A brief history of quarantine, and what it can teach us about social distancing today
In the hope of halting the devastating advance of bubonic plague, in 1377 the city of Ragusa (modern Dubrovnik, Croatia) issued a ‘Trentino’, (from the Italian ‘Trenta’, meaning ‘30’), a 30 day isolation period for anyone trying to enter the city. An isolation area was established outside the city walls and citizens of Ragusa were forbidden from entering on penalty of being fined and detained there themselves. Only those assigned by the Great Council to tend the sick were permitted to enter.
Similar laws were introduced in the cities of Marseille, Genoa, and Pisa. In 1423, Venice set up a ‘lazaretto’, a quarantine bay for merchant ships, on the island of Santa Maria di Nazareth, a system that was soon modeled throughout much of Europe. The initial isolation period was extended from 30 to 40 days. The Trentino became a ‘quarantine’, from the Italian ‘Quaranta’, meaning ‘40’, giving us the word ‘quarantine’.
It’s not known precisely why the isolation period was extended to 40 days, but historians have suggested it may have been done to reflect Christian practices and teachings. Lent is observed for 40 days, Jesus fasted in the desert for 40 days, and Genesis tells us during the great flood it rained for 40 days and 40 nights. It may also have been changed because of the ancient Greek doctrine of ‘critical days’ that teaches contagious diseases to develop within 40 days after the initial exposure.
Of course, 1377 wasn’t the first time the sick had been separated from the healthy on a mass scale. The book of Leviticus in the Old Testament, for example, states that anyone “defiled” with leprosy is “unclean” and “shall dwell alone, without the camp shall his habitation be”.
But, quarantine of medieval Ragusa was a watershed moment in medical history as the practice of quarantine was enforced by the state. Since then, quarantine has been the cornerstone of every government strategy for the control of contagious diseases.
Given the criticism our current government is facing for not locking down the UK sooner to halt the spread of coronavirus, it may come of no surprise to learn that medieval Britain was slow to implement quarantine too. While cities across Europe started quarantining plague victims in 1377, it would take England more than 200 years and numerous outbreaks to finally draw up what was known as the ‘plague orders’. But by the time the ‘Great Plague of London’ hit in 1665, these orders were being ruthlessly enforced.
Parishes were required to provide public ‘pesthouses’ where plague victims would be isolated. If there was not the capacity to quarantine there, as was often the case, victims would be locked inside their home with their entire family, who would almost certainly contract the disease and die too. The door would be padlocked shut by a local constable, who would mark it with a red cross and the words ‘Lord have mercy upon us’. Watchmen were posted outside to ensure no one tried to get in or out, and ‘plague nurses’ were appointed to tend the sick and report those who died to the authorities. Those who could afford to do so heeded the old dictum Citò longè tardé, ‘go quickly, go far, return slowly’, and fled the infected areas.
Plague is still with us and, alongside antibiotics, quarantine is still one of the most effective methods we have of slowing transmission. In 2014, parts of the Chinese city of Yumen were quarantined after one man was found to have died of the plague. In 2017, an outbreak of plague in Madagascar infected 2,348 people and killed more than 200. It would have claimed many more were it not for the swift actions of health authorities who closed schools, banned public gatherings, and quarantined the sick.
Quarantine was still being used to control periodic outbreaks of plague in the eighteenth century, but many social reformers had come to think of quarantine itself as an outdated practice. Fierce debates broke out between those calling themselves ‘anticontagionists’, who opposed the use of quarantine, and ‘contagionists’, who defended it.
American ports were routinely placed under quarantine in the eighteenth century to try and control outbreaks of yellow fever in the Caribbean. Despite the disease killing thousands of people, many Americans viewed quarantine as an infringement of their personal freedom and protested its use fiercely. Physicians such as Benjamin Rush (1745-1813), who angrily wrote to his friend James Madison in 1801: ‘The commerce of our country has suffered greatly by our absurd quarantine laws in the different states. These laws, which admit the contagious nature of our American yellow fever, have produced a reaction in the governments of Europe which has rendered our commerce with the cities of Europe extremely expensive and oppressive”.
When cholera broke out in Europe in 1830 and the United States in 1832, the health authorities were swift to impose a quarantine. Ships were not allowed to enter European ports if they had come from an area stricken with cholera and in the cities, severe restrictions were placed on freedom of movement. But these measures were deeply unpopular. The nineteenth century was witness to the industrial revolution and global trade was right at the heart of it. Anticontagionists protested quarantine on the grounds that it wasn’t effective and severely damaged commerce.
There were even those who believed cholera was a hoax, designed by political opportunists to damage business interests. In 1832, one writer in the Lancet medical journal called cholera a “humbug got up for the destruction of commerce”. The debate between quarantine, public health, and personal liberty raged on and on. It wasn’t until doctors identified the unique infectious agents of diseases like plague, cholera, and yellow fever in the nineteenth century, that health authorities could start to understand how various diseases were spread and if quarantine was warranted. Immunization programs, advances in the study of epidemiology and microbiology, and improvements in public hygiene soon followed; for many, quarantining was a medical relic. The 1911 edition of the Encyclopaedia Britannica defined ‘quarantine’ as a “thing of the past in the United Kingdom and in the majority of other states”, an “old sanitary preventive system of detention of ships and men”.
How wrong they were. When the so-called ‘Spanish Flu’ pandemic struck in 1918, it found a world torn apart by war and vastly unprepared to cope. Despite the name, this strain of influenza didn’t originate in Spain. Spain was the only country whose media reported on the scale of the pandemic, other countries kept it hushed up so as not to demoralize their troops. As Spain was the only nation speaking about the pandemic, the rest of the world came to believe it was Spanish in origin.
In the spring of 1918, soldiers all along the western front suddenly became stricken with an aggressive strain of the flu. The disease was extremely infectious and rapidly spread through the troops. When the war ended in November 1918, the soldiers returned home and brought a second wave of the virus with them. Governments around the world had spent so much time trying to play down the severity of the virus that by the time they grasped the severity of it, they struggled to implement the necessary containment strategies. Major European cities closed schools, churches, and theatres. Mass gatherings were prohibited, social distancing was recommended, along with the use of facemasks, but it was all too little, too late.
By the time it was finished, the Spanish Flu is estimated to have claimed more than 50 million lives worldwide.
It has been 643 years since a quarantine was first made an official strategy for controlling infectious diseases. Since then, public health measures to reduce contact between infected people have been at the heart of every state initiative to reduce infection. From the black death to swine flu, quarantine has been essential in limiting rates of transmission.
But that does not mean that such measures have been welcomed by the public – far from it. State-enforced quarantine has long been regarded with suspicion. There have always been those who distrust the state’s motives for implementing it and view it as a direct threat to personal liberty.
Now we are amid another global pandemic and quarantine measures are again part of the fight. History is repeating itself in the dissenting voices of those who challenge government lockdown, in the fear commerce will be irrevocably damaged, and even in conspiracy theories that the whole thing is a big hoax. But there is a reason social distancing is being turned to again, and that is because it helps keeps us safe. We will come out on the other side of this, just like every generation before us has.