Prevention is far better than cure. Revisiting the past to strengthen the present: the lesson of Bernardino Ramazzini (1633-1714) in public health E-Book

Giuliano Franco

• Herausgeber: Youcanprint
• Kategorie: Fachliteratur
• Sprache: Englisch
• Veröffentlichungsjahr: 2020

Beschreibung

Doctor at the court and academic of the Modena and Padua Universities, Bernardino Ramazzini (1633-1714) lived in the second half of the seventeenth century. Without renouncing to his vocation as a doctor, he visited the craft workshops to identify the threats to health, examined the diseases of workers and proposed a variety of preventive measures. Aware of the need to avoid extremes of all kinds, he recommended moderation in all types of behaviour. The expression «prevention is far better than cure» summarises his precept. Through the description of the context in which he lived and the analysis of his observations and proposals, the essay explores Ramazzini’s main works by revisiting his thinking in a contemporary way, highlighting the modernity of his anticipatory reflections and focusing on his visionary ideas.

Leseprobe

Contents

Preface

Overview

1 - Introduction

2 - An all-around doctor and scientist

3 - The historical context

4 - Territory and demographic structure of the Duchy of Modena and Reggio

5 - Culture in Modena Capital

6 - Economy, techniques & technology of production in the seventeenth century

7 - Work and health:an epistemological relationship

8 - Work and health in Ramazzini’s thought

9 - Medicine and doctors in the second half of the seventeenth century

10 - The commitment to the health of peasants and artisans

11 - The Diatriba about workers’ diseases

12 - The Commentatio on princes’ disorders

13 - A semantic readingof the Diatriba

14 – Quam artem exerceas? What is your job?

15 - The epidemiological approach

16 - Residential proximityto environmental hazards:a paradigmatic case

17 - Health risks from exposureto metals

18 - Work-related lung disorders

19 - An eponymousof a work-related syndrome:the hypersensitivity pneumonitis

20 - Physical effort, poor posture and fatigue: the epidemicsof musculoskeletal disorders

21 - Stress on mind and body

22 - Health problems associated to nightwork and long hours of work

23 - Occupation and voice disorders

24 - Environmental noise and health

25 - Health problems from exposure to radiations, workplace heat and external climate

26 - Medications and risks to health

27 - Odours, headache, and hypersusceptibility

28 - Eye fatigue

29 - Work-related cancer

30 - Discovering the link between environmental hazard & risk to health

31 - Risk communication

32 - Old and new preventive approaches: hazard identification, risk assessment, and health protection measures

33 - Personal protective measures

34 - The theme of moderation in the Diatriba and the Commentatio

35 - Workers well-being and workplaces health promotion

36 - Sedentary job and physical activity

37 - Food intake

38 - Alcohol drinking

39 - Exposure to tobacco

40 - Inequalities and vulnerabilities: then and now

41 - Gender inequality and vulnerability

42 - Inequalities and vulnerabilities: ethnic minority workers

43 - Ethical issues in health protection of workers: a framework

44 - Principles and ethical virtues of the Diatriba

45 - First, do no harm and pursue the good

46 - An empathic attitude toward individual and people

47 - Serving the interest of the people and ignoring external pressures

48 - Love for study, willingness to improve, humanitarian attitude

49 - Fostering the integration of practical medicine (Medicina practica) and experimental research (Medicina theorica)

50 - Prevention is far better than cure

51 – On the development of risk prevention and workers health protection

52 - Occupational health & whole-person health

53 - The lesson of Ramazzini

54 - Afterwords. The legacy of the pioneering work of the Magister

Biographical notes, relevant historical events and other facts

Relevant quotations

Bibliography - 1. Ramazzini’s works and writings

Bibliography - 2. References

Figures & Table

Giuliano Franco

Prevention is far better than cure 

Revisiting the past to strengthen the present: the lesson of Bernardino Ramazzini (1633-1714) in public health.

Cover: Portrait of Bernardino Ramazzini, Philosopher and Physician of Carpi. Work by Anthony Stones based on the engraving by. G. Seiller (Geneva, 1716). From: Glass B, Stones A, Franco G. Diseases of Workers by Bernardino Ramazzini. A Tribute. Wellington: Department of Labour. 2000 (by courtesy of Anthony Stones).

© 2020 Giuliano Franco <[email protected]>

This book is based on the Italian version “Meglio prevenire che curare. Il pensiero di Bernardino Ramazzini, medico sociale e scienziato visionario” published in 2015 (222 pages). The book has been thoroughly reviewed and enriched by illustrations of the Diatriba (1713 edition) and other writings. The text and notes have been reviewed and updated in the light of most recent scientific literature. This edition includes some biographical notes, a timeline of relevant historical events and other facts, the most relevant quotations of the Diatriba and other works, and a bibliography including both Ramazzini’s works (quoted in the text) and consistent scientific and scholarly references.

Title | Prevention is far better than cure - Revisiting the past to strengthen the present: the lesson of Bernardino Ramazzini (1633-1714) in public health.

Author | Giuliano Franco

ISBN | 9788831663021

© 2020. All rights reserved to the author

This work is published directly by the Author through the Youcanprint self-publishing platform and the Author holds all rights thereof exclusively. No part of this book can therefore be reproduced without the prior consent of the author.

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Preface

Busy occupational and public health practitioners who do not have the time to keep up with the burgeoning specialist literature may find it easier to ignore history completely. The result is an increasing distance between historians and practitioners, a situation that results in the impoverishment of a public health robbed of his historical perspective: the origins of disciplines, the scientists who contributed to their development, the research on which the practice is based1. This essay proposes to the doctors, especially to the young doctors, but also to those who in different ways are involved in occupational and public health, a reading of Bernardino Ramazzini work (Figure 1).

The self-congratulatory and sometimes even iconoclastic impetus occasionally ascribed to Ramazzini’s works prompted me to reconsider the way how to treat the subject. This essay has neither the purpose nor the ambition to analyse the matter in the guise of a biographer or a historian, who I am not. It does not aspire to be included among the high quality and highly valued writings of several distinguished scholars, mainly historians, who wrote quite extensively about the Carpigian. Rather than a critical or a historical analysis of his writings to be compared with the works of most eminent scientists and philosophers of the recent and less recent past, it wants to be a simple educational and straightforward proposal for a modern rereading and revisitation of Ramazzini’s words. For this reason, that is to bypass some trivial or biased interpretations of his thought and to avoid the discussion of other analyses, Ramazzini’s own words have been widely reported2. By limiting the historical references to those that could not be actually omitted, the essay endeavours to distil his lesson through the current experiences, thus removing disputable and ambiguous hypotheses, inconsistent judgments, questionable interpretations, and vested-interest statements. Therefore, this essay tries to let the Magister talk as far as possible and aims, through his words, to make comprehending the original and innovative character of the De Morbis Artificum Diatriba3and other writings in the context of current advances in the field of occupational health. In Ramazzini’s words, readers will be able to discern his ancient, but ever vital contribute within the current trends and future challenges for both research and prevention in the field of occupational health and public health4. In such way, it is possible to appreciate that several, if not all, preventive and promotion interventions in workplaces find their ideal origins in the past as evidenced by the visionary words of an eminent doctor and social scientist5.

Overview

Although work-related disorders represent today a challenging issue from the economic, social and health point of view6, in the second half of the seventeenth century, the health of workers was not a priority for the states. Therefore, it may be surprising that a scholar paid attention to workers health conditions in a period characterised by a deep economic and cultural recession. Doctor at the Este court and academic at the School of Medicine of Modena, Bernardino Ramazzini was a brilliant clinician, a doctor who cared about humble’s health, a scientist who inquired into unusual realities7. He systematically analysed the relationship between the environment and disease by observing working techniques, describing work-related disorders and proposing preventive measures8. For his main work, the Diatriba, he is acknowledged as the founder of occupational medicine9.

In working environments, he identified the hazards that could harm health and caused specific disorders in individuals and in groups of workers who carried out the same activity. He classified diseases according to the type of job performed and described, in addition to several morbid forms of historical interest, still widespread pictures (bronchopulmonary pictures such as asthma in millers and hypersensitivity pneumonitis in those who sifted the cereals10, musculoskeletal disorders11, psychosocial problems12, noise damage13, breast cancer in nuns14), of which he suspected and sometimes understood the pathophysiological mechanisms.

Although a long scientific and regulatory journey has been made by introducing and refining methods and tools for the recognition of diseases, the diagnosis of work-related illness is mostly based on information gathered by the patient through work history. It was Ramazzini who first invited his colleagues to be rational15 and to always inquire as to a patient’s occupation since health is profoundly affected by the kind of work16.

Ramazzini’s interest went well beyond the description of clinical aspects of diseases. Sceptical about overuse and effectiveness of treatments of his time17, he was more concerned with prevention—prevention is far better than cure was his precept18. Ramazzini assumed that every preventive measure depended from the knowledge of risk19. He firstly identified and assessed the work-related risk and secondly, he suggested preventive measures. The risk assessment started from the observation of a morbid event not only in the single individual but also in the group of workers exposed to the same risk. In this way, he anticipated the modern epidemiological tool for the analysis of health status alterations both in working and in living environments20.

As for preventive measures, he foreshadowed a variety of actions that are well established today. As for what today is called engineering measures, he suggested removing the polluted air emitted from the minerals and advised too that the best way to contain dust pollution was to carry the work in a spacious place and not in confined quarters21. As for what today is called organisational and administrative control, such as reducing the working time to limit the exposure to a risk factor, he recommended men employed in the standing trades to interrupt the too prolonged posture and suggested to women widely involved in hard jobs, «nothing in excess»22. This advice is often found in other pages, indicating the need to be moderate23. The effectiveness of the suggested measures could be currently challenged; however, one should mention that his conceptual approach (firstly, identification of the hazard; secondly, mitigate the risk; thirdly, protect the individual) is consistent with preventive interventions now wholly established24.

In addition to health problems directly linked to occupational risk factors, Ramazzini was attentive to those related to lifestyle and proposed measures to limit the risk by suggesting healthier behaviours25. As to the sedentariness, he considered that the best thing was exercising the body and prescribed it first of all26. As to obesity, although the second half of the seventeenth century was the time of severe famines, and that manual workers had resources just sufficient to obtain a frugal livelihood, Ramazzini reminded that those who live longer and who are less suffering from diseases are the same ones who lead a sober and simple life—a well-known truth27. As to tobacco smoking that he defined an incurable and bad habit, Ramazzini was somewhat prophetic life— the vice will always be condemned and always maintained28. As to wine consumption, Ramazzini claimed that nothing is more hostile, either openly or subtly than the unreasonable intake of wine, and drew the attention on the damages, not only physical, that its abuse could provoke29. The set of indications in the works of Ramazzini shows how he anticipated the idea of considering the workplace as a privileged site to involve workers in health promotion programmes that aim to improve their well-being30.

While current relationships between patient and doctors are based on the assumption that physician’s first and primary duty is to the patient and are founded on deontological codes originated from the ethical principles, in the second half of the seventeenth century it was not the time for a doctor-relationship strictly based on these values. Ramazzini regularly showed an empathic attitude towards his patients or workers. He also displayed effective communication skills when he explained to the workers what was necessary to do to protect health from occupational hazards31. The expressions manifested a paternalistic attitude typical of the doctor of that time towards the patient; they aimed to instruct the subject to take appropriate behaviour to avoid or limit exposure to hazards32. His messages always revealed his commitment to the patient’s welfare and his effort in helping patients to cope with illness but did not recognise any autonomy to individuals, who were mainly passive subjects33. Although sometimes his frankness went beyond the political correctness boundary of our time34, Ramazzini remained in sharp focus and respectful of any humble or vulnerable individual35 and revealed an honest paternalism based primarily on the language of moderation36. Although one can speculate on a certain grade of independence from the powers of the Church and the civil authorities37, it could be asserted that the Diatriba, which is primarily inspired to the Hippocrates precept (first, do no harm), offers a view unquestionably aimed to protect and improve workers’ health38. It is easy and perhaps even surprising to find some of these elements (beneficience, autonomy and justice) in current codes of ethics for health professionals, which guide and assist the ethical behaviour towards the various stakeholders: workers and their representatives, company, other public and private bodies, and colleagues39.

In Ramazzini’s work, we find the elements that characterise current regulations to safeguard the health of those who work. He anticipated the well-established points and the current trends of occupational health: (i) understanding the association between environment and health, (ii) suspecting the working and environmental origin of every disease, (iii) suggesting interventions aiming at protecting workers health, (iv) promoting workers health issues by addressing sedentariness, lack of exercise, food intake, and any abuse40. He proved far-sighted and prescient when he paid attention to the behaviour of individuals, to whom he recommended following a balanced lifestyle—advice more and more valued because life does not consist of simple living, but in being well41. His lesson remains alive and offers as a model of behaviour for every doctor, for the community of occupational health professionals, for those who practice in companies and the public health field42.

1 - Introduction

On 5 November 1714, Bernardino Ramazzini passed. His figure, work, ideas, message, virtues have been the subject of some celebratory events that have outlined his profile as a doctor, scientist, innovator, nonconformist spirit, enlightened genius, who lived in a period like that of the second half of the seventeenth century, characterised by a profound socio-economic and cultural recession that influenced every aspect of human life. Although it is difficult to add anything to the writings of historians43 and the publications of scholars of the Magister44from Carpi, the commemorative events of the third century of his death represented an opportunity, not only repetitive and not only ritual, to focus on his thought45.

It is worth mentioning, on the one hand, his innovative drive, which still today surprises in the light of the evolution of the protection regulations and on the other his curiosity towards natural phenomena that have made possible observations and discoveries in the meteorological and geological field documenting his vocation of a complete scientist.As regards the contribution in the medical field, it has been emphasised the modernity of teaching which, ignored for many decades and understood in its entirety only in the last century, is still utterly relevant today. Ramazzini’s lesson provides topical elements both for the medical practice in general and for the health protection of those who work. It cannot fail to amaze how Ramazzini, who lived in a period in which medicine is often practised by health professionals who sometimes took the form of the Commedia dell’Arte masks properly described by Molière in The Imaginary Invalid, stood as a critic, sometimes with lashing and mocking words, of the useless if not harmful practices of colleagues46. He strongly recalled the importance of the practical medicine of which he claimed a role equal to that of theoretical medicine. He manifested his doubts about the efficacy of many popular treatments and censored the colleagues used to repeat prescriptions of drugs. On the other hand, he was a supporter of a simple medicine based on correct nutrition, rest and cleanliness. Such orientations were somewhat unusual and even daring at that time; some suggestions, regardless of the existence of the Inquisition, were in contrast with the influence of the Church regarding the cleaning of the body and the burial outside the churches.

Many are the innovative elements of his thought that could be exercised in the current medical profession. The understanding of the association between environment and health, the suspicion of an environmental origin of any pathology, the need to collect the working history of all patients are universal teachings that today constitute mandatory educational goals for medical students. Some other proposals are also popular: the prudent suggestions in undertaking therapy, advice aimed at adopting useful professional practices and the recommendations to show a compassionate attitude towards patients.The lesson for the occupational physician is also modern. Ramazzini proved visionary when, abandoning his vocation as a doctor who cared for the patient, proposed to visit workplaces to identify dangers and investigate the damage that the work environment produced on those who work. He used an approach that today we would call epidemiological. The procedure was based on the observation of the group of workers, on assessing the risk and on proposing some measures that today we would define risk prevention, health protection, and risk information. His precept, expressed in his Oratio xiii given in 1711 by the expression «longe præstantius est præservare quam curare» (prevention is far better than cure), still proves the preventive vocation of theMagister47. Ramazzini also turned his attention to the behaviour of individuals. Aware of the need to avoid extremes of all kinds, he was inspired by the doctrine of classical philosophy when he recommended moderation in every sort of behaviour. Therefore, he advised «ne quid nimis» (nothing in excess), an indication expressing the need to follow a regular and balanced lifestyle. He also suggested healthy lifestyles (refraining from smoking, drinking wine moderately, controlling the passions of the soul) and recommended regular physical exercise for those who carried out a sedentary occupation and ventured to counsel temperance in the «venereorum usus» (sexual intercourse). All these indications demonstrate how Ramazzini anticipated the idea of considering the workplace as a privileged site to involve workers in health promotion programs that try to improve their lifestyle and well-being in a perspective that recognises health as a value48. The ethical aspects of the work, which take on the characteristics of the virtues aiming at the good of the people and counteract inequalities, should not be neglected. His ethical attitude is demonstrated not only by his choice to begin medical practice away from the cities but also by the attention to the living conditions of people. Hence, Ramazzini showed those universal values that today are revived in a different form both in the deontological code of the medical profession and in the codes of conduct to which occupational physicians, in compliance with the law, must abide in the exercise of their function49. The ethical and deontological aspects of Ramazzini thought are exposed and commented in chapters 43-47.

2 - An all-around doctor and scientist

In a considerable extent, Ramazzini owes his fame to his Diatriba50 and historians and scholars have valued the figure above all for this contribution (Figure 2-2). However, at that time his fame was established for scientific merits for other works. During his stay in Modena, in the last decade of the seventeenth century, he carried out an intense activity of practical doctor, scholar and academic. His professionalism and courteous manners were appreciated by all51 so that it was the same Duke Francis II to summon him to court from time to time «for up an hour, to discourse and converse with edifying readings, discussion on literary matters, having felt the pulse»52. However, his observations of natural phenomena stimulated him and inspired his research activities. In addition to dealing with the investigation of mercury movement in the Torricelli tube, he described the surface of the territory of Modena and the geological structure of the land, of which he represented the hydrogeological section graphically53.

Inspired by the Hippocratic lesson, Ramazzini devoted himself to the study of the relationship between climatic factors and the onset of diseases. He then published a series of geophysical writings that laid the foundations for studying the association between climate and disease54(Figure 3-2).The ingenuity and brilliance of the observations did not go unnoticed. The studies on the sanitary and climatological conditions of the territory were appreciated by European scholars and were worth the admission to the prestigiousCaesareo-Leopoldina Academia Naturae Curiosorum55. Similarly to other geniuses of the time who studied natural phenomena even outside the spheres of their profession, he proved himself a worthy researcher, endowed with a great depth of intellect and breadth of vision. The Diatriba is the work that made his figure immortal. In his work he gathered the observations made as a doctor and as an investigator of the territory, combining clinical remarks of the patient-worker with the description and analysis of working conditions, the environment, work techniques and related risks. In this way, he anticipated those researches on the diseases of the workers and those trends in the preventive field that will emerge after many years. He proved to be an acute observer of the working realities and nonetheless regularly showed an empathic attitude towards his patient, also displaying excellent skills as an experienced communicator when he explained to the workers (in reality, the doctors who read the Diatriba) what was necessary to do to protect health from occupational hazards. Some questions, perhaps rhetorical, could be formulated on the meaning of this work and the figure of the Magister. Is he a precursor of new ideas in the medical field? Is he an innovator in the social sphere? Is he the founder of a new discipline? Can he be considered an illuminist? Many historians analysed the work, discussed the context in which it was written, explored the contents, magnified the originality, thus helping to focus on the figure of Magister. His work is that of an exponent of the neo-Hippocratism who valued the practice of ancient medicine and represented a concrete medical-social conquest of the century56. By addressing some of the so-called social determinants of health57, he anticipated the future social medicine58. Indeed, one cannot help but remember his aptitude for paying attention to the humble and disadvantaged conditions of the people’s life, as evidenced both by his choice to start medical practice far from the cities and by his thinking about behaviour and responses to the therapies of common people and wealthy nobles59. Historians of the late nineteenth century recognised the value of the work60. However, doctors took on the role of protagonists in assessing and appreciating more fully the value of the Diatriba. It was Maggiora who expressed himself in this way about the aims and contents of the work:«In foreseeing the real task of hygiene and convinced that the doctor’s office is not only to cure the sick but also to prevent diseases and to promote a general improvement in health, [Ramazzini] conformed to these concepts a good part of his wise and beautiful scientific work [...] the hygienic work almost all the result of very accurate original observations [...] still today worthy of consideration»61. And among those who claimed his figure as a «tutelary deity», it was mainly the occupational physicians, thanks to the studies of Luigi Devoto, to pay more attention to his personality and his works62. At the same time, other scholars expressed their admiration for the Diatriba, which was recognised as the first treatise on occupational medicine and an original text of preventive medicine63. Ramazzini was acknowledged as the founder and father of occupational medicine64 and other disciplines65 and defined as an all-around scientist66 for his curiosity for natural phenomena, his cultural polymorphism and his multifaceted scientific activity67. To fully understand the manifestations of admiration and appreciation that have accompanied the history of the Diatriba it is necessary to place the work in the historical and socio-economic contexts that characterised the places where Ramazzini lived.

3 - The historical context

Bernardino Ramazzini was born on 4 October 1633 in Carpi68, in the Duchy of Modena and Reggio, an independent State in the Northen Italian peninsula69 (Figure 4-3). It was the same year in which Cardinal Bellarmino dragged Galileo Galilei before the inquisitors in a process that ended with the condemnation and dismissal of Galileo for Copernican theories. To understand his genius, we must consider the age in which he lived and the place where he worked. The period between the end of the Italian wars that reflected the wider European rivalries and the second decade of the seventeenth century coincided with the moment in which the Italian civilisation exercised its maximum influence on the western ones.Although there were considerable differences between the various territories in terms of development, population and wealth, Italy represented a model of cultural and scientific progress. In the Italy of the cities, there was a frantic development in the technical and commercial fields, goods and services were widely available, efficient governments of the territories limited the feudal rights of the princes70. The development of sophisticated financial mechanisms in the economic field, the high quality of manufactured products, the renewal of the techniques of production of goods, the integration of agriculture with cattle breeding, the introduction of valid administrative tools guaranteed prosperity. This phase of growth continued throughout the sixteenth century until the early decades of the seventeenth century. The period from 1600 to 1618 represented the culmination of mercantile and manufacturing prosperity. Towards the twenties of the seventeenth century, the peninsula was hit by wars that contributed to eroding commercial potential and curbing manufacturing activities. It was the Thirty Years’ War in Germany that determined the initial crisis, while the conflict between Spain and Holland made commercial sea routes dangerous. The flourishing system was about to collapse. There was a drop in demand for goods, a decline in manufacturing production, a shortage of food products, and a fall in tax revenues. Pestilence transmitted by belligerent armies hit Italy. The plague epidemics of 1630 and 1656 and the occasional epidemics of typhus, smallpox and malaria involved significant sections of a population that, weakened by malnutrition, lived in precarious hygienic conditions. These conditions marked the commencement of a long period of famine and Italy prepared to face a deep economic recession.

At the same time, also due to the growing oppression of the Church against intellectuals and academics who were not loyal to the orthodoxy, Italy lost its cultural influence71. Western Europe assumed a role of increasing importance in the economic and cultural fields and witnessed the birth of the scientific method that opposed dogmatism. Thanks to research in the areas of mathematics (the analytical geometry started by Descartes, the infinitesimal calculus presented by Newton), of physics (Newton’s universal gravity theory, Boyle’s gas laws, Huygens’ wave theory of light) and the inventions in the field of technology (the adding machine of Pascal, the calculating machine of Leibniz) started the modern science. In the areas of biology and medicine, several scholars and doctors emerged (Harvey, van Leeuwenhoek, Redi, Boerhaave) whose contributions offered some of the basis on which modern medicine is grounded. The cultural and economic centre of gravity, therefore, shifted from Naples-Rome-Florence-Venice to Paris-Amsterdam-London. Italy thus ceased to represent the model of cultural development and technical innovation72.

The period was characterised by a deep recession affecting every aspect of life also in the territory of the Duchy of Modena. The social problem was alarming. The testimonies provided a dramatic picture of the situation73. In this historical context marked by famine, epidemics and wars, the Magister conducted his studies, which led him in 1690 to hold the course De Morbis Artificum in the University of Modena and finally to publish the editio princeps of the Diatriba in 1700.

4 - Territory and demographic structure of the Duchy of Modena and Reggio

Due to the delegitimisation of the Este descent and the consequent devolution of the territory of Ferrara to the Papal States, Modena hosted Cesare d’Este, expelled from Ferrara by Pope Clement VIII and became the State capital on 29 January 159874. The status of the Este Duchy was strongly influenced by the relocation of the Court from Ferrara. Government and bureaucratic structure were transferred en bloc to the city, along with officials, staff and archives. Modena assumed the role of capital of the Duchy, but «in Modena the Court had to start from scratch, having arrived in tatters, an army of poor people without families and a future, led by a couple of bastards laden with children and debts, persecuted, or at best abandoned by the relatives»75. Like other Italian cities, whose economy depended above all on agriculture and artisan processing, the territory of the Duchy was also involved in the decline of the peninsula. There was a decrease in population, stagnating prices, reduced trade, the crisis of many manufacturing activities, the contraction of agricultural production and cultivated area. If at the beginning of the seventeenth century the Italian population amounted to just under 14 million people, in the period between 1600 and 1660 epidemics caused a reduction estimated between 10 and 15%76. At the same time, the population of Modena, which reached about 18,000 around the year 162077, decreased both due to the general demographic reversal and the effect of the plague78. During the plague epidemics of the years 1630-31 and 1656-57 the mortality, even if lower than the values around 40% observed in neighbouring cities (Brescia, Verona, Padua), reduced the population of Modena to ten thousand inhabitants79. Only after 1680, there was a slow but constant resumption of births and an increase in the number of inhabitants reaching 20,000 in the eighteenth century80. The average population density was around sixty people per square kilometre, reaching about one hundred in the low plain. The urbanisation rate of the ducal territory was in line with the Italian one: 15% of people lived in the cities of the Duchy, while most of them lived in rustic houses and scattered villages in the countryside and the Apennines81. The economic decay of the period, which determined the progressive urbanisation of the peasants, accompanied by the lack of labour demand, made life in the city increasingly critical. The concern and intolerance of the citizens who feared the invasion of miserable crowds to threaten the order and public health led to the issuing of tenders against urbanisation, against all «crippled, full of sores, vagabond, gypsy and rascal» and to strengthen the guard at the gates of the walls to protect the city82. The establishment of the Opera dei Mendicanti with the charitable function of offering help to the poor and with that of the magistracy responsible for the census and control of beggars dated back to that time83.

City structure and characteristics remained unchanged compared to the previous centuries. Modena had narrow streets, low arcades, poor hygienic conditions: «At that time the inhabitants of the city were allowed to keep all sorts of animals in their homes, including pigs. They threw excrement, bones, waste, debris and any other kind of rubbish in public streets and squares. Missing from paving, flooded by frequent floods and without any special commissioner or local staff in charge of cleaning, streets and squares always were cluttered with dust or mud, from trash, manure and all sorts of rubbish. It is easy to imagine the damage of aesthetics, hygiene and smell»84. The disposal of sewage and the purging of the 42 sewers took place in the days dedicated to rest when work activities were suspended. In this regard, it is well known the episode described in the xiv chapter of the Diatriba that stimulated Ramazzini’s interest in exploring a topic overlooked. Not as well known is the appeal to the authorities of his colleague of Studio Francesco Torti about the necessity to provide for the coverage of the open-air canal facing the hospital because of the «stench that offends not only the sick [...] and beyond indecency makes the wall and beds very damp»85.

5 - Culture in Modena Capital

In the European context, the economic and military importance of the Duchy was somewhat limited, and the events of the community were of little interest. Thanks to the protection accorded to letters and music, the figures of the Este Court are nevertheless worthy of attention86. Like the sovereigns of other Italian States, the Este family was committed to preserving authority and legitimising its power through the organisation of celebrations, ceremonies, parties, games and shows87. Festivals tended to support social cohesion through greater integration between the Court, aristocracy, personalities, and the people of Modena88. They represented an opportunity for employment for artists and favoured some distribution of wealth deriving from the production of goods and services89. The impulse given to culture, above all to music characterised that period90. The cantatas, which together with other vocal works, represented the most widely cultivated genres, consisted of arias and recitatives produced on didactic and moralising themes within the framework of the Accademia dei Dissonanti91. Duke Francesco II also gave impetus to the theatrical movement even through the construction of new theatres, which he controlled both as regards the choice of performances, instrumentalists and singers. Among the singers, a prominent place occupied the young Margherita Scevina Salicoli, a virtuoso at the Este Court who played in theatres throughout Europe92.

Although the competence and patronage of Francesco II in the field of music are well documented, the same cannot be said for other cultural areas. Indeed, the role played by the Court in establishing two institutions (the Accademia dei Dissonanti and the Studio) which, alongside the founding of the Este library, facilitated the commencement of the Enlightenment and Reformation of the following century in Modena is questioned93.

The culture in the Duchy had a significant presence94. Benedetto Bacchini, a scholar and religious figure, started the publication of the Giornale dei Letterati95, a journal that hosted articles written in the field of literature and science to which Ramazzini contributed as an editor for physics and medicine96. Some artisans provided support to cultural and literary movements. Following the transfer of the Este to Modena, it was the printers who benefited most. They obtained the printing of the material used by the Court and published the first Gazzetta di Modena. Alongside the prints of poems and short stories, funeral orations and public documents, the printers pursued the acquisition of the rights to publish the writings of Court counsellors, educators, writers97. If the establishment of the Studio and the Accademia, on the one hand, contributed to the cultural growth of the city98, on the other it offered printers the opportunity to publish the writings of scholarly research in the literary, philosophical, medical and mathematical fields. Among the printers who started their business in the second half of the century, Antonio Capponi, already a bookseller for twenty years, opened its doors in 1693. It was this company that won the rights to print the Diatriba99, despite previous works by Ramazzini were published for the types of Solliani and Cassiani.

It is difficult to believe that the cultural, musical and literary environment significantly influenced Ramazzini’s thought and may have represented the soil in which the key observations and values were rooted and grown. Ramazzini frequented a refined setting, rather closed and muffled, in which the literati were subjected to the vigilant control of the Este Court which aimed at preserving the image of the prince and in which writers and poets had limited autonomy in literary experimentation. However, greater freedom of thought was allowed to scientists. From 1682 in Modena there was a Studio, one of the 15 universities then existing in the territory of the Italian peninsula100. The university was granted the power to issue its diploma, but only in the following century obtained a formal recognition as an Estense State body101. Around the year 1670, when the Galilean experimentalism moved from Tuscany to the Emilia-Veneto area centred above all on Padua, the contribution to scientific activity provided by Modena was modest, also because the relations of the best scientists with the ducal territory were rather complicated and unstable. Ramazzini too, thanks to his reputation as a scientist and doctor, whose therapeutic addresses were against the therapies practised at the time and despite disputes and controversies with other doctors, was called to the Padua Studio. To Padua also moved the talented mathematician Geminiano Montanari and similarly, Lazzaro Spallanzani moved to Pavia some years later. Although the scholars’ activities were freely exercised in the Estense society, these stories testify that the academic structures were not adequate to offer those development prospects that other, more attractive, places could guarantee102.

6 - Economy, techniques & technology of production in the seventeenth century

In the first twenty years of the seventeenth century, Italy reached the peak of manufacturing production and commercial activity. After that, the events of the Thirty Years’ War had a profound effect on the production system and caused the collapse of the best trade routes. The crisis provoked the downfall of demand which, together with bad harvests, the ravages of war, the occurrence of epidemics, led to a constant decline in the economy that lasted for two centuries. The prolonged recession was caused by the rise in the cost of manufactured goods, by the obsolescence of production techniques that were at the forefront in the sixteenth century, by the offer of products at competitive prices by other countries, by the shift to the north and west of the best trade routes103. In the aftermath of the devolution of the Ferrara territory to the Church-State and the transfer to Modena of the Este capital, the area was more densely populated, less rich and more expensive in terms of organisation and government expenses. Government costs represented 30% of the revenues against 4% of those required in the old capital Ferrara before the transfer of the government to Modena104. Modena controlled the surrounding territory to ensure its supply and did not differ from other city-states that exercised a function of attracting the most qualified professions and the production of luxury goods for the upper classes, while artisans of villages of surrounding countryside manufactured mainly low-quality products105. Although precise data on the distribution of occupations is not available, it could be assumed that it was in line with that of neighbouring cities. About 40% of workers were employed in the textile and clothing sector, over 20% in the production of foodstuffs, about 10 % in the manufacture of iron artefacts, another 10% in the processing of leather goods and lower percentages in the sectors of transport, wood, construction and other activities, including liberal occupations106.

A prominent part of the Modena economy was linked to the supply of goods and services that served to satisfy the needs of the Court107. In fact, over a tenth of the entire population (about two thousand people) worked for it. The merchants supplied foodstuffs and high-quality manufactured goods, while numerous specialised operators (such as engineers, architects, painters, sculptors, turners, glaziers, blacksmiths, carpenters, tailors, embroiderers, shoemakers), sometimes paid by the day or by fixed-term contracts, carried out their assignments, the maintenance of the residences and their contents108. Attending the Este palace favoured Ramazzini’s relations with the aristocracy, servants, and other scholars. This allowed him to observe and describe the activities of various characters: from the Duke’s secretaries («how true is the saying that he who can keep the favour of princes deserves high credit») to the lackeys («panting footmen running at headlong speed in front of the coaches of their masters»). Besides, he noticed the artisan production that provided the palaces with large furnishings and goods: high-quality furniture, musical and scientific instruments, weapons, gold and silver objects109. Ramazzini observed the diseases affecting several workers engaged in the production of the good for the Este family and aristocracy. He happened to see chamber pots and gilded evacuation chairs and at this regard, and did not fail to describe the case of a young gilder intoxicated by mercury. Likewise, he described the affections observed in goldsmiths, watchmakers, artisans processing their handiwork, and in painters. Although the manufacturing sector based on the production of wool and silk products was declining, the Este palace guaranteed the demand for valuable products, in particular, felt headgears, which were very requested from abroad. In this case, perhaps it may be surprising that the Magister did not have the opportunity to examine the felting operations as a possible source of mercury poisoning110.

The increasing expenses of the government made it necessary to search for other sources of financing in addition to taxes and gabelles. In the mid-seventeenth century, upon payment of large sums, the government granted traders and entrepreneurs in a monopoly (the so-called privativa) of the production and trade of non-agricultural goods. In this way, the government pursued both the increase in revenue from duties on leisure goods consumption, such as tobacco, and the reduction of burdensome imports. At that time, the government granted the tobacco monopoly, the salt monopoly and the monopoly of the collection of rags for papermaking111. To all these are activities, Ramazzini dedicated his attention.

Thanks to the revenues deriving from the growing tax levies and the increased public spending, construction of several building infrastructures began: the ducal palace, the fortification of the town, the summer residence in Sassuolo, the creation and redevelopment of churches and monasteries. All these initiatives required the employment of several hundred workers. Ramazzini observed the works requiring poor postures and strenuous efforts and described the health damage of masons112, stonemasons, brick-workers and carpenters113. He did not neglect the sectors that offered a significant contribution to the economy of the Duchy: the production of ceramics and agriculture. Since prehistoric times the presence of vast clay soils in the area favoured the development of fictile manufacturing114. The spread and growth of poor ceramic production were ensured by the low cost of clay, deficient in calcium and rich in iron. Ramazzini often had the opportunity to visit the shops and thoroughly described the production technique of ceramic and terracotta. Except for the wooded or the completely clayey parts, the open area was intensely cultivated115. Consequently, the Diatriba devoted much space to the treatment of farmer diseases, but surprisingly not to animal husbandry, which was a widespread practice116. During his extended stay in Modena, Ramazzini personally visited the workplaces as repeatedly stated throughout the Diatriba. However, he could not always obtain firsthand information such as those related to mines or to salts pits. Sometimes he consulted some colleagues to get the necessary information on working processes and activities that were not present in the Este territory117.

He felt the need to expand his investigations into other areas. And after his move to Padua in 1700, he had the opportunity to visit the production sites of the Serenissima, as he always desired118. At the beginning of the century, Venice was still an industrial power and had 140,000 inhabitants. The arsenal was among the most significant industrial complex in Europe and employed three thousand arsenalotti like carpenters, workers caulking hulls, oar makers. The city was renewed and modernised. New occupations took root: mill grinders, glass workers, carpenters, reaping workers, sugar refinery workers, leather workers, tinkers, blacksmiths, goldsmiths, printers, weavers and silk producers119. The life in the Serenissima allowed Ramazzini to complete the Diatribawith the addition of 12 chapters. As stated in the preface to the supplement, Ramazzini completed the work during the summer that he spent, neglecting other commitments, to identify new categories of workers and examine their shops. Several chapters of the supplement contain information he collected in Venice or Padua, as in the chapter dedicated to grinders of razor and lancets: «in this city there is a man who is highly skilled in this trade of sharpening razors and lancets». In several other chapters, Ramazzini mentioned the productive techniques in use in Venice: in that dedicated to apothecaries, in that on the manufacturers of soap, and in the chapter on tinsmiths (whose houses and workplaces were concentrated in a single district to limit the trouble to the inhabitants). In these chapters, he described the technique related to observations explicitly made in the Serenissima. It is likely that in Venice, he watched the activities of carpenters engaged in the construction of ships and those of seafarers. However, part of the material used to compose the supplement, as well as the result of the proper research of sources120, were derived from his direct Modena experience121.

As you can see, the Diatriba dedicated much space to the description of production techniques. With few changes, they were mostly those of the Middle Ages and Renaissance. Significant innovations would only initiate with the Industrial Revolution122. Ramazzini was thoroughly interested in every production technique («Since the plan of this work compelled me to make repeated visit to workshop in order to explore thoroughly the exciting causes of the diseases to which workers are exposed, I was much inclined to insert here certain observations made by me») and specified he had in mind to prepare a monograph on their analysis and description123. He provided information on various production processes that were described in a simple way (glass-workers, process of card flax, hemp and silk, printers, method of preserving seeds, weaving, woods, carpenters, brick-making, wells excavation) and sometimes with more detailed information (potters, workers with gypsum, process of wool cleaning, bleaching and dyeing, process of oil extraction from nuts, tobacco workers, soap-makers). In some cases, he demonstrated himself a fair observer of the whole production process: «it would take too long to describe how they make soap […] certainly the process is more elaborate than one would suppose, and more laborious too»124.

7 - Work and health:an epistemological relationship

Understanding the relationship between work and health requires to define the two terms. The term work means any activity aimed at the production of goods and services. The word assumes a somewhat negative connotation that derives from the original meaning, according to which the concept of work denotes a sense of suffering125. The Latin terms labor (from which the English labour) and laborare imply the dimension of fatigue and effort of the manual activities of peasants and artisans. This meaning is also contained in the French term travail (literally torment, suffering) which derives from the late Latin and means torture with the tripalium, an apparatus with three stakes used to punish the subject tied to it126.

Defining health is not immediate and straightforward. You can refer to the well-known definition of the World Health Organization (WHO). Accordingly, «health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity»127. It has been argued that the current WHO definition of health is no longer adequate for dealing with the new challenges in health care. If applied to the letter, it would appear that very few individuals could admit to being in such a condition128. The definition has been criticised as being absolute and not measurable129. Assuming that the concept of health cannot be absolute and despite many attempts to replace it, no alternative definition has reached a high level of consensus130. Although redefining health is a complex goal, several proposals have been made for adapting the definition of health to the modern world. Recently, a more flexible and pragmatic definition was advised. Health should be considered as «a dynamic attitude based on the ability to adapt to different conditions and to self-manage in the face of social, physical and emotional challenges»131.

The terms work and health, thus defined, are linked by a two-way relationship. If health can affect work, the latter can affect health. On the one hand, work can be a source of gratification for the individual and, by exerting a positive influence on it, contributes to well-being132. On the other hand, work more often has a negative effect and constitutes a risk factor for the health of those who work. The burden of the work-related health-problems is evidenced both by the high number of people involved in the problem 133 and by studies aiming at assessing the risk factors among working people. More than 40% of people working in the European Union reported exposure to risk factors (such as postures, work rhythm, transport of heavy loads, noise and vibrations, dust and chemicals) potentially responsible for health damage134. Exposure to these factors led to the onset of work-related problems in 8% of cases135.This percentage, which is higher than that of the previous surveys carried out in 1999 and 2007 when respectively 4.7% and 7.1% of the working population reported problems, reflects the progressive deterioration of the health conditions of workers. These problems increase with age and are more frequent in women in the health care sectors and men in the construction and manufacturing sectors. The most common pathologies were bone joint or muscle problems mainly affecting the back, bone, joint or muscle problems primarily affecting the neck and shoulders (which mainly affect workers with lower education) and mental health changes, stress, depression or anxiety (reported by people with higher education levels). Heart problems, breathing or lung problems, and headache were less frequently described as the most severe work-related health problem. The least often reported were infectious diseases, hearing problems, and skin problems136. These health problems, which result in the loss of many millions of working days, demonstrate how workers still frequently present health damage due to work and show how the need to take measures to safeguard the health of those who work still exists. Worldwide legislation on health and safety in workplaces is based chiefly on different types of approach137. The first type of approach pragmatically includes legal obligations to carry out precise actions to protect workers health from risks. The second type is based on an integrated service, with specific objectives, activities, responsibilities and rights of the stakeholders138. This approach is set up by Conventions and Recommendations of the International Labour Organization, which are designed to be adapted to specific national law139. A comprehensive approach to workplace health is followed in the European Union140. According to art. 153 of the Treaty on the functioning of the European Union, the Union supports the activities of the Member States in several fields, including (i) improvement in particular of the working environment to protect workers’ health and safety, (ii) working conditions, (iii) the information and consultation of workers, (iv) equality between men and women with regard to labour market opportunities and treatment at work. The most important legislative act that sets out a goal that all EU countries must achieve and enacts the EU strategy on health and safety is the European Directive on the introduction of measures to encourage improvements in the safety and health of workers at work. These measures are contained in a series of directives that Member States transpose into national legislation141.

Increasingly, health protection is now considered an aspect of primary importance to be supervised within the process that leads to asset production or service provision by the company. It is recognised that risk prevention and the creation of healthy and safe working conditions are fundamental not only to improve the quality of work but also to promote productivity and competitiveness of the company. This strategy also helps to optimise the sustainability of social security systems. To ensure better protection for workers, the European Commission has adopted a specific policy that defines the objectives, focusing in particular on the study of effective prevention systems, on the assessment of new risks and emerging risks, on the need to face the progressive ageing of the working population142.

But in the second half of the seventeenth century could have been imaginable an approach based on the analysis of the risks present in the workplace, on the importance of the health problems of workers and on the need to adopt protective measures to avoid them imaginable?

8 - Work and health in Ramazzini’s thought

To fully understand and adequately appreciate the contribution of Ramazzini, it is necessary to ask several questions. What was his thinking about the value of work? How did he consider the relationship between work and health? How could workers health be protected? What were the possible measures to counter the risks? What to suggest to the workers to avoid risk? Rather than the social aspects linked to the poverty and the unacceptable living conditions of the population, in his work, the Magister expressed constant attention to work, most of the humble and filthy craftsmen, but also of more formal and honourable occupations143. He affirmed that anyone could have understood the benefits that the activities carried out by the artisans, although apparently despicable and detestable brought to ordinary life. Such works were useful and necessary for the general good because they ensured prosperity and wealth. And he emphasised this assumption by recalling how Charlemagne after defeated the last king of the Lombards, did not choose to dispose of the material wealth of the latter but ordered the transfer to France of the most eminent masters of the liberal arts and the mechanical ones. «Regna fovent Artes» (governments foster the arts) declared Ramazzini, who pointed out the relationship that existed between the state and production activities, assuming that it would be responsible for supporting both the businesses and protecting the health of those who exercised them144. He was, in fact, aware that already at the beginning of the seventeenth century many rules had been prescribed to ensure satisfactory working conditions: «not only in antiquity but in our own times also laws have been passed in well-ordered cities to secure good conditions for the workers». However, the laws were more oriented towards workers control by the state to safeguard the stability of the countries. Only many decades later, systems and tools would be developed to improve the conditions of the population145. If on the one hand, Ramazzini had manifest the value of work as a factor of prosperity for the state146, on the other he did not fail to observe how severe damage to human health was attributed to work. He wrote that «we must admit that the workers in certain arts and crafts sometimes derive from them grave injuries». But he did not limit himself to realising that the work could produce injury to the worker. As a modern interpreter of the necessity to satisfy the health needs of workers, he focused on the commitment to implement protective measures for the health of the workers themselves. He then turned to the governors inviting them to be far-sighted in proposing and applying rules to favour work and ensure its performance in conditions of healthiness.

This topic is treated today in terms of assessment of working conditions and compliance with health and safety laws and social responsibility standards. As to the first point, compliance with the law involves employers responsibility and ensure that the activities are performed, after assessing the risks, without prejudice to the health and safety of workers147. As to the second point, a socially responsible company can be defined as a company that carries out economic activities incorporating precautions that prevent risks and prejudices for the community148. A company therefore that aims to contain the environmental impact caused by the production activity, to guarantee respect for human rights, the safety conditions of workers, avoiding situations of child exploitation, which aims at the quality of the goods using products safe for health and applying internal rules that respect the correct management of human resources149. These elements characterise the so-called process of Corporate Social Responsibility150. According to these objectives, a significant challenge will be the future governance of responsible research and innovation151.

9 - Medicine and doctors in the second half of the seventeenth century

As we saw in the previous chapter, Ramazzini had turned to the governors inviting them to ensure that the work was carried out in healthy conditions. He asked his medical colleagues to be committed to visiting the craft shops and to protecting workers' health. Doubtful about their willingness to engage in such activity («Perhaps some readers will take offence at my lingering among latrines and sewers; but one who investigates the realm of nature ought to regard nothing as too mean to inspect, still less if he professes the art of medicine»), he did not miss to address ironic remarks to them («I wonder whether I shall bring bile to the nose of the doctors, as the saying is -they are so particular about being elegant and immaculate- if I invite them to leave the apothecary’s shop […] to come to the latrines») (Figure 5-9). To the same picky colleagues, he did not fail to recall that Ippocrates [in De Flatibus] stated: «For a doctor must inspect the unseemly and handle the horrible»152. As it can be assumed from these few sentences, Ramazzini’s relations with his medical colleagues were not smooth153.