This research considers the ways in which medical knowledge and allied practical resources were deployed across Roman Britain. It is proposed that a decision to treat was made upon the indigenous population of Britain during the period forming that of the Roman occupation i.e. 43 – 410 AD, according to location and perceived socio economic value of the patient. Location appears to be associated with availability of local medical resources as well as the location of trade links, road networks and relationships between indigenous population and Roman occupier. It is also proposed that this selection process and the circumstances resulting in the availability of resources in Roman Britain, is echoed in modern times where a population is being subdued by an occupying force. For this reason, the lessons learned from Roman Britain may be translated into planning and strategies associated with modern warfare and even with considerations about the deployment of peace keeping forces across the globe. 

This research asks if the ways in which gender, age, potential value as a working commodity and the variances represented by geographical localities, all impacted upon treatment delivered – both the outcome of a decision to treat and the availability of necessary skills and resources.   

One outcome of the treatment decision was the impact upon relationships between Roman and British peoples – the occupying force and the indigenous peoples. Conversely, the relationships further added to the decision to treat. Where relationships were more difficult, resources were located at distance in more friendly and therefore safer and more developed or more defendable locations. Tensions also made the decision to treat less likely. Just as today, emergency services are aware of potential patients, buildings, and areas that are inhospitable even to the degree that police escort is requested prior to attendance by ambulance, paramedic or fire service.  In Roman Britain, without modern digital communications, and given the state of occupation, the request for a medic to enter difficult locations was likely to go unanswered. 

There are also modern parallels relating to the rejection of medical support being offered by an occupying force; it is not only a case of being unwilling to accept help but also a matter of differences of faith, medical knowledge, and the acceptance of  the tools and the procedures themselves. The established belief is that the Romans brought with them a step change in medical skills, equipment and surgical procedures and that the Iron Age was a period of dire risk of poor clinical outcomes from illness or injury. This research challenges that view and asks whether Iron Age medical practices were both skilled and sustained during Roman occupation. 

It is important to ask where Iron Age medical practices continued into the Roman era in Britain, too, and to identify what was special about those locations. Was there an association with locations experiencing tension with the occupying forces; did the location of Roman military, trade or travel related resources play a role in determining who was treated and who was not. . 

Another factor is that, for the indigenous population, faith was closely linked to health and treatment. Faith tends to represent a variable in  decisions about treatment. Roman medical resources, when given, were more consistently applied even by type of surgical procedure. Training for medics was more about process than beliefs.  This is especially true following the establishment by Augustus of a hierarchy of military medical training, practices and supervision.

Even in Roman Britain there is evidence of skilled Iron Age surgery in pockets located according to several factors including the nature of relationships with the Romans. This research will lay them bare. Similarly, there are clearly evidenced Roman surgical procedure ‘factories’ with marks upon the skeletal remains that almost allow one to identify that one medic delivered many procedures to multiple patients, in one location. Just as today, surgeons concentrating on one form of procedure become expert in it to the degree that they are far faster, and the clinical benefits to the patient far more positive in terms of quality or recovery and survival, than their peers. Roman Britain became a powerhouse for ophthalmology, for instance, with several sources of reliable evidence signposting that Roman medics delivered more cataract revisions in Britain than elsewhere in the Roman world. 

It is proposed here that the evidence signposting how  sustained Iron Age i.e. non- Roman medical treatment was far more commonplace in geographic areas of tension. It is also proposed that as a consequence, the decision to treat was weighted against the occupied population where relationships were poor, the location of expert Roman medical resources was at distance, and the socio-economic value of the patient low. Roman medics were simply not about to risk themselves in order to travel long distance into unfriendly territory, in order to attend a non-Roman patient, regardless of their ranking within their own tribe. The decision to attend or to stand down would not have been a personal one rather tone taken by Roman military leadership. 

Commander Simon Thompson, NHS Consultant Psychiatrist and qualified medical doctor having rank in both Airforce and Army as well as service during active tours of duty abroad, explains the decision-making around provision of medical support from an occupying force; ”It is largely about the balance of risk and duty. Military medics are a valuable commodity, being highly experienced and trained to give medical aid to their colleagues. Losing one of them would have a catastrophic effect upon the troops especially should they be located away from central command and the opportunity for replacement.  Military medics are fully employed within their own troops. There would be little time to spend on travel to treat civilians and any decision from command to undertake such a task would require an armed escort, further depleting resources. The circumstances affecting a decision would be the same regardless of the time period, modern or historic” (Squadron Leader Dr.  Simon Thompson, January 2020). 

Troops in Roman Britain were stretched and under pressure to achieve and to maintain, control. Operating at the limit of the Roman – held global territory and with pressures from elsewhere, resources were not limitless. Military activity, medical and otherwise, would have been closely managed by their leadership. 

The background to these hypotheses is that a comprehensive understanding of medicine and surgery in Roman Britain has been constructed over several decades using four main types of evidence – written, artefactual, skeletal and architectural. 

This range of evidence has formed the basis of established belief about the nature of medicine and surgery in Roman Britain. Established belief is that the occupation mobilised a strategically-formed medical resource consistently across Roman Britain drawing upon the models associated with the framework developed by Augustus i.e. through the legions and their established trained medical troops, known throughout the Roman Empire as medicus, and largely utilising battlefield triage techniques combined with static military facilities and hospitals. The traditional view is that background health and nutrition improved under Roman rule. This research questions that view, using methodologies to determine risk of mortality and nutritional or physical health, to refresh the review of skeletal remains found in Britain from both Iron Age and Roman periods. 

However, despite the volume and range of evidence taken into the framework of traditional understanding, some of it seemingly anecdotal, there are still gaps in the record that have been filled by extrapolating from what is recorded elsewhere in the Roman world. There are also issues relating to the quality of material creating the archaeological record for instance the recording of grooming artefacts as medical equipment. More recent literature has explored these elements and they are  addressed within the chapter on Literature Review.  

This research:

• Strips back the traditional record relating to medicine and surgery in Roman Britain, including written, artefactual, architectural and skeletal material, in order to reach a baseline comprised of robust material having no erroneous or misleading elements for instance equipment that may have been used for grooming rather than for surgery;
• Fills visible gaps in the record using new evidence filtered against a robust criteria and without applying variable or unsound adjustments;
• Adds further substance to the quality of evidence used so that a refreshed understanding may be reached about who was treated, who by, how, where and why (or why not). 

This exercise will also provide answers to the currently unanswered question as to who was not treated, and why not. The scope of this factor is likely to include location in terms of accessibility and nearness to available resources, relationships between Roman occupiers and the indigenous peoples, and the localised beliefs embedded at the time of the occupation for which significant new evidence is emerging to indicate that Roman beliefs and behaviours did not consistently replace Iron Age aspects.  This research throws light upon why that might be, in this case the Roman response to illness or injury when sustained by non-Roman patients, and the location of necessary resources.