View: Quarantine quandaries and questions of trust

The arrival of plague in Bombay in 1897 posed a new kind of quarantine problem. As a port Bombay was used to quarantines which were routinely applied to ships. In 1878, for example, the Times of India (ToI) reported on a Town Council meeting where the efficacy of quarantine rules […]

The arrival of plague in Bombay in 1897 posed a new kind of quarantine problem. As a port Bombay was used to quarantines which were routinely applied to ships. In 1878, for example, the Times of India (ToI) reported on a Town Council meeting where the efficacy of quarantine rules was debated.

Ships from the Red Sea which might have infectious diseases on board were required “to hoist a yellow flag and were placed in a particular position until the health officer of the port had obtained sufficient information about the sickness on board.” If required the ship had to isolate itself until disinfected or declared free from sickness.

This was the procedure first imposed by Ragusa and Venice, the city states of the Adriatic Sea which derived their wealth from maritime trade, but which were also vulnerable to diseases that would come along with the merchandise. With the arrival of bubonic plague in the 14th century the danger increased, yet these cities knew that isolating themselves entirely would be economically devastating.

Temporary isolation then was the solution – first for 30 days imposed by Ragusa (now Dubrovnik) and then 40 days, or quarantena, by Venice. Rules were agreed, with ships allowing inspectors on board and sticking to the full period, if required, but with the city sending provisions. Later on variations developed, for example with quarantine being reduced by the number of days the ships were sea, effectively a quarantine in transit.

Isolating people with diseases had been practiced since ancient times, notably for leprosy which was infectious and disfiguring, but didn’t kill victims soon. During epidemics healthy people preventively isolated themselves, a practice that many are following with Covid-19 now. But quarantines were for people who didn’t appear sick, but had been exposed, and hence had to be kept under isolation to see if the disease developed.

All this was relatively easy for maritime transport since the sea effectively isolated potential sources of infection on ships. Even when unloading passengers or cargo was required, ports usually had islands nearby where this could be done while staying isolated from the mainland, or barges could be used for this purpose.

Quarantine on land was another matter. By 1897 Bombay was well linked by rail and this posed a real problem. In November that year ToI reported on elaborate plans drawn up to examine rail passengers. When they arrived at Kalyan outside the city “all third-class passengers found to be travelling from infected districts are made to alight from the trains and are again located in special carriages in the rear where they are locked up with a view to prevent them alighting at any intermediate station.”

When the trains reached Byculla the captive passengers were taken under police escort to the quarantine camp at Wari Bunder near the docks. They were provided food there, but had to stay for 24 hours after which “such of them as can produce a guarantee from a respectable citizen of Bombay are released on the understanding that they present themselves at stated periods for medical examination.” Without a guarantee they had to stay until the medical officers felt they were safe to leave.

One problem with this can be seen in the focus only on third class passengers. A subsequent report spelled out this discrimination with first and second class passengers being exempt from quarantine, though Medical Officers could put them there if they seemed sick. Exemptions were also given to “servants of any European or leading Native” as long as their employers agreed to have their clothes washed and disinfected soon after arrival. The clothes of the employers didn’t seem subject to the same requirement.

Despite these regulations the plague was soon killing an estimated 1900 people per week, which doesn’t say much about the efficacy of quarantine. And if one thing is proven by the history of quarantines it is that their efficacy is determined not by the ability to physically or forcefully isolate, but to persuade people to co-operate.

The original Venetian quarantine required trust on both sides – that the ships were correctly reporting their history and status of health, and that the Venetians weren’t isolating them for commercial gain and would treat them fairly during the isolation. Without trust it didn’t work. And, as Bombay discovered in 1897-8 a system where only the poor were quarantined was not designed to build trust.

There are many examples of this. For centuries Malta operated a very effective quarantine on the many ships that stopped at the island. The Christian order of the Knights of St.John which governed the islands from 1530-1798 built a special quarantine station on an island near the port and had elaborate systems for running it properly, which were inherited by the French and then British who subsequently took control.

Even letters transiting through the island were fumigated to present them carrying any disease. But in the 1840 an American diplomat began suspecting the letters were being read during the process to provide the British valuable information. He protested mail quarantining, and finally managed to win exemptions for Americans that started to undermine the whole process.

A more complicated case is that of Typhoid Mary. This was Mary Mallon, an Irish woman who had migrated to the US to work as a cook in New York. When a typhoid epidemic hit the city Mallon was found to have worked in many affected households. Since she never fell sick herself she refused to recognise the connection, until she was forcibly detained and examined. It was discovered that she was a rare example of an asymptomatic carrier of typhoid, who didn’t fall sick, but who carried the bacteria.

The typhoid epidemic could have had more general causes of poor hygiene, but it suited the authorities to pin the blame on Mallon as a quick way to solve the problem and avoid larger questions. But it didn’t solve the problem for Mallon, who was a poor woman who still had to earn a living the only way she knew. So she evaded detection and started working as a cook again, and again the typhoid cases started.

Finally, Mallon was detained and put into indefinite quarantine until she died, 33 years later. The authorities justified this since she did carry the bacteria, so could theoretically develop the disease, except she never did. She was vilified for being irresponsible, but equally could be seen as a poor woman who was never given a way to live or have her medical condition properly explained to her, and so refused to trust the authorities and as a result ended up in perpetual quarantine.

With the advent of vaccines and modern medical treatment the threat of quarantines seemed to have largely faded from our lives. We thought of them as applying to dogs, when taken across countries because of rabies regulations, or the plant quarantines imposed by countries to prevent plant diseases spreading. Indians travelling to parts of Africa where yellow fever was still prevalent, but who forgot to take the vaccination before going, were occasionally unpleasantly surprised to be whisked off to quarantine on returning.

In the 1980s the panic around HIV saw a return of forced quarantining. In 1989 Dominic D’Souza, one of the first people to be detected with HIV in India, was forcibly quarantined by the government of Goa for 64 days, until a legal team was able to get him out. (The story is vividly told in the film My Brother Nikhil). Only when people realised that such forcible tactics were pushing victims deeper into hiding, making them harder to detect and stop the disease spreading, was quarantining stopped and more effective, trust based solutions developed.

Recent outbreaks of zoonotic diseases like Ebola have again seen an upsurge in the issue, where panic driven by sensational reporting has pushed politicians into announcing quarantines that are not calculated to build trust. The victims are often the medical and humanitarian workers who go to help, only to be forcibly quarantined when reaching home. In 2014, for example, Kaci Hickox, a nurse with Doctors Without Borders, was detained on returning from Africa, and despite showing no symptoms was forced into a 21 day quarantine.

This kind of panic driven quarantine has possibly caused a further problem – deliberate evasion by those who have the resources or connections. In 2007 Andrew Speaker, a young American lawyer, was detected with multi drug resistant tuberculosis. He was not obviously suffering from the disease, and when he received his diagnosis was about to fly to Greece for his wedding.

As it happens, Speaker’s soon-to-be father in law was a scientist with the USA’s Centers for Disease Control (CDC), so he did know about the dangers of infecting people while travelling, yet chose to travel anyway. When informed by CDC that he had to return to possible quarantine, he panicked and flew to Canada – potentially infecting many more en route – and drove across the border to the USA undetected. When he was finally found it sparked a debate on how Speaker had used his influential connections to irresponsibly evade quarantine.

We are now seeing this playing out with Covid-19, which has changed the pattern of past epidemics by being spread not, as was alleged before, by the poor and marginalised who could not evade quarantine, but by the rich and well-connected who can.

For example, in Uruguay, a small country so distant from the source of infection that it could have expected to avoid the disease for a while, cases suddenly exploded after a glamorous socialite and fashion designer flew back home from Spain, didn’t declare her possible exposure and attended several parties at which she ended up infecting a number of people.

And then there is the startling case from Kolkata where the son of Arunima De, a very high level bureaucrat in the state government, flew back after being exposed in the UK. He didn’t just evade examination on return, but proceeded to go out in the city for a few days, unimpeded by his mother, who was aware of how the state was gearing up to tackle the disease, or his father, who is a doctor.

He soon developed symptoms and tested positive, but was still not taken by his mother to the infectious diseases hospital mandated by the government, but to a private hospital, where he potentially infected even more. In the same time De attended high level government meetings, potentially infecting other senior bureaucrats, and her husband examined patients, potentially infecting them.

Finally, when the news broke the family was forced into isolation, and have attracted considerable, very well deserved condemnation. When people like a senior bureaucrat and doctor, who should be leading the response to Covid-19 behave this way simply to avoid quarantine, how can there be any hope of building the trust that is the only way in which quarantining has ever been able to work?

Source Article

Lois C. Ferrara

Next Post

Italy virus toll tops 4,000, New York joins California in lockdown

Sat Mar 21 , 2020
NEW YORK: The grim toll of coronavirus deaths in Italy, the world’s worst-hit nation, surged past 4,000 on Friday as New York and other US states joined California in ordering a lockdown to try to bring the pandemic under control. While new infections were being detected around the planet, there […]