Book explores previous international efforts to fight disease


Fearing illness from a foreign country, public health officials clamped down on travel and trade, imposing lengthy quarantines. These measures have curbed tourism, raised the price of goods and slowed their distribution.

The epidemic in question was not the coronavirus, but the bubonic plague. Binghamton University Associate Professor of History and Public Health Alex Chase-Levenson explores public health efforts to combat the spread of the plague in his recent book, The yellow flag: quarantine and the British Mediterranean world, 1780-1860. Published at the height of the coronavirus pandemic in 2020, her book recently won the Stansky Prize from the North American Conference on British Studies.

The yellow flag chronicles Britain’s participation in Europe’s “universal quarantine” of people and goods from the Eastern Mediterranean and North Africa, then largely part of the Ottoman Empire, which continued to suffer periodic bouts of plague for nearly 150 years after the flea-borne disease was eradicated from Europe. These quarantine measures have also shaped responses to national epidemics, such as cholera.

“This is the most massive quarantine system that has existed in terms of global reach, ambition and systematic power,” Chase-Levenson said. “At the beginning of the 19th century, every person, ship, mail or commodity that crossed the Mediterranean from the Middle East or North Africa to Western Europe was quarantined, whether or not there was a disease in the Middle East East or North Africa.

Plague epidemics were not frequent in many Ottoman cities. In fact, the universal scope of the quarantine system meant that often more than 90% of ships detained at any given time came from ports with no recorded disease. No one was exempt; until around 1850, everyone – from sailors to leaders – was subject to quarantine, even in times of war.

In the days before the World Health Organization, the rules were enforced by local health boards in each port city, which communicated with each other by mail. They faced pressure to comply with the standards: if a port relaxed its own rules, ships from the surrounding country would be quarantined when they traveled to another city. This pressure enabled Western and Central European countries to develop a common set of comprehensive standards that resembled a transnational border control system, but which was neither controlled nor managed by a central authority.

Under this system, all ships had to have a health certificate issued by a European consulate somewhere in the Middle East. This health check determined that the ship was “clean, suspect, or filthy”, based on the prevalence of the plague; this status determined the length of quarantine, often around 18 to 21 days on a “clean” ship or 35 to 40 days for a ship deemed bad.

The restrictions also applied to passengers, although commercial goods – considered riskier – were often quarantined longer than people.

“There was no germ theory of disease at that time. There were vague ideas of contagion, and those vague ideas generally seemed to suggest that porous materials and fabrics were particularly risky,” Chase-Levenson explained. .

At the time, the main trade goods en route to Europe included cotton and silk, making these restrictions both onerous and costly. Shipping anything easily perishable was out of the question, and long periods of quarantine also increased the possibility of theft of goods and smuggling.

How the quarantine ended

While quarantine was ostensibly about the bubonic plaque, it also represented a barrier between two cultures and civilizations. In fact, the geography of the historic quarantine resembles the current migration crisis in the Mediterranean and the attempt to prevent the entry of migrants and refugees into Western Europe.

The 19th century saw the spread of Orientalist stereotypes, which attributed illness to so-called “luxury and excess” in Asian culture and to misconceptions about so-called Islamic fatalism. The disease filtered into those assessments and helped shape those negative perceptions through the quarantine system, Chase-Levenson explained.

Contrary to Western opinion at the time, Islamic societies had their own measures to stem epidemic diseases. The quarantine itself was often one; in modern times, Egypt implemented a quarantine system in 1831, and the practice spread to all major ports of the Ottoman Empire in 1839, although Ottoman supporters of quarantine were motivated in part by concern about the commercial penetration of European powers. Coinciding with these measures, after the Egyptian epidemic of 1835, the plague began a rapid decline in the Middle East.

This led in part to the elimination of the quarantine system, but many other factors were at play at the time, including the pressure of mounting European imperial intervention on the southern and eastern shores of the Mediterranean. The clearest example is Algeria; after the French invasion in 1830, ships from the North African country were subject to quarantine for the next 11 years, and pressure to end this rule helped destroy the reputation of the Marseille health board , previously the strongest quarantine authority in the Mediterranean.

Confidence in the value of quarantine also began to decline after it failed to stop the spread of cholera in 1832 in Western Europe. Medical theories also evolved to adopt “anti-contagionism”, which attributed illness to “miasma”, a type of gaseous exhalation related to landscapes such as marshes or swamps, or sudden changes in temperature.

What can we learn from universal quarantine? The local boards of health that applied it helped lay the foundations for international disease control later in the 19th century and up to the present day: the international health conferences from 1851 to 1938 and the World Health Organization, created in 1948. The first health conference, as it happened, was all about dismantling universal quarantine, Chase-Levenson said.

And while “quarantine” might sound like a familiar concept due to the recent pandemic, those early health tips likely would have handled things very differently, according to Chase-Levenson. Every traveler from an affected part of the world, or even from countries with less strict rules, would have spent considerable time in a quarantine station, known as a lazaretto, to ensure that they were not carriers of disease.

Would this level of quarantine have stopped the spread of the coronavirus? It’s hard to say, according to Chase-Levenson. After all, the volume of trade and travel is much greater than 200 years ago, when travel was limited to ships, trains and horses.

“Quarantine, of course, was developed against bubonic plague, cholera and yellow fever, which are frightening epidemic diseases. Even though the COVID pandemic persists and has killed millions around the world, it is far less devastating than these diseases,” he said. “If we were faced with something like plague or cholera, given the current politicization of disease control, things could be much worse. Maybe that’s something to be grateful for.

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