publichealth-2 A

Transcriber:	Yvonne Cherne
Brief Bio:
Date finished:	5-3-2007
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file: hph_lec2a.mp3

A History of Modern Public Health: Quarantine, part A

So quarantine is the topic that we are going to be investigating
and discussing in this part of the course, and what I want to do
in this class and in this section is have a look at some initial
definitions of quarantine, and what the impulses of quarantine
are, and why I believe the study of quarantine is important to
the history of public health. And the way that we are going to do
that is by looking at one disease in particular, plague, and the
human responses to outbreaks of plague in different times and in
different places throughout history. So we will be looking at
Italy from the 14th, 15th, and 16th centuries. We will be looking
at China and Australia and their responses to plague in the late
19th and early 20th century. And we will be looking at the ways
in which quarantine was used to restrict the spread of plague by
restricting the movement of people and the movement of goods
between countries, between parts of cities, and thereby trying to
break the chain of transmission of the disease.

Then having looked at plague and quarantine, we are going to have
a look at quarantine in a different context in relation to
cholera. And we will be looking at the way in which quarantine
was adopted in New York in the 1890s to restrict the spread of
that particular disease. But also what I am going to be doing in
that particular section is drawing some comparisons with the
examination of quarantine against plague in Australia, and
looking at how quarantine is used as a tool to restrict
immigration or to provide a focus for intervention against one
particular section of the community. So in the case of Australia,
we will be looking at the victimization of the Chinese during the
plague outbreak in the early 20th century, and in the case of
cholera in New York, we will be looking at how quarantine was
used to restrict immigration of Russian Jews from Europe.

So there are various ways in which we can look at quarantine and
how it has been used historically. And they are the main points
that I want to draw together in the conclusions, the way in which
quarantine draws a boundary around places and around people, the
way in which it raises questions about disease causation and the
way in which disease is transmitted, and the way in which
quarantine can be used as a way of, if you like, an ideological
or political tool to control the movements of particular sections
of the population. So that is the summary of the class on
quarantine.

So we will move now into section A, and I just want to outline in
introductory form why I believe the study of quarantine is
important and the main points that I want you to take away from
this class on quarantine. But before I do that, I want to step
back a little and ask the question of why it is important that we
should study epidemics in the first place. After all, the study
of epidemics is something that you will be all familiar with from
your courses on epidemiology. The study of epidemics is the, if
you like, the roots from which the study of epidemiology grows:
without epidemics, you can't have an epidemiology. So it would be
interesting for me to ask the question to you why you think we
should study epidemics. And I'd like you to think about that as I
go through some of the reasons why I think epidemics are
important.

First of all, an epidemic is crucial because in the study of
social history and in the study of public health, it is crucial
because it is an event, it is not a trend. And when I say an
event, what I mean to suggest is that it is a very visible event
in a local community. An epidemic, an outbreak of disease, quite
often a disease that might be highly disfiguring such as
smallpox, a disease that might have a very rapid onset and move
towards death such as cholera, these are very visible events in a
local community. And that is why an epidemic is important as
opposed to looking at other forms of morbidity and mortality for
example such as cancer or heart disease which tend to have an
underlying morbidity and a rather more constant presence within a
community. An epidemic is a, if you like, a spike on the graph of
mortality and morbidity, and therefore it becomes an interesting
event to study from a historical perspective.

And that is because it provokes a response. An epidemic provokes
a response that is quite often panicked, is quite often ill-
measured, and it is quite often a response that is not prepared
for. And in that sense, historian Asa Bricks (?) argued as far
back as 1961 that epidemics are useful at testing the efficiency
and the resilience of local administrative structures, and
epidemics are capable of exposing relentlessly political, social,
and moral shortcomings in the society that they afflict. And one
of the most common responses to an epidemic across time and
across national boundaries has been the quarantine. And so a
quarantine is one aspect of studying epidemics that is important
because it is one of the oldest and most traditional ways in
which human beings have responded to a biological threat.

So having looked at that question of why it is important to study
epidemics, I'd like to go on now to just explore some initial
thoughts about quarantine itself, quarantine being one of the
most common and, as I say, traditional forms of human response to
an epidemic threat.

One of the first points to make is that quarantine involves in
some sense the avoidance of the sick. And that is a key point
about quarantine, is separating the sick and the healthy, to
reduce the level of communication between them and therefore
reduce the possibility of disease transmission.

And the avoidance of the sick has a very long and traditional
history. For example, there are clear instructions on isolating
lepers, disinfecting homes, and other procedures discussed in the
Old Testament books of Leviticus and Numbers. There is for
example ample evidence from the ancient Greek writings of
Eucleides (?) that people were advised to avoid the contagious.
The Roman authority Galen in the second century A.D. studied
anatomy and internal causes of disease, yet still found time to
warn that some diseases such as plague, tuberculosis, skin and
eye infections made it dangerous to associate with those
afflicted. In the 5th century A.D., the Byzantine emperor
Justinian enacted one of the first laws calling for the delay and
isolation of travelers from the regions were plague was known to
be raging. Similar forms of control were practiced in 7th century
China and other parts of Asia and Europe during the Middle Ages.
So the avoidance of the sick, just to reemphasize, has a long
history, even though most of the examples that we are going to be
looking at in this particular class date from the mid 14th
century and into the early 20th century.

A second point about quarantine that I would like to emphasize is
that there are different ways in which quarantine can be achieved
and secured. There is a difference between maritime quarantine on
the one hand and municipal quarantine on the other. So the former
involves the quarantine of ships and the regulation of trade
between different places; the second, municipal quarantine,
involves the separating off and the creation of a cordon
sanitaire around a city and an urban district in order to reduce
the amount of movement between different places across a land
boundary. So quarantine creates a boundary that marks off a space
between which communication is restricted, the movement of people
is restricted, and the transport of goods and economic trade is
also restricted as well.

So quarantine creates this boundary. And that is a very important
theme that runs through this particular class, because it is not
just a spatial boundary that is created, it is also a boundary
around particular groups within the population who are thought to
carry an epidemic threat. So it is crucial that you keep that in
mind, this idea that quarantine creates this, not only a spacial
boundary, a cordon sanitaire, but also a boundary around
particular subgroups of the population.

And in that sense, the study of quarantine can demonstrate how
public health is used as a political and ideological tool. So
quarantine is used to control the movement of people and
particular groups within the population, and that fits into other
social mechanisms and important themes such as immigration, such
as the right to work, and also ideas about what it is that causes
disease. Because one of the points about putting a boundary
around particular sections of the population is that certain
groups within a population and particularly ethnic groups such as
the Chinese or the Jewish population were considered to be
particularly susceptible to disease at certain periods in time
and in certain places. And part of the idea around creating a
boundary around those particular groups and their susceptibility
to disease feeds into the ways in which disease itself was
propagated. And quarantine raises questions about whether disease
was caused or transmitted either via human-to-human transmission
or via infected particles in the air. We are going to those
theories of disease causation in greater detail in the remainder
of this lecture, but the point I want to emphasize just here is
that quarantine raises questions about how disease is actually
caused.

So to summarize, quarantine is far more than simply a tool to
break the chain of transmission of disease between human beings.
Recently, Mosto has asserted that "quarantine is far more than
the mere marking of or creation of a boundary to ward off a
feared biological threat lest it penetrate a healthy population.
One can't limit the consideration of quarantine to the control of
a contagious disease without minimizing and underestimating the
deeper emotional and broadly aggressive character of any policy
that dictates separation along the lines of quarantine. The
element of blame and stigma associated with quarantine is
especially real for those diseases linked to the poor, the alien,
or the disenfranchised." And Mosto goes on to say "when an
epidemic illness hits hardest at the lowest social classes or
other fringe groups, it provides that grain of sand on which the
pearl of moralism can fall."

So having considered some of the wider social implications of
what quarantine actually is, I think it would be a good idea now
to actually consider the definition of quarantine itself. The
word "quarantine" originates from the Italian words "quarantina"
and "quaranta giorni". The term refers to the 40-day period that
ships entering the port of Venice were required to remain in
isolation before their goods, their crew and passengers were
allowed to disembark during the plague-ridden days of the 14th
and 15th centuries. In about 1374, Venice enacted its 40-day
quarantine regulation, and this is the first instance of formal
quarantine that historians have been able to study.

There is a question of course about why 40 days is used as the
regulatory period for which the ships were required to remain in
isolation before disembarkation was allowed. The origins of the
40-day period are in fact rather vague. It may be 40 days because
Renaissance observers noted that after that period, after the 40-
day period, people stricken with the plague either died or
recovered without further spread to other people. From medieval
times on, shutting the gates of a city or port to all those
suspected of being ill and isolating those sick people discovered
to have entered the city represented the best and often only
means available to stemming the tide of an epidemic.

And this is why you have a difference between maritime quarantine
and municipal quarantine. Effectively, the principles of
municipal quarantine, the idea that the movements of goods and
people off a ship onto land being restricted, was imposed upon
cities and urban areas. In effect a similar form of boundary was
drawn around an urban area to restrict the movement of people and
of goods.

And what this suggests in fact is that under a system of
quarantine, illness somehow resides in places, and it was places
themselves that had to be kept separate. Of course the movement
of people and of goods has to be controlled, but only in those
people and those goods (that) brought one place into contact with
another. So quarantine classifies localities. It classifies
localities as being either healthy or being sick, and in that
sense quarantine is about the medical and the public health
management of space. It is about the public health interventions
that restrict movement between places, and that is a key theme in
the history of public health as a whole.

So on that point, we draw a close to section A where we have
introduced the importance of studying epidemics historically,
where we have talked about the wider social implications of
implementing a system of quarantine, and where we have actually
thought about the definition and origins of the term "quarantine"
itself.

When we come back, we will look at some specific historical
examples.