Global Health

John J. Kirton, John J. Kirton

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351933407
• Edition: 1
• Topic: Politik & Internationale Beziehungen
• Subtopic: Politik

In recent years, especially since the end of the cold war, the field of global health has become increasingly linked with and central to the more traditional concerns of international relations. The spread of communicable diseases, the challenge of migrating health workers and the development of new technologies and medicines have all contributed to the ever-expanding issue of global health. International organizations such as the World Health Organization, the utilization of techniques such as the creation of the framework convention on tobacco control and the development of civil society organizations such as the Gates Foundation, have all changed the face and framework of global health. Among the many benefits to the expanding interdisciplinary study of health is the possibility of preventing millions of unnecessary deaths occurring every year. By assembling from a wide array of disciplines and fields the central works that define the field in international relations today, this innovative work explores the future of global health and the possible benefits of expanding the interdisciplinary path even further.

Part I
The Foundations and Evolution of the Field

[1]
Disease, diplomacy and international commerce: the origins of international sanitary regulation in the nineteenth century

Mark Harrison
Wellcome Unit for the History of Medicine, University of Oxford, 45-47 Banbury Road, Oxford OX2 6PE, UK

E-mail: [email protected]

Abstract

During the early nineteenth century, European nations began to contemplate cooperation in sanitary matters, starting a diplomatic process that culminated in the International Sanitary Conferences and the first laws on the control of infectious disease. This article examines the origins of these conferences and highlights certain features that have been neglected in existing scholarship. It argues that while commercial pressures were the main stimuli to the reform of quarantine, these were insufficient in themselves to explain why most European nations came to see greater cooperation as desirable. It places special emphasis on the diplomatic context and shows that the peace of 1815 produced a climate in which many European nations envisaged a more systematic and liberal sanitary regime.

The first International Sanitary Conference, held in Paris, in 1851, is generally regarded as a milestone in international sanitary cooperation. Although there was little agreement among the twelve nations that sent delegates to the conference, it established the principle that quarantine and similar sanitary measures ought to be fixed by international agreement, so as to minimize the expense and inconvenience arising from a multiplicity of practices. The Paris conference applied only to the Mediterranean but all subsequent international forums and laws on the control of infectious diseases stemmed from these tentative steps towards international sanitary collaboration, more than 150 years ago. Yet historians have shown comparatively little interest in the origins of the Paris conference or in attempts to control the spread of diseases across borders prior to 1851. Above all, we have little idea of why the idea of international collaboration suddenly became attractive to many countries in the decades before 1851: it was by no means an easy or natural evolution, as quarantine had typically been regarded as an instrument of foreign policy, to be used aggressively in furtherance of national interests.

In so far as an explanation has been attempted, it has stressed the growth of international commerce and particularly the trading interests of Britain and France.¹ The fact that these countries took the initiative would appear to suggest that they saw international agreement as a means of diminishing impediments to their maritime trade. Other factors, such as the growth of political liberalism have also been suggested as reasons why certain states sought to reduce the burden of quarantine, although there is little agreement about how far ideology had a consistent bearing upon sanitary policies.² Yet neither explanation seems sufficient in itself to account for the radical shift that was needed for states to contemplate cooperation in sanitary matters. As Peter Baldwin has noted, mercantile interests were far from uniform and tended to be regarded as having a rather narrow view, sometimes incompatible with the national good. Two important questions therefore arise. First, how and with what degree of success did mercantile groups enlist the support of others in their campaign to reform quarantine regulations? Second, how did the reform of quarantine come to be identified, not only with national interests, but with the welfare of humanity in general?

It is not possible here to reconstruct the process whereby the critics of quarantine were able to forge coalitions in their respective countries, but it is possible to examine the international context from which the desire for sanitary cooperation developed. As is well known, the Congress of Vienna (1815) brought to an end an atomized system of international relations in which armed conflict had been common. The system of diplomacy inaugurated at Vienna recognized the existence of different national interests but sought agreements that transcended them. Although this system fell into disarray in 1823, congresses were replaced by smaller conferences on specific topics, and these often proved to be more effective than the rather grandiose gatherings they replaced. It was in this context that the concept of international sanitary cooperation was first articulated, marking a fundamental shift from the state of affairs prior to 1815. While the growth of international trade loomed large in these discussions, other considerations were also important, not least the balance of power and the avoidance of war. Both within individual countries and in the international arena, the proponents of quarantine reform grew in support and stature as their campaign became enmeshed with these broader political and humanitarian concerns.

Quarantine’s ancien régime

By the middle of the fifteenth century, legislation banning commerce with infected places was common in many Mediterranean countries, particularly those closest to reservoirs of plague in Central Asia. Although the plague was still regarded as a ‘blight of God’, prayer and penitence – formerly ‘the first and sovereign remedy’ – were gradually supplemented by more secular interventions.³ Some countries, especially the Italian states, also began to develop permanent bureaucracies to administer quarantine and lazarettos, in the belief that plague was a contagious disease that could be prevented by thwarting its transmission.⁴ This belief rested on two related observations. First, of all the maladies afflicting Europe, plague alone originated outside the continent; second, it appeared to be a specific disease, with easily recognizable symptoms that could be differentiated from common fevers. Quarantine was invariably imposed whenever the disease was reported in the Levant, which had long been regarded as the conduit of plague into Europe. It was also sometimes imposed against ships from the West Indies, when epidemic disease (most likely yellow fever) was known to be prevalent.⁵ In the seventeenth century, these measures were usually ad hoc in nature rather than the subject of specific statutes.⁶ Even in the Mediterranean, more vulnerable to plague than northern Europe because of its proximity to the Levant, quarantine stations were isolated and their practices irregular. In France, for instance, there were only two quarantine stations along the Mediterranean Sea, at Toulon and Marseilles. Contemporaries were struck by the lack of coordination between these stations and also by the fact that quarantine often continued to be imposed at the ports when the plague was ravaging the interior. This situation led, in 1683, to the first statute relating to quarantine, which began to standardize practices across the country.⁷

In many Mediterranean countries, quarantines came to enjoy a good measure of popular support and were widely credited with the freedom of certain countries from plague. Liberal quarantine regimes like those at Marseilles, however, were generally the exception rather than the rule, and other Mediterranean stations, such as those along the Barbary Coast, became notorious for malpractice and exorbitant charges. But in some European countries, most notably France and Britain, the eighteenth century saw increasing divergence of opinion on quarantine. While such measures continued to command popular support, the medical profession began to divide sharply over the utility of quarantine and the theory of contagion that underpinned it. At the same time, merchants involved in the export trade with the Levant grew increasingly critical of quarantine restrictions, which cost them a great deal through delays, charges and the destruction or damage of goods by fumigation in quarantine houses. Arrangements in the Mediterranean were the main cause of complaint but the enactment of quarantine statutes in northern countries during the eighteenth century constituted an additional burden.⁸

Perhaps the clearest example of this polarization of opinion was the response to the plague in Marseilles in 1720. The outbreak was immediately traced to a merchant vessel that had arrived from Syria, and neighbouring countries lost no time in imposing quarantine against French shipping; a sanitary cordon was also imposed around Marseilles and other infected provinces. The cordons appeared to prevent plague from spreading beyond southern France but some medical practitioners questioned the contagious nature of the disease. If plague were contagious, why did it appear only at certain times of the year? Might not epidemics be related to other factors, such as seasonal climatic changes and states of the atmosphere? Such ideas had steadily gained ground since the revival of Hippocratic medicine in the Renaissance, and by the late seventeenth century they were being clearly articulated by the English physician Thomas Sydenham (1624–89), amongst others.⁹ Many of the medical practitioners who commented on the epidemic in southern France employed such explanations as an alternative or supplement to contagion. The fact that the Levant was afflicted more often than Europe was explained by the fact that it was subject to great heat, the plague ‘poison’ arising from the rapid putrefaction of dead animals and plants; likewise, plague tended to occur in Europe during the summer, when conditions approximated to those in the East. Quarantine therefore seemed to be unnecessary, as well as injurious to trade.¹⁰

In Britain, the incorporation of quarantine into statute law provoked similar debates. The first act was passed in 1710, and further legislation followed the arrival of plague in Marseilles, creating a quarantine station in the Medway and elevating the maximum penalty for evasion to death.¹¹ However, the draconian powers of the 1721 Act were modified as the threat from the Mediterranean diminished.¹² As in France, the broad consensus over preventative measures that had existed in the 1600s was beginning to break down: medical opinion was diverging and exporters were growing increasingly impatient of restrictions on trade. Critics claimed that quarantine in Britain was unnecessary if men boarding ships in the Levant were healthy, as the voyage of seven or eight weeks was long enough to ensure that plague was not present.¹³

Some critics went further and suggested that quarantine in Europe could be relaxed in view of the fact that ships leaving the Levant with foul bills of health were required to perform quarantine at Malta, Leghorn and Venice. But quarantine was far from infallible. In Spain, for instance, the authorities experienced great problems in imposing an embargo against ships from Marseilles, despite posting guards along the Mediterranean coast. Ships also attempted to dock in Spanish ports with fraudulent bills of health, which falsely claimed that the ships had sailed from non-infected ports. Cordons imposed along land borders were even more porous,¹⁴ and plague epidemics were often blamed on illicit traders who stealthily crossed borders to evade customs duties and quarantine.¹⁵

Even supporters of quarantine admitted that this was a problem and some concluded that the answer lay in more efficient systems of disease notification, which would mean that quarantine could be resorted to selectively. The British physician William Brownrigg, for example, conceded that less resort need be had to quarantine if the bills of health issued from plague-infected countries were more reliable.¹⁶ By the 1770s, bills were issued routinely by some of the Italian states and by foreign consuls in the Ottoman dominions. Bills normally declared the time and place from which they were granted, the names and numbers of crew and passengers, and indicated the health status of the vessel. They also recorded whether or not quarantine had been performed and the nature of any merchandise carried.¹⁷

One of the problems with the system was that consuls had to depend on unreliable sources of information. All it took for a consul to issue a foul bill of health was a single reported case in a Levantine city or its environs, and some British merchants suspected that consuls were deliberately fed false reports by their commercial rivals. ‘The Greeks carry on three-fourths of the Dutch as well as the Italian trade’, protested a group of Smyrna merchants, ‘it is therefore their interest (and unfortunately that of every other nation) to depress ours as much as possible.’ For this reason, the merchants, championed by the prison-reformer John Howard, advocated the construction of a model lazaretto in Britain, thereby dispensing with the need to quarantine ships in the Mediterranean. In view of the distance from the Levant, Howard proposed that a quarantine of no longer than forty-eight hours need be performed, if no cases of sickness developed among crew or passengers. Although the British government had hitherto rejected the idea on grounds of cost, the Levantine merchants claimed that a boom in trade with Turkey would more than repay it.¹⁸

Despite its obvious flaws, quarantine remained firmly entrenched for the rest of the century, both in the Catholic Mediterranean and in the Protestant North.¹⁹ Quarantine was imperfect but it was the art of the possible, and to abandon any form of protection was incompatible with contemporary theories of statecraft, which viewed population as a source of wealth and power. Johann Peter Frank’s multi-volume treatise, A system of complete medical police, exemplified this line of thinking. An exponent of enlightened absolutism, Frank proposed a comprehensive system to protect and improve the health of all persons through generous state provisions and the regulation of so...