publichealth-2 C

 

Transcriber:	Yvonne Cherne
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Date finished:	6-3-2007
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file: hph_lec2c.mp3

A History of Modern Public Health: Quarantine, part C

Welcome back. In section C, we are going to look at some specific
historical examples of quarantine, and we are going to be using
the example of plague in three particular countries:
Italy, China, and Australia. And the first example of Italy
concentrates predominantly in the medieval period, and the
examples of China and Australia bring us to the more recent past
and specifically the 19th and early 20th centuries.

And there are two key points that I would like you to take away
from these examples. First of all is the acceptance that
quarantine indicates a community has decided to organize its
health services on some level. The second point is that
quarantine raises questions about how disease is caused and how
it is transmitted. So quarantine as a specific public health
intervention on the one hand indicates that a population is
willing, at one level, to submit itself to a rather restrictive
intervention and a restrictive means of control over its movement
for example, and also it raises questions about how a disease is
caused, because it is important to emphasize that the medical
knowledge concerning the transmission of plague was very
uncertain, and the way in which plague was transmitted from place
to place and between human beings was unknown, and in fact, it
was unknown until the end of the 19th century. And so we have a
question here about why quarantine might be considered effective
and might be seen to work even though medical knowledge over the
causation of the disease was imperfect.

One thing to remember about quarantine, as I mentioned in the
previous slide, is that it is an organized response, an
acknowledgement that health services have to be provided at an
administrative level. And this was not always the case. An
organized health-service-related response was not necessarily the
only way in which human beings reacted to the epidemic threat of
plague.

And plague did not respect status or social class, but the
response to plague in some senses was dictated by status or
social class. So from Florence and Venice in the mid 14th century
to London in the mid 17th century, the common response was to get
out of the city, and the key phrase here is "flee early, flee
far, and return late."

So here we have a representation of one of the ways in which part
of the population of London escapes the plague epidemic of 1665,
and that was over land. And you can see the trails of carts that
were moving beyond the city walls, people transporting themselves
from within the city to without the city as far away as possible
from the urban areas, from the concentrations of pestilence to a
rather less congested, less overcrowded rural environment. And
the next slide shows people performing a similar migration, but
this time not across land but by boat, and this would have been
people taking themselves out of the city of London on the Thames,
having commandeered some form of water transport.

Now all the key points about these two slides, the fleeing by
land and the fleeing by water is that it would have been most
common in those classes who could either afford transport or
afford to commandeer a vehicle, or perhaps those sections of the
population who were wealthy enough to own a residence beyond the
city. So they could take themselves away to their rural
residence, maybe their country residence, and avoid the
biological threat posed by the coming plague. Clearly that was
not possible for all sections of the community.

The next slide shows the collection of the dead bodies and the
corpses from within the city of the victims of plague and their
removal out of the city to a burial place. And you can see from
the final slide in this set of 4 the methods by which the dead
were buried, with a bell taken before them to indicate that here
there was a corpse of somebody who had died from plague. And on
the right of the image you can see two people called "the
searchers." And these were appointed officials responsible for
going into the homes of the deceased and deciding what cause of
death and what the final illness of the deceased actually was.
And that was why they were called "searchers," because they would
go into individual dwellings and search for the cause of death,
and the cause of death would be recorded. And that was one of the
ways, of course, in which the onset of plague and the emergence
of an epidemic outbreak was discovered, because the searchers
would collect the information, they would record it, and in
London at this time the numbers of deaths from individual causes
would have been published in what was called a "Weekly Bill of
Mortality." So the approaching epidemic could be monitored and
prepared for.

There were of course other responses to plague and epidemic
outbreaks that may or may not have been part of a quarantine
policy. One for example was the disinfection of belongings and
clothing. And you can see here on this image the disinfection of
clothing, and you can see the possessions in the trunks and the
chests that were being disinfected, probably from a plague victim
-- that they previously belonged to a plague victim -- or perhaps
in this example from southern France in the 19th century, perhaps
they were the possessions of travelers who were entering the city
and had come from a place that had been known to be infected with
plague, and they were having their possessions disinfected before
they entered the city itself.

Another response -- and this is an example from Rome in 1656 --
is the possessions that in the previous slide were being
disinfected would have been burned. And so this is an example of
where possessions were collected within a particular
neighborhood, they were taken away from houses where a case of
plague or cases of plague had become known, and the possessions
themselves were destroyed.

And finally, as part of a response to epidemic outbreaks, and
particularly of plague -- and this has resonance for what we are
going to be talking about later on when we look at quarantine --
is that particular ethnic groups might become the focus of anger
and agitation. And this example from 1493 shows Jews being burned
in the time of plague. And this idea that one particular ethnic
group was either responsible for the plague itself, or in this
case, in the case of the Jewish population, partly because of
their hygienic habits and practices, they were actually
relatively free from the plague itself, and they became the focus
of disenchantment and anger in the face of powerlessness to
control the plague in other ways, it became not uncommon for Jews
to be burned.

So moving on now from some of the typical responses that the
population might have to the threat of an epidemic outbreak such
as fleeing the city, disinfecting their belongings, and exacting
their ire on particular ethnic groups, let us consider now - and
this is important for the historical examples that we will look
at shortly - the actual beliefs about the causes of disease, and
so here what we are thinking about is, if you like, the medical
response to plague.

You may remember from our introductory class ideas about the
causation of disease itself, and you may remember the discussion
over the relationship and the interaction between human beings
and their environment being a traditional concept that has its
historical roots in the ancient Greek Hippocratic writings. And
this is important when we consider medical responses to plague as
well. The predominant idea was that disease was caused by rotting
material such as rubbish, decaying organic matter, and human
excreta which produced gasses and gave off gasses and infective
atoms that caused in some way for the air to become infected. So
in other words, smell was disease. And these venomous atoms that
were given off by this decaying organic matter could actually
pass, the belief was, from human beings to human beings by direct
contact. And you can imagine that if that is the underlying and
predominant medical idea over how a disease is caused, that it is
logical that the way in which the transmission of disease and the
chain of transmission of disease is broken is to prevent that
human-to-human contact. And that provided the logic for
quarantine.

And it also reflects itself in this image that we have here of
the quarantine doctor. And I would just like to go through and
talk in some detail about this image and some of the points we
can draw from it. First of all, just as a little background, the
picture is drawn in 1661 by Thomas Bartolin from his volume
"Historarium anatomicarium medicarum rariorum" (?) -- forgive my
Latin pronunciation there -- and it is a representation of a
plague doctor. We do also have pictorial evidence that these
plague doctors were in existence in southern France in the late
18th century as well. And this image probably originates from
Italy. The person underneath the robe would be a physician, a
doctor; and in that sense, given the time period, it would be a
man because physicians were men in that time period. The
significance of the costume is that the physician would be
protected from the infected air, the miasmas, that were produced
by the rotting materials. And the actual material that was used
would have been a woven material or perhaps leather, and quite
often it was not unknown for the material to have been coated in
a waxy substance. And the theory behind that being that the waxy
substance would cause these venomous atoms to stick to the robe
so that they would not penetrate the robe itself; they would just
stick to the outside of the robe, and the physician would not be
exposed to those venomous atoms.

The second point about the clothing is that clearly the physician
here is wearing goggles, and that it to protect the eyes from the
infected air. The significance of the beak is that the beak was
actually hollow, and what it would contain, it would be stuffed
with perfumed materials such as herbs that were alleged
disinfectants, and they would act as a filter for the infected
air so that the physician would not ingest the venomous atoms
that were present in the atmosphere. And the significance of the
stick is that the stick would quite often be lit, and smoke would
be given off, and the smoke would also have the effect of
disinfecting and purifying the air as the physician walked
through the town or the city area, visiting houses where plague
had been reported and where the physician was required to
administer whatever therapeutic means it was considered to be
appropriate to cure the patient.

So the plague doctor, who we have just spoken about, would not be
an uncommon sight in quarantine cities in northern Italy from the
14th century onwards. The first example, as we mentioned in
section A, of quarantine emerged in the late 14th century in
northern Italy. The quarantines were organized by health
magistrates. And what the quarantine did was it forbade trade and
communication between places when it was known that plague was
prevalent in certain cities and communities. And this was a
municipal quarantine, and quite often, if it was a port city, the
municipal quarantine would go hand in hand with a maritime
quarantine. And the idea would be that cordon sanitaire was set
up around municipalities.

And what I would like to do now is just read you some examples of
the plague ordinances that were issued in some northern Italian
cities in the 1340s. This particular ordinances against the
spread of plague comes from Pisteria in 1348, and the first
clause of the ordinance says, and I quote: "So that the sickness
which is now threatening the region around Pisteria shall be
prevented from taking hold of the citizens of Pisteria, no
citizen or resident of Pisteria, whether they are from or of what
condition, status, or standing they may be, shall dare or presume
to go to Pisa or Luca, and no one shall come to Pisteria from
those places. Penalty: 500 pence. And no one from Pisteria shall
receive or give hospitality to people who have come from those
places. Same penalty." The second clause of the ordinances says,
and I quote: "No one, whether from Pisteria or elsewhere, shall
dare or presume to bring or fetch to Pisteria, whether in person
or by an agent any old linen or woolen cloths for male or female
clothing or for bedspreads. Penalty: 200 pence and the cloth to
be burned in the public piazza of Pisteria by the official who
discovered it."

An additional clause states that "bodies of the dead shall not be
removed from the place of death until they have been enclosed in
a wooden box and a lid of planks nailed down. Further, no one
shall dare or presume to raise a lament or crying for anyone who
has died outside Pisteria, or summon a gathering of people other
than the kinsfolk and spouse of the deceased, or have bells rung
or use criers or any other means to invite people throughout the
city for such a gathering. Penalty: 25 pence from each person
involved. However, it is to be understood that none of this
applies to the burial of knights, doctors of law, judges, and
doctors of physic whose bodies can be honored by their heirs at
their burial in any way that they please." And from Milan in
1374, we have an ordinance that says: "We wish that each person
who displays a swelling or tumor shall immediately leave the
city, castle, or town where he is and take to the open country,
living either in huts or in the woods until he either dies or
recovers. Parish priests shall examine the sick to see what the
illness is and shall immediately notify the designated searchers
on the pain of being burned alive."

So what you have from these plague regulations and what you can
see is first of all the crucial importance of segregating the
healthy from the sick and sending the sick out from the city but
also preventing the sick from entering the city itself. And the
idea that these ordinances are accepted and that they should be
under the force of penalty -- that they should be complied with
under the force of penalty -- suggests that they clearly have
some legal backbone to them. Also, the idea is important that the
disease can be transmitted not only by human-to-human contact but
also by linen, woolen cloths, and clothing and bedspreads. So
despite the fact that it was considered human-to-human
transmission was considered important, quarantine is also
instituting regulations that forbid the movement of goods.

And also what you have and what is crucial when we are talking
about the cries of lament for the dead is this class distinction
that emerges. The people who are instituting these rules and
regulations, the judiciary, the dignitaries of the local city
seem to have a different set of rules and regulations as opposed
to the population as a whole. And that is important when we are
considering stigmatization and the direction of blame for an
outbreak or the persistence of an epidemic. Clearly there is an
indication here that it is the lower class of citizen who are
responsible for the continuation of the plague. And there is also
a fear here that the local dignitaries do not want the lower
classes to gather together, because clearly there is a fear that
the gathering of people might engender some form of anger or
response or uncontrollable revolt within the locality.

As time progressed, it was not uncommon for the quarantine
regulations to be redefined and in many cases sharpened up. So in
Florence in 1630, the city itself was divided into six zones, and
a designated sanitary official had responsibility for each zone,
and these zones were subjected to intense public health
intervention whenever a case of plague was reported. In Genoa in
the 17th century, the city tried to protect itself from other
infected places, and it banished the city of Alliero, and the
whole island of Sardinia was suspended. And effectively what that
did was it cut off Alliero and Sardinia from Genoa, so there were
no communications of people or of trade, and so therefore
supposedly the chain of transmission was broken.

However, as you can see from this detail in figure 6 (which is
actually a detail of the previous figure 5), in Genoa in the
1650s the population who were known to be effected with plague
were not simply banished to the countryside and the rural areas
as they had been in Milan in the 14th century. What you can see
in the foreground of this detail in figure 6 is the pest house,
and quite often the plague victims would have been removed from
within the city and taken to the pest house, and the pest house
crucially was located outside the city walls. So part of the
quarantine regulations in Genoa in the 1600s was that, yes, the
population who were infected had to be removed from the city, but
they were removed to an institutional setting. And again, this is
an indication that there is some form of acceptance that there
had to be an organized health service, some form of organized
public health intervention in order for quarantine to operate
successfully.

So the formal origins of quarantine can be located in Italy in
the 14th century, and refinements to the system of quarantine can
be traced into the 15th, 16th, and 17th centuries.