file: hph_lec2d.mp3
A History of Modern Public Health: Quarantine, part D
What I would like to do now is move on to the example of China in
the late 19th and early 20th century and briefly to demonstrate
how those systems that were instituted in medieval southern
Europe in the 15th century came to be implemented in the Far
East, in this case China, in the 19th and early 20th century.
And what I want to do is concentrate on plague that was endemic
in this part of the world in China in the second half of the 19th
century. And here, the emphasis again is on the importance of
trade routes. You can't see it very well on the map, but this
representation is intended to show the movement and spread of
plague around western Guangdong province from the 1860s to the
early 20th century. The dark solid lines represent the probable
diffusion and path of plague during this period. The black
circles represent an identified plague epidemic -- and you can
see that the dates are given there -- and also the black squares
unidentified epidemics which we know from the sources that there
probably was an outbreak of an infectious disease in that
particular place, but the records can't confirm whether that was
actually plague or not.
But the key point here - and this again in some senses echoes the
idea that plague was transmitted over trade routes and
communication routes between urban areas -- the key point here is
that Beihai, which is towards the southwest of the mainland on
that map, increasingly became a node for trade during the second
half of the 19th century. It was used by Cantonese merchants in
the 1870s and 1880s, and in 1876 it was established as a treaty
port, and also it became heavily used by steam ships. And this
had implications for the spread of plague around the Guangdong
province in this particular period that this map shows.
So plague becomes prevalent in China - China obviously is a,
generally a reservoir for plague, is a traditional reservoir for
plague -- but you can see that there are a series of epidemics
recorded from the late 1860s onwards.
And there were a variety of popular responses of epidemics of
plague. One example would have been the plague festivals, and
these ritual god/plague festivals centered on exorcistic rites
that were aimed at placation of the plague gods and the expulsion
of plague demons. The festivals might be prophylactic or they
might take place after an epidemic had broken out, and these
festivals might last for as long as a week. Other community
practices were inspired by religious, similar sorts of religious
beliefs but had unintended health consequences. So one typical
response would be to increase neighborhood street cleaning,
advocate the sweeping out of houses. And these were actually in
China in this period - they had a similar religious underpinning
as the plague festivals in terms of driving out the plague
demons, but you can understand that they also had a public health
effect in terms of the general sanitary impact. And it also was
not uncommon for there to be charitable medical relief efforts
during periods of epidemics. However, grafted onto these
varieties of popular responses were the westernized models of
sanitation and quarantine that had emerged in medieval Europe in
the 15th century, and in particular what we are concerned with
here is quarantine.
And what we have from the early 20th century onwards as part of
the new policy of reforms was the setting up of a centralized
sanitary system. And this was partly in response to the fact that
Chinese public health officials feared that left unchecked, the
spread of plague would demonstrate that China was incapable of
administering its own territory. So the idea of quarantine and
plague control was very important to Chinese officials from a
policy and international perspective.
So for example the Beiyung (?) sanitary services was set up in
Tandooin (?) province in 1902, and this was modeled on the German
and Japanese public health structure. So the sanitary system was
organized and managed by the police, and it was administered by a
public health infrastructure that would be recognizable to a
German public health professional at the beginning of the 20th
century.
And this led to eventually the attempt to set up a central
sanitary service by the Ching government from 1906 onwards. And
this sanitary service was tested in 1910 and 11 by an outbreak of
pneumonic plague in Manchuria, and quarantine was a crucial part
of the response to this outbreak of plague. So the city of
Shenyang in 1910 and 11 in response to this outbreak of pneumonic
plague was divided into seven police districts each of which had
a plague prevention office. So here there are clear echoes of the
example that I mentioned for Italy when parts of Florence was set
-- also broken down into zones that were the focus of public
health action. Each district in Shenyang was allocated 12 police
officers and 2 medical doctors. These districts were cordoned
off, and the traffic into and out of these districts was
controlled, so effectively each district had its own quarantine
system. Rickshaws, trams, and carts were each given flags which
allowed them to move between districts. So effectively the
transport vehicles were certified to be free from disease, and
they were allowed to move between districts once they had been
issued with a flag. In addition, residents within each district
were provided with colored arm bands identifying which district
they were from. So residents were allowed to move between
districts, but if they were coming to or from a known infected
zone of the city, then they would be able to be identified by
their arm band.
Another point to stress about the quarantine system that was set
up in Shenyang was that six quarantine and isolation stations
were created, not only for those suspected of having the disease
but also for contacts. So people who may or may not actually have
contracted the disease but
were just in contact with a known case were also removed to these
quarantine stations for observation and monitoring. So what you
have here is a system being instituted in a Chinese city in the
early 20th century that is almost identical to the systems of
quarantine that were instituted in Italy in the 15th century and
beyond.
Similar forms of quarantine can be found in the example from
Sydney in the early 20th century. Plague was introduced into
Sydney, Australia, from a ship sometime in late 1899 or early
1900, and initially it was highly localized in the wharves around
the ports and harbor area, in the warehouses associated with
maritime trade, and also in shops in the suburban areas and the
adjacent residences.
And there were 3 forms of response in Sydney to the plague
outbreak: First of all the removal of patients and contacts;
secondly the quarantine of city districts -- and we will go into
the various public health measures that were associated with
those, the quarantine of those city districts; and thirdly,
prophylactic inoculation. But it was actually the geography of
the epidemic that made these preventive measures rather more
clear-cut. And you can see on the slides here the plot of the
cases of plague in Sydney during the 1900 epidemic. And the map
on the left-hand side shows the number of plague cases as
recorded in places of work, and you can see the heavy
concentration around what is in fact the port and harbor area.
And on the right-hand side you have a representation of plague
cases by place of residence. And you can see, yes, there are
cases in, as with the figure on the left-hand side, there are
cases located around the port and the wharves, but what you also
have is a fanning out of the epidemic on the west, to the west
and to the east of Sydney in almost like a ribbon development.
And what those cases by residence are actually showing are
incidences of the disease that occurred in residences, around
shops and retail outlets.
The diffusion process of the plague, it was likely that it
occurred through the transport network that connected these shops
and residences with the port and harbor area. So supplies from
the central city warehouses which functioned as foci for the
plague would be transported along roads and networks to a system
of stores and stables and shops and suburban factories that were
beyond the city center and were in the suburban areas. And so
that is why you get this east and west, if you like, ribbon
outbreak of cases that were associated in residences that were
close to shops. So it is likely that there was the passive
transport of the plague bacillus, the flea vector and its primary
host, the rat, usually in sacks of grain, produce, hay, or other
goods that had been shipped from the central city wharves and
stores to suburban locations. So these sorts of conditions and
the knowledge of the geography of the outbreak, and the fact that
the wharves acted as the central focus of the plague epidemic
helped to inform the public health response.
Another way in which the response was conditioned was partly due
to international agreements over how plague would be best dealt
with from a public health perspective. And what you have on these
two slides are the outcomes of an intercolonial plague conference
that was held in Melbourne, which is of course in Australia, also
the focus of our case example here of Sydney -- the outcomes of
an intercolonial plague conference that was held in Melbourne in
1900.
And we can go through point by point the recommendations of this
colonial conference. First of all it was suggested that all cases
of plague should be monitored and that whenever there was an
outbreak, other colonies should be informed. So here you have
again this idea that the connection of places is very important
for the communication of plague. In other words to protect one
part of the British empire from plague, knowledge was required of
the outbreak of the disease in another part of the empire.
And crucial to this monitoring would have been the second point,
and that would be that plague would have to be notifiable. So in
other words, doctors had to become responsible for reporting the
existence of a case of plague to the suitable public health
authorities. This information could be gathered, each case could
be monitored, and other colonies in different parts of the empire
could be informed of the existence of disease.
Similarly, as part of the quarantine procedure, shipping should
be regularly inspected, disinfected, and fumigated.
People - the fourth point -- people who were crossing colony land
borders had to be subjected to a medical passport system which
effectively declared that they were free from the disease and
they were not transporting the disease across colonial borders.
And a fifth recommendation of the conference was that all rats
had to be destroyed. Obviously, if they were carrying the rat
flea -- and remember, by this time the plague bacillus had been
identified in bacterial laboratories towards the end of the 19th
century -- and the method of transmission was comparatively well-
known, and it was well-known that if you were to destroy the rat
population, public health authorities had a reasonably good
chance of controlling an epidemic. So the destruction of rats
became an important component of a policy to control plague.
Sixthly, the recommendation was that prophylactic inoculation
should be offered to the population, and that individuals should
be placed under surveillance, and also that facilities should be
provided for bacteriological research so that once an individual
was clinically diagnosed as having plague, that clinical
diagnosis could be reinforced with a bacteriological diagnosis,
too.
And you can see from the table here that shows the five major
plague epidemic periods between 1900 and 1925 is the impact that
the epidemic had in Sydney and Brisbourne, Newcastle, and
Townsville. These are the places that were most effected by the
plague. And you can see that although there are relatively few
numbers of cases in these epidemics, ranging from 303 cases in
Sydney in 1900 to as few as 14 cases in Newcastle in 1905, the
actual number of deaths in relation to those cases is quite high.
So you are getting mortality rates in some examples of up to 50
percent: as many as half the cases would end up and result in a
death from plague. So that shows the epidemic impact of the
epidemic period in Australia in the first quarter of the 20th
century. And so while the number of cases may have been
relatively low -- and this might be reflective of the success of
the quarantine systems that were put in place and some of the
other measures that were instituted on the recommendation of the
intercolonial plague conference -- once plague had actually taken
hold, then the number of deaths was actually quite high in
relation to the number of cases.
So how did the Sydney authorities respond to the outbreak of
plague that took place there in the early, very early years of
the 20th century? Well, first of all they undertook mass
removals. They weren't just looking at individual cases of
plague. In one example, in one week in April in 1901, a total of
120 people were removed from two hotels in one week. And this
mass removal of the potential source of plague provoked violent
scenes between the inhabitants, the police, and the health
authorities. There was a dramatic response to this forced mass
removal.
A second response was to concentrate on individuals, and not only
cases, of whom 263 were hospitalized during the epidemic in 1901-
02, but also of contacts. And almost 1500 contacts, potential
cases of plague, were housed in pavilions in the city.
Significantly, however, there was strict separation of supposed
Chinese contacts, and 45 Chinese people were housed not in
pavilions, not in hospitals, but in makeshift tents, and that is
of crucial importance, and we will come back to that in a little
while.
The first order of the plague department in Sydney was issued in
Sydney in March of 1901. And again, this separated the city into
various areas that were cordoned off by police and were blocked
off with physical areas. And within these areas, basic
environmental improvements such as the burning or rubbish and the
cleansing and disinfecting of houses took place. And these areas
were concentrated in the downtown city areas that were closely
associated with maritime economic activity. And in relation to
that as well, the harbor areas and the wharves were dredged. And
there are some quite startling results of the dredging: 9 pigs,
168 dogs, 93 goats, 87 fowl, 640 rats, a monkey, 27 puppy dogs
tied up in bags, and 27 pieces of meat were dredged up from the
harbor areas. There was also a systematic destruction of rats,
and during the epidemic period more than 1100 rats were
destroyed.
The following set of images shows some examples of the public
health response and the quarantine effort that took place in
Sydney in the early years of the 20th century during the plague
outbreak. This particular photograph shows the landing of plague
cases in this quarantine station during this epidemic. You can
see the barge-like vessel that would have transported people from
either the central city areas or infected ships to the quarantine
station. And you can see the crowds that amassed on the harbor
side there. These would have been people who would have either
had the plague or were suspected of having the plague and would
have been subjected to a number of days in quarantine.
And this photograph from Sydney shows a team of rat catchers that
was employed within one of the city zones that were cordoned off,
and they were responsible obviously for making sure that the
city's rat population was kept under control.
And the final image of this set of three from the Sydney epidemic
is a disinfecting team. And ou can see on the left-hand side of
the picture one of the portable disinfecting machines that would
have been carried into a house and would have been used to
fumigate the house and cleanse it of any potential remaining
infected material from the plague. And the people in the costumes
clearly would have been responsible for administering the
disinfection. And what strikes me about this image is the
remarkable similarity in some senses to the pictorial
representation of the plague doctor that emerged during the
medieval period: the idea that the team are wearing robes to
protect them from the infection; they have masks on; and this
general idea that, whatever we think about how the disease is
transmitted, the people who are responsible for administering the
public health or the medical response have to be protected in
this sort of way.
So having looked at those images that constitute some aspects of
the quarantine policy in Sydney, what I want to do in the
following section is look at some of the implications of that
quarantine policy and in particular how it resulted in the
scapegoating of the ethnic Chinese population in the city.
