Camillo de Lellis and the Ideal of Global Healthcare

1. Introduction

Since antiquity, healthcare and nursing have been inspired by the highest respect for human life. Therefore, this arduous task has been carried out mainly by religious people and orders throughout history. In the 1^st century AD St. Paul sent to Rome a notable woman and deaconess, named Phoebe, to provide assistance and hospitality to those in need. In the 4^th century AD, following the first Council of Nicaea, St. Basil the Great established the first xenodochium. This early hospital-city featured separate buildings for the poor, the sick, and strangers, providing accommodation for nurses and doctors. Subsequently, infirmaries were established within monasteries, such as those founded by St. Benedict in Montecassino and Salerno; it was from these early healthcare facilities that the first hospitals would evolve. The oldest functioning hospital is considered to be St. Bartholomew’s Hospital in West Smithfield, London, founded in 1123. In Counter-Reformation Europe, the role of Christian spiritual congregations in healthcare and poor relief remained crucial. A leading figure in this field was St. Camillus (Camillo de Lellis, 1550-1614) [1]. Due to his profound humanitarian commitment, Camillo de Lellis is highly venerated within the Catholic Church. He was beatified (1742) and then canonized (1746) by Benedict XIV. Between the 19^th and 20^th centuries, he was adopted as patron Saint of the sick and the hospitals (1886); nurses (1930); and military healthcare (1974). His relics are preserved in the church of St. Mary Magdalene, a few steps from the Pantheon, in Rome. A statue representing him stands in the central nave of St. Peter’s, alongside others of founders of religious orders. A church dedicated to him was built in the Sallustiano district at the behest of Pius X, between 1906 and 1910, and elevated to minor basilica by Paul VI, in 1965.

The life of St. Camillus, a giant in the Counter-Reformation – as well as literally, as he was taller than two meters! – was an adventurous one. Born in Chieti to a good family of the local aristocracy, Camillo took up the military profession at a very young age following in the footsteps of his father, Giovanni de Lellis, an officer in the service of the Spanish crown. With his father Camillo left for a campaign of the long-running Ottoman-Venetian wars, facing violence, danger and illness of both body and soul. While stationing in the marshes, near the mouth of the Tronto, he contracted malaria. Later on, he suffered an injury to the right foot: an itchy ulcer, which later became infected and spread, until it progressively corroded the flesh of his entire leg. Also, he became a gambler. Driven by necessity he began assisting in hospitals, but then formed a company of nurses, with whom he took on the task of serving the sick, similarly to what other confraternities and clerical orders, such as the Fatebenefratelli of Giovanni da Dio, were doing at the time.

Since the last century, Camillo and his company have been the subject of numerous studies that have outlined their remarkable contribution to nursing [2]. However, it is still possible to emphasize two important aspects of Camillo’s work particularly relevant to this Journal, namely the relationship between healthcare and environment, and the concept of global healthcare, that would later become a Camillian ideal.

2. Healthcare and the City

First and foremost, the term environment in Camillo’s life covers the city of Rome. Camillo arrived in Rome in 1571, at the age of 21, to be treated for the wound he had sustained while stationing in the Marche region. At the time of his arrival, Rome was a large, cosmopolitan city, full of contrasts, swinging between opulence and poverty, and very unhealthy. During the 16^th century, indeed, Rome was plagued by multiple urban diseases [3]. More or less serious outbreaks of plague raged alongside acute forms of typhoid fever and, of course, syphilis. Moreover, the city was affected by flooding. Torrential floods descended from the Alban Hills and the Volscian Mountains, inundating the plains, eventually stagnating and creating marshes. The Tiber’s floods submerged the lowest parts of the city, covering squares with slime and filth, transforming them into gigantic stinking pools. The flooded areas facilitated the breeding of anopheles mosquitoes, which transmitted malaria. Floodings and epidemics were followed by famines that weakened the population, causing locals, particularly farmers, to abandon their settlements and move away spreading infectious diseases.

Since antiquity, malaria has been known as a fever, often intermittent, causing headaches and chills, typical of marshy areas surrounding urban settlements. Also, Hippocrates linked malarial fever and misery with certain seasons (late summer and autumn) [4]. Malaria’s arrival in Rome, probably in the first century AD, was a turning point in European history. It went down in history as an “Italian disease’”, as its name, reflecting a pathological concept of a miasma suspended in the air causing epidemics, attests. In the days of Camillo, malaria, both epidemic and endemic, was devastating many areas of Italy. In addition to the Tronto valleys, where Camillo himself contracted it, the Po and the Adige valleys were affected; and so, on the Tyrrhenian side, the Maremma area; in the countryside surrounding Rome, the Roman Campagna, and the coast between Ostia and Anzio. Authoritative and abundant evidence attests to the poor environmental conditions in Rome [5]. Luigi Mocenigo, reporting to the Venetian Senato in 1560, wrote that in summer “the foreigners who come to Rome […] almost always run the risk of illness or death” (“i forestieri che vengono in Roma […] quasi sempre corrono pericolo d’infermità o morte”). Shortly after Camillo’s arrival in Rome, a Medici ambassador wrote, regarding those who had moved to the countryside, that: “all those who have changed their climate have either died or fallen seriously ill” (“tutti quei che hanno fatto mutazione d’aria o sono morti o ammalati assai”).

In the following decade things did not improve. According to historian Fernand Braudel, a resurgence of malaria took place in the summer of 1581 [6]. Pope Sixtus V – elected in 1585 and extremely active in the field of urban and sanitary planning – worked hard to solve the situation. On 28 March 1586, he hired the architect Ascanio Fenizi of Urbino to reclaim the Pontine Marshes. Shortly after, however, an anonymous chronicler noted that: “The Pontine Marshes that were drained last year […] have returned to their original state”. That year, in August, Sixtus V died of malaria, as did his successor, Urban VII – who happened to cover the shortest pontificate in the church history (15-27 September 1590).

In the city, Camillo experienced the healthcare environment, too, as he was admitted to San Giacomo degli Incurabili – an historic hospital in Rome, located between via del Corso and via di Ripetta, in the Campo Marzio district [7]. His first stay at San Giacomo lasted from March 7 to December 31, 1571; from the 1^st April onwards, however, it was for work as Camillo’s name shows up among those of the employees. At the end of the year, he was dismissed for negligent conduct, as well as for his compulsion gambling which often distracted and led him to the banks of the Tiber to play with the barcaroli. At the beginning of 1572, he left and wandered around Italy for years; he returned to enlist in the Ottoman-Venetian War experiencing once again harsh conditions like dysentery, hunger and even cannibalism. After the peace settlement that was signed on 7 March 1573 Camillo briefly returned to Rome, to gamble away all the earned money and even his cloak. He was reduced to begging.

Two years later, when the worst seemed to be over thanks to a construction work at the monastery of the Capuchins in Manfredonia, the sore on his foot reopened, and Camillo was forced to return to Rome, hoping to be readmitted to San Giacomo by virtue of the indulgence granted for the Jubilee Year of 1575. At the time his second stay at the hospital begun. From 23 October to 18 November 1575 he was treated; from 19 November 1575 to 20 June 1579 he worked, attaining the position of nurse, and then of wardrobe keeper. This second stay at San Giacomo was an entirely positive experience. It came to an end only because Camillo was able to do his novitiate in Abruzzo. However, a new infection of the wound brought him back to San Giacomo, where he entered in mid-October 1579. Once again, he was first treated, then appointed superintendent, until September 1584. In this period, Camillo’s diligence, honesty and discipline earned him appreciation and attracted indispensable donations to the hospital. Of the greatest importance were those by Cardinal Antonio Maria Salviati (1537-1602), who made rebuild the structure of San Giacomo from the ground up in 1579.

Camillo’s service at the hospital is attested by three registers, which reveal not only his managerial skills, but also his thoughts and views about health and assistance in the healthcare environment. The hospital was the third oldest in Rome, after Santo Spirito in Sassia and San Giovanni in Laterano. Established in the 14^th century, during the pontificate of Nicholas V (1447-1455), and placed under the protection of Santo Spirito, it was entrusted first to the Society for the Poor and Sick (Compagnia di Carità verso i poveri e gli infermi) of S. Maria del Popolo, then, from the end of the 15^th century, to the Society of the Divine Love (Compagnia del Divino Amore) founded by Caterina da Genova and later led by Ettore Vernazza. With the bull Salvatoris nostri (1515) by Leo X, it was re-founded, that is, transformed into a rest home for the long-term and incurably ill, without distinction of social class and sex, and with a particular focus on syphilis. Elevated to the status of arcispedale, it became a reference for all hospitals for the incurably ill in Italy and Europe and for all the charitable congregations founded over the years.

The hospital service, however, endured many problems in relation to healthcare. The Society of the Divine Love came to a standstill following Vernazza’s death, in 1524, and ceased altogether after the sack of Rome, in 1527. Two years later the hospital passed to the Capuchin order, but the monks were not prepared to treat the sick. Nor were the laypeople working in the house, who were uneducated and unskilled – if not criminals serving their sentences. The service was terrible. The hygiene of the hospital and the patients was neglected. Persons with fever were left aside to fend for themselves, without food or water, or mistreated – tied up, beaten, even buried alive. The priests supposed to administer the sacraments, too, showed fear or disgust for this environment and the incurably ill.

3. Global Healthcare

The healthcare in the hospital and its issues were tirelessly monitored by Camillo, who often intervened. He corrected those responsible, instructed them, dedicated himself personally to the most serious cases, established a weekly distribution of Communion. Slowly his project of devoting himself to monastic life and founding his own order dedicated to the care of the sick was taking shape. Camillo’s brothers would combine the skills of healthcare workers with the qualities of spiritual fathers. They would offer global healthcare and nursing by attending for the whole person, including body and soul. The focus of their service was the patient, regarded as a master to be served with humility and courage.

Camillo shared his project with a group of companions in prayer and in caring for the sick, whom he asked to serve those in need with the highest devotion, “with the same love a mother has for her only sick child”. These words were written by Camillo in the Rules, composed between the end of 1584 and the beginning of 1585 [8].

The Rules mainly concern the tasks and methods to be followed in hospital service. Two cornerstones are the good governance of the hospital and the commitment to assist the incurably ill. The work required by the Rules was arduous, but Camillo himself carried it out, as he warmed the feet of the sick before putting them to bed, patiently deloused his patients, gave them a warm bath, and powdered them with aromatic herbs. The healthcare provided by Camillo’s brothers would be free, and they would be obliged to live in poverty and prevented to accept donations for their service. Also, they had not to force patients to do anything against their will, not even to receive the sacraments, and in particular confession.

When submitted to the Congregation of Bishops and Regulars for approval, the Rules met with considerable resistance. But now to the papal throne had ascended Sixtus V, who was born a poor farmer’s son, and a Franciscan from a young age. From the very beginning of his pontificate, Sixtus V had dealt with the problems of Rome and promoted reforms, including the strengthening of the urban hospital network. As he planned to renovate the old hospitals and to build new ones, the recruitment of an adequate staff for the standards and health emergencies of the time was required. This made the moment favourable for Camillo’s project, which obtained the papal approval to establish his Company of Ministers of the Sick with the breve of 18 March 1586. Shortly after, Camillo was received in a private audience by Sixtus V in the Vatican. On that occasion he asked to be allowed to sew a red cross onto the black cassocks as distinguishing badge for his Ministers, and this request was officially approved, too, with the breve of 18 June.

But Camillo’s project had only begun and was too ambitious to be confined within the hospital of San Giacomo. At the end of December 1586, Camillo and the Camillians moved to the church of Santa Maria Maddalena in Campo Marzio and the surrounding village. The new housing was combined with a new hospital, Santo Spirito. Thereafter, the Camillians’ activities and fame grew so much, that they started receiving requests from outside Rome. The first request came from Naples, where a new house was opened in October 1588.

The charitable work of the Camillians gave hope for their elevation to a major order: a formal request was presented to the Sistine Congregation Pro sacris ritibus et caeremoniis, but the process was interrupted by the death of Sixtus V. His successor Urban VII had a very short pontificate, as already mentioned, and in the meantime Rome went through a new epidemic – it was typhus – causing acute fevers and numerous deaths. This created the epidemiological emergency scenario contemplated by Camillo’s Rules. The Camillians greatly supported the civil administration by providing first aid and rescue. Their work impressed the new pope, Gregory XIV, who recognised the Camillians as an order of regular clerics in the bull Illius qui pro gregis of 21 September 1591.

The next pope Clement VIII, previously an opponent to the elevation to order, also became grateful and benevolent towards Camillo, who was elected General of the Order on 8 December 1592, while Cardinal Salviati officially became protector of the Order from 1593. Salviati would later oppose Camillo’s idea of further extending the charitable work of the Order, but Camillo convinced him. On 14 June 1594 Camillo arrived in Milan to offer the services of the Camillians to the Ca’ Granda, founded by Francesco Sforza in 1456, and prototype of the new kind of hospital administration. The management requested six Camillians to provide care for the body and soul of the Ca’ Granda’s patients. Camillo left there thirteen. By August 1594, he was already in Genoa in order to open a new Camillian foundation.

Camillo’s drive towards expanding hospital – that perplexed Cardinal Salviati – caused a serious rift in the Order, since most of the Camillians mainly inclined towards spiritual assistance and considered themselves overwhelmed by physical tasks such as feeding, making beds, cleaning the hospital and caring for the hygiene of the sick. Tasks of this kind would demoralize and depress the spirit of the fathers. But Camillo had laid down his Rules and in his view the nurse was a total caregiver and a servant of the sick, hence the impossibility of separating spiritual comfort from physical care. To defend his view, he continued to travel throughout Italy establishing teams of Camillians in several hospitals. He always upheld his ideal, even in his final years that he spent in retreat at Santo Spirito. Shortly before his death, between June and July 1614, he wrote and distributed a letter-testament where he reaffirmed the principles and ethics of his Order: never take care of the spiritual without the physical (“che non si pigli mai cura dello spirituale assoluta, senza il corporale”).

4. Afterlife

Camillo’s project was continued after his death in a world-wide perspective. In the 18^th century, the Order crossed the ocean to establish new missions and provide healthcare in South America. In the 19^th century, two female congregations were established: the Camillian Sisters and the Daughters of St. Camillus. From now on, women contributed to the Camillian project, bringing their own experience and dispositions to the ideal of “maternal” care. In the 20^th century, healthcare took on a global dimension, reaching the Far East, Kenya and Central Africa, the Caucasus and Haiti.

Rome, the city where it all began, never ceased to remember and honour Camillo’s work. At the end of the 1960s, the Second Vatican Council established a new constitution for the order: thus, in many parts of the world, including Brazil, Austria, Colombia and Peru, associations of lay men and women inspired by the Camillian project and committed to nursing were formed. Camillo’s enduring legacy seems to hover over San Giacomo, which Cardinal Salviati bequeathed to Rome with the stipulation that it be used as a hospital. In 2008, the Lazio region decided to close San Giacomo, and in 2019 it was announced that it would be reused as a luxury property. Oliva Salviati, however, descendant of the Cardinal, appealed for the reopening of the hospital, and in 2023 the appeal was upheld by the Court of Cassation [9].

Camillo de Lellis’ ideal of a comprehensive nursing care deserves to be remembered and celebrated both in the cultural context of the 16^th century – a century of great scientific discoveries concerning world and humankind – and in the history of nursing, for it laid the foundations of modern healthcare and anticipated future advances of assistance to the sick of the modern age.