by Sonia Shah
But as international commerce grew over the course of the nineteenth century, quarantines and cordons sanitaire came to be seen as unreasonably disruptive to trade. Social reformers and free-trade advocates sought more openness across borders, not less. Quarantines were “a most unwarrantable tyranny over the merchant,” a prominent New York City newspaper railed in 1798.32 The business losses incurred under quarantine were “calamitous,” according to the physician Daniel Drake.33 “Quarantine is useless,” added the British physician Henry Gaulter in 1833, “and the injury it inflicts on the commercial relations and maritime intercourse of the country is an absolute and uncompensated evil.”34
The very idea that infectious diseases spread from person to person—thus making them vulnerable to isolationist measures like quarantines—came to be seen as old-fashioned as well, a “scientific superstition,” as the nineteenth-century French physician Jean-Baptiste Bouillaud put it, “with which it is to be hoped that we shall soon be finished.”35 Charles Maclean, in 1824, titled his diatribe against quarantines, or rather “engines of despotism,” Evils of Quarantine Laws, and Non-Existence of Pestilential Contagion.36
Nineteenth-century medical elites believed that diseases, rather than being contagious, were the result of environmental phenomena, like stinky miasmas and clouds of gas. As New York’s resident physician James R. Manley summed it up in 1832, cholera was “an atmosphere disease … carried on the wings of the wind.”37 What would be the point of holding up shipping traffic and the free movement of people if that was the case?38
Maintaining this belief required some mental acrobatics, for the reality of contagion was clear enough to see. In rural areas, where people lived far apart and were less likely to pollute each other’s drinking waters, diseases like cholera clearly spread sequentially from one sick person to another, moving methodically from household to household, just the same as the quarantinable diseases of old such as plague and smallpox. But most medical elites lived in cities. They tended to discount the experiences of rural peoples, and in any case epidemics looked different in the cities. There, pathogens like cholera spread by both social contact and contaminated waters imbibed by many people at once. The outbreaks unfolded dramatically and simultaneously, just as if everyone had been enveloped by some inescapable cloud of disease, or had been struck by mass poisoning. And if some people fell ill while others didn’t, physicians said this was because of their depraved moral condition: drunks, prostitutes, and other disreputable types were more vulnerable than respectable citizens, they explained. (Here, too, inconvenient evidence to the contrary was easy to dismiss. When people in Montreal wrote to newspapers that cholera was attacking the “respectable,” disbelieving editors refused to print their letters. Or if a “respectable” person did die of cholera, medical experts argued that he or she must have had some secret vice.)39
With medicine and commerce thus ideologically opposed to quarantines, New York City’s resolve to effectively enact them had progressively weakened in the years before cholera’s arrival. In 1811, the city council and the state legislature relinquished their authority over enforcing quarantines to local health officers at ports. In 1825, they exempted any vessels arriving from Canton or Calcutta from quarantine restrictions. (Just why these two cities were exempted is unclear.)40 With the implementation of quarantines left to local health officers, enforcement was piecemeal at best. Steerage passengers on incoming vessels might be inspected, but first-class passengers would be allowed through, healthy or not. Motivated individuals could circumvent quarantine by bribing health officers, escaping poorly guarded quarantine centers, or simply fraudulently declaring themselves to be healthy. Ships easily flouted quarantine restrictions. If, say, health officers at ports such as New York City’s required that vessels had to spend two to four days in quarantine before docking, captains would simply steer their ships to nearby ports in New Jersey or Throgs Neck where such restrictions didn’t hold.41
Nonetheless, New York came close to enacting a quarantine against cholera. The governor of New York State had observed cholera’s progress across the Atlantic and into Canada during the spring of 1832. Concerned, he dispatched a physician, Dr. Lewis Beck, to conduct a statewide reconnaissance to determine whether the disease posed a risk to the city.
Beck conducted a detailed study, discovering that cholera cases had started breaking out along the path of the Erie Canal and were indeed headed south to New York City, as a modern visualization of his data shows. By contemporary standards, quarantine would have been the appropriate recommendation to the governor. The pattern of cholera cases did seem to “favor the idea that cholera is contagious,” Beck admitted.42
But that was just an illusion, he went on. In fact, only the immigrants, the poor, and the drunks sickened, and only in the “filthy part of the village.” The respectable people who sickened, he explained, had been infected by “eating of a large quantity of green peas” or partaking “immoderately of cucumbers and other vegetables.”43 New York City had nothing to fear and quarantines were unnecessary. “It appears to be abundantly settled,” Beck reported, “that cholera cannot be kept out of a country by quarantine laws.”44
And so cholera traveled unhindered down the waterways toward New York City. Local people girded themselves by doing things like avoiding green and unripe fruit and adopting the upstanding middle-class mores recommended by their physicians: moderation in labor, food, and sex.45 People in canal towns strung up large pieces of meat on poles to soak up the cholera vapor. Others burned barrels of tar, hoping to rid the air of cholera.46
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The third containment measure that New York City failed to implement continues to falter today: prompt public alerts regarding the arrival and the spread of the disease.
For fear of disrupting trade, the mayor of New York and the city’s board of health refused to notify the public about the contagion in their midst. So did every other town and city that was stricken by cholera, which issued vague reports of “sudden deaths” of “unknown disease” rather than admit that cholera had erupted in their community. (Unaffected neighboring towns were less reluctant to call the disease by its name, which is how news about cholera’s spread got out.)47
Prominent New York City physicians, deluged with patients sick with cholera in the summer of 1832, begged the mayor to issue a public alert. Both he and the board of health denied cholera had emerged at all.48 Outraged and alarmed at the “tardy and obstinate” behavior of city officials, a group of leading physicians published a blistering public bulletin condemning the municipality (which they called the “Corporation”) for valuing “dollars and cents above the lives of the community.”
This no doubt has led them so pertinaciously to deny the existence of Cholera in this city—even after the fact was established by the united testimony of the whole Profession … We appeal to the good sense of our Citizens whether there can be any apology for the criminal neglect of the Corporation, in relation to the distresses of the thousands who are now crying out to us for aid … It is time that you should be removed from the office, which, instead of dignifying, you only disgrace.49
City officials may have destroyed evidence of the arrival of cholera-infected ships in the weeks before the outbreak, too. Following up on claims made by the port physician that the city had secretly quarantined passengers from a cholera-infected ship, investigators found that otherwise intact quarantine-hospital records for the months in question—April, May, and June 1832—had disappeared.50
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To be fair, the choices that nineteenth-century leaders had to make about whether or not to implement disease control strategies were not between two equally compelling options. The choices were between predictable costs and unpredictable benefits. They knew that quarantines and alerting the public about cholera would disrupt private interests, but they couldn’t be sure that either strategy would actually protect the public. It’s not surprising, then, that they opted for near-certain p
rivate benefits rather than mostly uncertain public ones. Plus they were under no obligation to do otherwise.
By the twentieth century, that had changed. Starting in 1851, about a dozen European nations in conjunction with Russia launched a series of international meetings to hammer out an agreement to alert one another about the presence of infectious diseases within their borders. After five decades of acrimonious debate, by 1903 they’d agreed to report cases of cholera and plague to each other, to implement maritime quarantines for cholera, and to allow other nations to inspect ships from cholera-infected ports, as part of an International Sanitary Convention.
But powerful private interests continued to sabotage their efforts, despite the international agreement. One of the most daring and well-coordinated international conspiracies to conceal an infectious disease outbreak occurred just a handful of years after the convention was signed.
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Cholera broke out in Naples, Italy, in 1911. It was the eve of a nationwide celebration of the country’s fiftieth anniversary, which was expected to draw millions of tourists. The Italian prime minister, more interested in protecting commerce and prestige than the health of his people, made his intention to flout the International Sanitary Convention clear in a telegram sent to his public-health authorities: “The aim is to obtain and maintain the greatest possible secrecy” about the unfolding cholera epidemic in the country, he instructed. “The Government will be merciless with all those who are slow or negligent.”
Italian authorities paid newspapers and reporters secret monthly retainers of 50–150 lire a month to avoid mention of the dreaded “c” word; they intercepted and censored telegrams that contained the word “cholera”; they tapped the phones of those who might leak the news, threatening them with imprisonment. They conducted nighttime raids on medical societies, confiscating cholera-education materials. And while they continued to maintain records on each case that occurred, they stamped case reports with the word “secret,” in bold type, and the reminder: “N.B. No official bulletin was published.” Cholera victims were transported to hospitals in the dead of night, while local papers blared, “There is no cholera, and never was!”
U.S. officials signed on to the cover-up as well. “No unnecessary publicity will be given as to the existence of cholera in Italy,” the secretary of state reassured skittish Italian authorities by telegram. So long as the Italians promised to take care of the messy cholera discreetly, the United States would ignore the strictures of the International Sanitary Convention. “Bills of health, after completion, shall be given to the Master of the vessel, sealed,” the secretary of state affirmed, “and knowledge of contents known only to the consul and the medical officer, not even the Master is to know the contents.” While the surgeon general didn’t bother warning the public about the risks of travel to cholera-stricken Italy, in private correspondence he advised his personal acquaintances to cancel their plans to visit Italy that summer. The French government also agreed to the terms of Italy’s conspiracy.51
The historian Frank Snowden estimates that the secret cholera epidemic in Italy killed up to eighteen thousand between 1910 and 1912, and spread into both France and Spain. While the details of Italy’s secret cholera epidemic did not make an appearance in the historical literature until decades later, when it was exposed in detail by Snowden, close readers of German novels could have figured it out at the time. The German novelist Thomas Mann and his wife had visited Italy during the secret cholera epidemic. In 1912, Mann published his novella Death in Venice, in which a German writer visits Venice, finding the city under some kind of “nameless horror.” The writer ultimately perishes after consuming overripe strawberries, commonly believed by Mann’s contemporaries to be a major risk factor for cholera infection.
Italy’s cover-up was among the most daring, but it was hardly the last. Political leaders continue to prioritize commerce and national reputation over public health. In 2002, Chinese authorities treated the emergence of SARS as an official state secret. A spokesman for the Guangdong health department said that information about the brewing epidemic would be dispensed solely by “the party propaganda unit” and that any physician or journalist who reported on the disease risked persecution, the critic Mike Davis reported. Aside from a few newspaper reports from the city of Foshan—which mentioned only a spate of unexplained respiratory deaths—the international community and public-health authorities around the world had no idea about the outbreak.52
It was only months later, when a local resident happened to mention what was happening in Guangzhou in a message to an online acquaintance, that the international community learned of the new pathogen’s emergence. The recipient of the message forwarded it to a retired navy captain named Dr. Stephen Cunnion, who posted the following query to an infectious-disease reporting system run by an international medical society, the Program for Monitoring Emerging Diseases (Pro-MED), on February 10, 2003. “This morning I received this email,” he began, “and then searched your archives and found nothing that pertained to it. Does anyone know anything about this problem? ‘Have you heard of an epidemic in Guangzhou? An acquaintance of mine from a teacher’s chat room lives there and reports that hospitals are closed and people are dying.’”53
After news of the outbreak reached the Beijing office of the World Health Organization, Chinese officials continued to stonewall. They admitted to only a few deaths from “atypical pneumonia.” They blocked, at least initially, investigative teams from the WHO from inspecting the military hospitals where SARS patients were being treated. It was only after a sufficiently alarmed WHO advised visitors to stay away from Hong Kong and Guangdong that the Chinese health minister publicly acknowledged the presence of the new killer virus. Even then, the minister insisted that the pathogen had been contained and that south China was safe, neither of which turned out to be true.54
The government of Cuba similarly suppressed news about a 2012 outbreak of cholera. According to The Miami Herald, Cuban authorities told local doctors to list cholera deaths as being caused by “acute respiratory insufficiency.” “We have been forbidden from using the word cholera,” a local man told the newspaper, adding that people had already been arrested and detained for transgressions. While news of cholera’s continuing spread leaked out of the country, the government announced that the cholera outbreak had been contained. In December 2012, they detained a journalist who’d reported on the cholera outbreak. (The doctor who had publicly reported on the country’s 2000 dengue fever outbreak had been imprisoned for over a year.)55 When you report cholera, “you get into trouble,” as a government official in Dar es Salaam, Tanzania, told the journalist Rose George.56
The Saudi Arabian government attempted to silence the virologist who discovered a novel coronavirus that had first popped up in a patient in a hospital in Jeddah in the fall of 2012. Cognizant of the SARS-like threat that the new virus posed, a virologist at the hospital, Dr. Ali Mohamed Zaki, posted his findings on Pro-MED, alerting its sixty thousand worldwide subscribers. By all accounts, Zaki’s timely warning averted what could have become a global outbreak. The coronavirus was rapidly sequenced, diagnostic tests devised, and public-health authorities around the globe discovered over a hundred more victims of what came to be called Middle East respiratory syndrome (MERS). According to Zaki, the Saudi Arabian ministry of health was not pleased. “They were very aggressive with me,” he says. “They sent a team to investigate me … And now they force the hospital administration to force me to resign.” The man who may have prevented a pandemic lost his job and had to relocate to Egypt.57
It’s not only governments with reputations for repression that have squashed information about new pathogens. The democratically elected government of India attempted to suppress word of NDM-1, too. The first reports on NDM-1 and its spread through India’s medical tourism industry appeared in the international medical literature in August 2010, in a paper in The Lancet coauthored by British and Indian scientists. Imme
diately upon its release, Indian medical tourism advocates started denying the public-health significance of NDM-1. “Such superbugs are everywhere,” pooh-poohed Dr. Vishwa Katoch, the Indian government’s secretary of health research. “India has a problem like other countries.” Research on NDM-1 and the naming of the plasmid after the city of New Delhi where it was first isolated was “a conspiracy to hurt Indian medical tourism,” opined The Indian Express. The conclusions of the research on NDM-1—that the business of medical tourism might need to be restrained—were “unfair and scary,” added The Hindu newspaper.58
Indian government authorities cracked down on the Indian scientists who had been involved in the NDM-1 study, intimating in letters and private meetings that their research on the new pathogen broke the law. “Permission is required to be obtained by the relevant authority,” a letter to the researchers from the health ministry stated. “You are hereby asked to explain the details about the study conducted.” University of Cardiff’s Timothy Walsh, who spearheaded the research, was accused of being a spy and was deluged with hate mail, he says. According to the Indian government, Walsh says, “I’m the devil incarnate and eat babies for breakfast.” With international collaboration on NDM-1 sharply curtailed by the Indian government’s interference, Walsh was forced to enlist journalists to acquire samples in India to continue his research on the plasmid.59
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The nineteenth century is infamous for the rise of the unethical capitalists derided as “robber barons,” but it’s post-twentieth-century globalization that has concentrated unprecedented power in the hands of private interests. Of the one hundred largest economies in the world, only forty-nine are countries; fifty-one are private corporations.60 By 2016, the richest 1 percent of people in the world will control more than half of the planet’s total wealth.61
The influence of these private interests dwarfs that of the public institutions that might seek to regulate them. And so when private interests run contrary to those of public health, it’s often public health that gets the shaft. A good example of this is in the area of antibiotic consumption.
