Epidemics. Aldershot (2004).
 See Bruce MacBain, "Appius Claudius Caecus and the Via Appia." The Classical Quarterly (New Series) 30.02 (1980), p.361, on senatorial reactions to the public works of Appius Claudius Caecus, including the Aqua Appia.
 Livy, Per. 11, Ovid, Metamorphoses 15.644-745 and Fasti 1.290-294, Strabo 12.567e, Valerius Maximus 1.8.2, Pliny, HN 29.16 and 29.72, Arnobius 7.44, Augustine, DCD 3.12a and 10.16g, Orosius 3.22.5.
 For example, Frontinus, De aquis I.1 and Pliny the Younger, Ep. 10.90, 91.
 The following position is set forth in Guy Geltner (2012), "Public Health and the Pre‐Modern City: A Research Agenda."History Compass 10.3: 231-245; Guy Geltner (2013), "Healthscaping a medieval city: Lucca's Curia viarum and the future of public health history." Urban History 40.03: 395-415; and Carole Rawcliffe (2013), Urban Bodies: Communal Health in Late Medieval English Towns and Cities. The Boydell Press.
 Geltner 2013, 395.