Thoughts on economics and liberty

Dr J.M. Cunningham’s scholarly and evidence-based oppositon of 1883 to quarantines/ lockdowns

THE SANITARY LESSONS OF INDIAN EPIDEMICS.

BY SURGEON-GENERAL J. M. CUNINGHAM, M.D.,

Sanitary Commissioner with the Government of India.

(Read: July 4th, 1883.)

IT was in the early part of 1874, if I remember aright, that a paper on Cholera in India was read by your late President (Dr. John Murray), and that in the course of the discussion which followed I had the opportunity of stating some of the views which I entertained in regard to cholera and other Indian diseases. I ventured to say that I considered the opinions ordinarily held about cholera were opposed to Indian experience; that there was no evidence that cholera is a special product, raised only in the delta of the Ganges, and thence disseminated over the world; and, moreover, that there was no evidence to prove that it is caused by any special contagium developed in the bodies of the sick, and communicated either directly or indirectly by human intercourse. [Sanjeev: He was wrong about the indirect part, but that indirect route is entirely eliminated by sanitation] After a lapse of ten years it seems not out of place that I should recur to this subject, and endeavour very shortly to set forth how far the views I then expressed have been affected by further experience. How far have they been modified, and how far have they been confirmed? How far, again, are the general principles which seem to hold good in regard to cholera applicable to other diseases, and especially to some of the other epidemic diseases of India? I esteem myself fortunate in being permitted to bring these matters under your special notice by the reading of this paper, which I have designated “The Sanitary Lessons of Indian Epidemics”, and which I shall endeavour to make as brief and practical as possible.

It can hardly be questioned that India presents a grand field for the study of sanitary questions. Its vast extent; the difference in its soil and geological formation; the well-marked and varied features in its physical geography; the variety of climate which it presents, as regards temperature, rainfall, humidity, barometric pressure, and other points; the differences of race, as respects not only nationality, but also food, clothing, and other habits; the differences of local conditions, and among them the differences in the means of communication over so vast an area, which in some parts are as good as they are in England, and in other parts are no better than they were one hundred years ago; —all these render India a country well worth attentive observation from a sanitary point of view.

India has taught us many lessons in other departments both of peace and of war, and I believe that it is well fitted to teach us most valuable lessons in sanitary matters also. All this will be readily granted. This statement will in all probability be accepted in the abstract; but it may be thought that, grand as is the field of observation, the means of observing are very small. It may be said that the facts are very difficult to ascertain, that error is very apt to creep into all regarding them, and that the whole record is one on which no great reliance can be placed. For this reason it would appear that the data which have been collected year by year in India have hitherto not received the attention which they deserve. It may be granted that the means of observation in India are not so good as they are in some other countries, but, at the same time, they are on no account to be despised. The minute particulars which are obtained regarding our European army, numbering 60,000 men, our native army, numbering 120,000 men, and our prison population, which is never less than 100,000, are all of extreme value, and may fairly take their places for exactness and for minute detail with any sanitary statistics which can be procured elsewhere; and although the statistics of the births and deaths among the general population are still in a very imperfect condition, they yet afford very valuable information—information which is yearly becoming more exact and more valuable in its bearing on the general history of disease in India. But even in its imperfect condition it is remarkable how completely the great facts embodied in these statistics concerning the general population accord with the details furnished by the bodies of troops and prisoners, the exactness of which cannot be disputed.

It may be thought—and I have both read and heard this opinion expressed again and again—that the truth regarding disease is to be learnt rather by an exhaustive inquiry into particular outbreaks than by a consideration of the facts extending over a large area. But it seems to me, as the result of large experience, that in epidemiology undue importance has been attached to local inquiries. Inquiry into particular outbreaks is, no doubt, very excellent in its way, and more especially into the local insanitary conditions which favour epidemics, the examination of which can never be too searching; but from an epidemiological point of view such inquiry cannot be accepted by itself, independently of the general history of disease. No man of sense or science set down in a village to form an opinion on the causes of the peculiarities in the season—of the excessive rainfall it may be, or of the unusual dryness, or of the potato blight, or any other abnormal condition of the crops would ignore everything except what came under his observation in that particular village. And yet this is very much what men do who make a purely, local inquiry into epidemic disease, and take no thought of what has been going on, or, it may be, is going on at the very time in other parts of the country.

The facts regarding the general history of disease must be considered as well as the results of local inquiry, and in this way these great facts will often prevent wrong conclusions being drawn from the little facts. It is, in truth, essential, if we are to arrive at any sound conclusions, that we should look at all the facts so far as they can possibly be collected. But there is nothing more difficult than to get at the facts. In the course of a long experience there is nothing which has struck me more forcibly than this. The reporters are so apt to confuse between fact and mere opinion, that in the minds of some it seems impossible to separate the two. Again, there is nothing more common than forming an opinion without any (or with insufficient) facts. Then again, there are other fallacies which are extremely common. There is the common fallacy of recording the facts all on the one side, and omitting all the facts on the other side. I have known a man write a report on a local outbreak of disease, which seemed to be very plausible and even convincing, who left out of consideration the whole history of disease among the general population in the neighbourhood, the slightest acquaintance with which would have shown him that his ideas were altogether wrong and would not stand a moment’s investigation, I have known another man write a goodly volume to prove his own ‘particular theory, and leave out of it all mention of one little fact which might have been stated in a single line; and yet that little fact was sufficient to show that his whole book was little better than a dream. I do not mention these instances to hint in the smallest possible way that such men are dishonest; but when men become possessed of a theory, they seem incapable of looking at anything except the facts which fit in with that particular theory. Another common fallacy is to neglect, or attach no importance to, solitary cases of epidemic disease. The diseases which sweep over India, and more particularly “cholera”, are diseases which are common enough without any epidemic being present. Solitary instances of cholera occur ever and again far beyond the endemic area, but they are too often passed by as if they were of no consequence. One is attributed to some error of diet, another to exposure, a third to some other cause, and no doubt these causes are not without their influence; but when solitary cases of this kind occur here and there over a large area—although they may appear to be of little consequence to the individual observers concerned with each case—they have to the epidemiologist, who views them all, a significance which is not to be ignored. Epidemiologists, who propose to deal with epidemics and to show the causes to which they are due, must at the same time be prepared to deal with these solitary cases; and I venture to think that even in temperate climates, where such cases, even of cholera, are not unknown, much too little has been made of them. To call such cases “cholera nostras” as distinguished from “cholera Indica”, is to make the nomenclature of disease depend on a preconceived theory. They are indistinguishable at the bedside, and the only difference is that while the one occurs in solitary instances, the other occurs in outbreaks of epidemic violence; but there is no reason to suppose that the cause or causes which produce one case of so-called “cholera nostras” may not produce a hundred or a thousand. No one attempts to make any such theoretical distinction between cases of small-pox—to call isolated cases “small-pox nostras,” and the cases of an epidemic by some other name. But, in dealing with epidemiological questions, there is yet another evil, which is perhaps even greater than any of those I have already mentioned. It is the evil which arises from taking mere coincidences as evidences of cause and effect. A person suffering from disease, or coming from a place in which disease is prevalent, is attacked, and soon after, one or other of those of his own house or of those living in the neighbourhood is attacked also. The conclusion is immediately arrived at, that the first person has been the cause of the others being attacked; but this is exactly one of those cases to which I have already referred, in which all the instances of one kind are cited, and all the instances of the opposite kind are ignored. It is quite true there are numerous instances on record, in which persons travelling from an affected locality have been seized with disease on arrival in their own homes, and their neighbours have suffered soon afterwards; but there are innumerable instances in which such travellers have been attacked, and yet others have not suffered. These are all left out of account. It is argued that in the one case the evidence is positive, and that in the other it is negative; but this is altogether a fallacious view of the question. There is no positive evidence either on the one side or on the other. The only facts we have are facts relating to time—the traveller suffers first, his neighbours suffer afterwards; therefore the neighbours have been affected by the traveller. This subject is one of very great importance, because a clear understanding of it lies at the bottom of all medical evidence. If it had been proved that a person suffering from cholera, or other epidemic disease, really propagates a specific poison, then the cases in which the neighbours were affected might be regarded as positive evidence; but, in the absence of such proof, no conclusion can be arrived at unless the facts on both sides are carefully collated. If the facts on one side only are considered to be evidence, it would be possible to prove almost anything. I remember when I was a boy it was a common remark that the frost came down with the mail-coach; and, no doubt, there were numerous instances in which the arrival of the mail-coach and the setting in of the frost were contemporaneous. Had I been anxious to prove that the mail-coach really did bring the frost, all that would have been necessary, according to the ordinary mode of medical evidence, would have been to cite the number of instances in which the two things were contemporaneous, and leave out all the other instances in which they were not contemporaneous. It may be said that nobody would do anything so foolish as this; but this is exactly what is done in regard to cholera, and the supposed spread of cholera by means of pilgrims.

All the instances in which pilgrims are first attacked and the general population suffer afterwards are cited; but nothing is said of the many instances in which either the general population is attacked first, or in which the pilgrims are attacked, and no cases follow in the localities through which they pass. Yet without these cases the evidence is altogether incomplete and one-sided, and therefore no sound conclusion can be based on it. The reasoning now is all carried on in a vicious circle. The supposed spread of cholera by human beings is asserted on the strength of facts selected all on the one side, and which are dignified by the name of positive evidence on the ground that these human beings have conveyed the “germ” or “contagium”, the results of which are manifest in the persons of those among whom the travellers have come. But if evidence be asked of the existence of this supposed germ or contagium, the cases of these same pilgrims and other travellers are cited And so, as I have already said, the argument proceeds in the same vicious circle. If the existence of the germ or contagium had been demonstrated, the case would be very different. Until it has been demonstrated, the evidence on the one side is just as important and just as positive in its character as the evidence on the other side. [Sanjeev: Robert Koch discovered the cholera bacterium in 1884, after the 1883 Cunningham paper, but Cunningham’s analysis would (correctly) rule out direct contagion EVEN if there was a germ. Indeed, there was never DIRECT transmission, always indirect. Sanitation eliminates even that.]

But, having got all the facts, so far as they can be collected, it is essential that the deductions drawn from them should be strictly logical. If the question were asked of a hundred people, “What is the cause of epidemic disease?” ninety-nine of them would probably reply that epidemics were due to contagion, that a sick person coming from some place or other brought with him the germs of the disease, and that those germs found a fitting place for development in the persons of other people. But such an explanation, however plausible it may appear at first sight, is really no explanation at all; for, if we follow back and trace the individual who is supposed to have brought the disease, and ask where he got it, and then trace the third person back and ask where he got it, and so on, we have still the same question to answer, “How did this disease arise?” The doctrine of importation merely puts the question off. If a community whom we may call Z. is suffering from an epidemic, there is little satisfaction in being told that this epidemic was imported from Y., and that the epidemic in Y. was imported from X., for if we trace back and back we must eventually come to A., and the question then arises, exactly as it arose with regard to Z., “ What was the cause of this disease?”

In dealing with epidemics, and, in fact, with the causation of all diseases, we must assume nothing. In the present day the germ theory is in great favour. Germs are supposed to account not only for cholera, small-pox, and enteric fever, but also for tubercle and ordinary malarial fever. There seems to be no limit to the germ theory of disease; but, as a matter of fact, do these germs really exist? Have they been found in diseases such as small-pox or syphilis, which are usually cited as the most striking examples of contagious disease? Is there a single so-called germ which can be shown under the microscope and recognised as the germ of any particular disease? Is there a single organism derived from a person suffering from a particular disease which can be said to be the cause, and not a consequence, of that disease? Is there a single organism found in disease which alone is capable of producing that disease? Every now and again the medical world is startled by the announcement that one of these specific germs has been discovered, and the announcement is far too readily credited, for, as time goes on, grave doubts are thrown on the accuracy of the supposed discovery. A year or two ago we were told that malarial fever was no longer a difficult problem to solve —a bacillus had been found to account for everything—but now we have two organisms in the field, which both claim the supposed honour: one the bacillus of Tommasi and Blebs, and the other of Laverac, which I believe is not a bacillus at all. Again, we had the bacillus of tubercle announced by Professor Koch, but, according to the latest intelligence, Spina and other of Stricker’s pupils have found in typhoid fever stools, in the sputum of pneumonia, asthma, and bronchitis, and in the lochial secretions, a bacillus which in form, size, arrangement, and reaction is indistinguishable from the tubercular bacillus of Koch. I have no intention of entering on the germ question in general, but the questions I have suggested are very pertinent in the history of Indian diseases, and more especially in the history of cholera and enteric fever, in regard to which I would venture to offer a few special remarks. What do we know, or what do we not know, about these diseases? Cholera is said to be due to a germ or poison spread by the skin—a poison which is bred in the delta of the Ganges, and thence carried over the world. These were propositions which were formulated by the Sanitary Conferences of Constantinople and Vienna, and are generally accepted as embodying the truth; but I venture to think that they both rest on a most imperfect foundation. They are based chiefly on a series of one-sided anecdotes, which are not only one-sided, but which are, moreover, opposed to all that is known of the great facts regarding cholera. Human intercourse is free and uninterrupted all over India, and yet for years together great parts of this large continent remain unattacked by cholera. Even in those instances where great fairs have been succeeded by a prevalence of cholera, this prevalence has never been general in all directions. The pilgrims going in particular directions no doubt have suffered, but the pilgrims going in other directions have, after the first day or two, when they seemed to be suffering from the influence of the place from which they had come, entirely escaped. The real explanation of the pilgrims’ sufferings is to be found in the fact that they have traversed a “cholera area” at a time when, ill-fed and filthy, exposed to hardship and fatigue, they have been in a condition most favourable to be attacked.

The history of attendants on cholera cases is in itself a sufficient answer to all that has been said in regard to pilgrims spreading cholera, for the evidence is complete that the attendants on cholera cases suffer no more than other people. I have now the details of nearly 8,000 attendants on cholera cases, and of these only 150 were attacked. Such a result cannot be accepted as evidence of contagion, especially when it is remembered that they were subject to the same conditions as the ordinary inhabitants of the place. [Sanjeev: Here’s further conclusive proof that cholera was never directly transmitted, hence quarantines would fail. The key issue is not whether cholera is contagious (it IS indirectly contagious) – the key issue is the impossibility of stopping its spread via QUARANTINE.]

On the contrary, it shows an absence of contagion under circumstances most favourable to contagion if any had really existed. If attendance on the sick for many days and nights is not a service of danger—and the whole experience of India shows that it is not—what is to be said of the innumerable instances of supposed contagion where the persons attacked were only residents of the same place, and never came into communication with the sick at all?

There is another great fact regarding cholera which is too often ignored—that even over an epidemic area the proportion of villages attacked is comparatively small. If cholera be due to human intercourse, how is it that even in times of severe epidemics the proportion of villages that escape is much larger than the proportion that suffers? The general direction of a cholera epidemic, moreover, is opposed to the idea that it is governed by human intercourse, or any other chance; and if the believers in the water-theory, as it is called, will examine the facts regarding the great rivers of India, they will find that the advance of cholera is in directly the opposite direction to that in which, according to their theory, it ought to be. They will find, moreover, that the children, who drink more water than any other portion of the community, are especially exempt. The real truth, so far as we have yet ascertained it, in regard to cholera is its remarkable localisation; and the real remedy is to be found, not in any endeavour to prevent human intercourse—which is impossible—or to destroy the germ, the very existence of which remains to be proved, but to carry out sanitary improvements, and if, in spite of them, cholera should still prevail, to move away from the affected locality. [Sanjeev: And this is why, even in 1883, before the cholera bacterium was discovered, it was clear that SANITATION, NOT QUARANTINE, is the appropriate remedy for cholera. Sherlock Holmes would have approved. I’m in awe of the brilliance of these thinkers.] The advantage of movement has been exemplified over and over again, and never more strikingly than in the outbreak at Meanmeer in 1881, when the troops, on three occasions, shook off the disease by moving into camp about a hundred miles away, and were attacked again immediately they returned.

Experience in regard to enteric fever teaches very much the same lesson as experience in regard to cholera. [Sanjeev: Typhoid (enteric fever) has a similar transmission mechanism: bacteria indirectly via faeces. The solution is sanitation, not quarantine. Yet for CENTURIES, fool “public health experts” locked up entire homes/towns in the name of stopping these diseases.] When this disease was first returned in India under its new name, medical officers commonly attributed it to importation. Some one had brought the disease; where it originally came from, no one could say. The explanation, such as it was, was very simple, and, at the same time, very unsatisfactory. And more accurate and extended observation has shown that it is not only unsatisfactory, but also altogether inconsistent with facts. We now know that enteric fever is a disease peculiarly common among young European soldiers recently arrived in India. We know that it occurs over a large extent of country in isolated cases; that it does not spread from the sick to the healthy; that the attendants are no more exposed to danger than other people; and that the common source to which it has been attributed so often in England, namely, the milk-supply, cannot hold good in India, for this simple reason—that the children, who consume most milk, are, with rare exceptions, exempt. What is the real nature of this fever it is not for me to say; but, considering that it presents itself under a variety of phases, that in its early stages it is almost always indistinguishable from the intermittent or remittent, it does not appear unreasonable to class it as one form of malarial fever due to climate aided by local conditions or the other causes to which malarial fever is due. There is certainly no evidence that it is due to any specific germ. Undue importance seems to have been attached to a name. There can be no question that the fever which is now returned so commonly in India as enteric fever is simply the same fever which used to be returned in former years as remittent fever; and whatever advance may have been made in pathology by the change of name, the tendency in the treatment has been decidedly hurtful—for there has been a hesitation in the administration of quinine, or a withholding of it altogether, when its use might have been attended with decided benefit. [Sanjeev: On this, Cunningham was wrong. But his batting average is great for someone in those days]

Mere fashion has, I regret to say, a good deal to do with even the statistics of disease. Although the mortality from fevers as a whole has certainly declined in India compared with what it used to be, the proportion of that mortality ascribed to enteric fever has been gradually increasing, while the proportion ascribed to remittents and other more generally recognised forms of malarial fever have been gradually decreasing. The general results of 1881—the last year for which I have the records with me—merely repeat the experience of former years. The percentage of liability to enteric among men under twenty-five years of age was 60; between twenty-five and twenty-nine years only 20; and between thirty and thirty-four years of age only 10. In respect of Indian residence the figures are even more striking, for during the first and second years of residence the percentage of liability to enteric was 60, while from the third to the sixth year it was only 27, and between the seventh and tenth years it fell to 7. It is difficult, and indeed I believe it is impossible, to reconcile these great facts with any theory which ascribes the disease to a specific germ, or specific contagium communicated from the sick to the healthy. It has been argued that the disease described as such in India is not really enteric, because in Europe enteric arises under conditions which do not exist in India. But, if clinical observation and post-mortem appearances are to go for anything, there can be no question that the enteric of India, as seen among European soldiers, is one and the same as the enteric seen in England, though in India the degrees of severity are very various, and it is often impossible to say whether the fever should be called enteric or remittent, or even intermittent. May not the true explanation of the facts be this—that disease, instead of being caused by one specific germ, is really the product of many causes, some of which operate most strongly under certain conditions, and others operate most strongly under other conditions?

When the evidence is carefully sifted, I venture to think that there is very little to support the theory that either cholera or enteric fever is due to a specific poison. It is important to make this point very clear, because until it is made clear the practical action to be taken is apt to be misunderstood.

You will ask, then, What can be the cause or causes of this and other diseases? I can only answer, that in the present state of our knowledge we cannot speak with any exactness. The explanation will, no doubt, be found in climatic and other conditions affecting certain localities, and materially aided by the insanitary condition of those localities. I have heard it argued that it is impossible to deny the existence of an entity as the cause of disease; the mere presence of the disease is in itself sufficient proof that this entity exists. But such reasoning is altogether fallacious. Disease may be due, as many other things are due, to a force or forces. The greatest powers we know of in the world are not entities at all —such, for example, as wind, steam, and electricity.

No one doubts their power, and yet we know that in neither one nor the other are the tremendous results to be ascribed to the existence of any entity, to anything which can be seen by the naked eye, or demonstrated under the most powerful microscope. You may think that these are merely theoretical views which have little or no practical application; but I believe that they are really of very great practical importance, and that they in fact lie at the root of all sanitary progress. The doctrines which have been so commonly preached of late years regarding germs and the danger arising from the sick, have been attended with most disastrous consequences, and there seems every reason to fear that these disastrous consequences may increase rather than diminish. Much domestic misery is caused by the removal of a sick person from the midst of his family. I have known wives separated from their husbands, and children from their parents, to die in a hospital unattended by those whose duty under any circumstances was to have nursed them in their extremity. I have known the greatest fear and alarm pervade a community on the first mention of disease supposed to be contagious—a fear which was so general and so great, that it was a matter of difficulty to obtain attendants for the sick; and when attendants were found they entered on their duties in a state of alarm which was little calculated to aid in their discharge, but rather fitted them to become easy victims to the prevailing disease. The consequences have been mischievous, not only in regard to domestic arrangements, but in regard also to national arrangements. The quarantines which have been set up at Suez of late years, and which are again and again imposed without the smallest necessity, are the natural outcome of the views which have been so loudly proclaimed. True, English authorities, although they have supported the germ theory very warmly, have at the same time expressed their decided opinion that quarantine is useless. But people cannot be blamed if, believing in germs, they should take every possible precaution to keep them out. They may say, “You yourselves have expressed your opinion that cholera, for example, is due to a specific poison which is carried from the delta of the Ganges by human beings all over the civilised world. You object to quarantine, it is true; you say it is useless, but here your views are distorted by your self-interest. You do not wish your trade to be interfered with, and therefore you tell us that quarantine is of no uses. At all events, we will try; if we fail to keep out all the germs which are so destructive to mankind, we may yet be successful in keeping out some of these germs, and surely, according to your own showing, every germ kept out must be a decided gain.” [Sanjeev: In this passage Cunningham predicts something like the 2020 lockdowns as the INEVITABLE consequence of the “germ theory”, which – when taken to the extreme – makes people fear EACH OTHER. CHILDREN ARE NOW VIEWED AS VERMIN BY PARENTS.]

The quarantine restrictions are imposed at the will of international boards sitting at Constantinople and Alexandria. They are one of the consequences of the Constantinople and Vienna Conferences, and, so far as their action has hitherto been seen, it seems to me to be one of unmixed evil. They proceed on the principle that there is a great danger arising from Indian ships, and that this danger can be averted by the measures which are taken under their orders. But the danger of which they speak is a purely theoretical danger. There is no evidence whatever that Indian ships have ever brought cholera. The Red Sea route, along which this constant source of danger is supposed to exist, has been singularly free from cholera, and that, too, over a period during many years of which cholera was prevalent in Europe.

During the seventeen years from 1865 to 1881, so far as is known, there is no ground for supposing that Indian ships have imported cholera either into Egypt or into Europe. What is perhaps even more striking is the further fact that although Egypt has been in direct and never-ceasing communication with India throughout this time, it has preserved a remarkable immunity from cholera. The general distribution of the disease in Europe and Asia during a series of years is clearly shown on the maps attached to Mr. Radcliffe’s “Papers concerning the European Relations of Asiatic Cholera”, published in the “Report of the Medical Officer of the Privy Council and Local Government Board”, new series, No. v, and which is all the more valuable for any purpose because Mr. Radcliffe is well known as a warm supporter of the doctrine that cholera is spread by human intercourse. From these maps and the Report itself it appears that there was cholera in Egypt in 1865, but it is admitted that this was not imported by ship to India. In 1866 there was a slight reappearance of the disease, but there has apparently been no cholera in Egypt from that time up to the present year. During the ten years 1865 to 1874, to which the report of Mr. Radcliffe refers, there is not a single year in which Europe was absolutely free from cholera, and in some of them after 1866, as in 1867, 1869, 1870, 1871, 1872, and 1873, there was considerable prevalence. In other words, notwithstanding the supposed danger from Indian ships, Egypt for fifteen years has been altogether free from the disease, and yet during many of these years India has suffered from most serious epidemics of cholera. The experience of Aden is even more striking. It suffered from cholera in 1865, and again to a slight extent in 1867; but although it lies within a few days of Bombay, and although it has been in daily communication with that and other Indian ports, it did not once suffer from cholera during the thirteen years 1868 to 1880. I do not refer to the outbreak at Aden in 1881, because it does not affect the general truth that over a long series of years this place has been singularly free from cholera. It is not necessary to go further back than 1865, and it would be difficult to ascertain the facts for the earlier years with any accuracy; so far as they are known, they confirm the experience of more recent times. It must be borne in mind, moreover, that the whole period above referred to—from 1865 onwards—is a period during which there was practically no quarantine along the Red Sea line. The fear of the importation of cholera from India into Egypt and Europe by means of ships is based, not on facts, but on the theories of the conferences as to what ought in their opinion to have taken place, but what, so far as the evidence goes, never actually has taken place. It is impossible, in the face of these facts, to maintain that Indian ports and Indian ships have proved a source of danger to Egypt, and through Egypt to other countries.

The boards proceed on the assumption that prevalence of cholera in India means increased danger to Europe; but this is an assumption which is altogether negatived by past experience, and it would appear rather that when cholera is in comparative abeyance in India this is the time of danger to other countries.

Again, it is admitted that the land traffic cannot be brought under quarantine restrictions; and so we have this very remarkable state of things, that while traffic of the land along which cholera does appear is practically left to itself, the traffic along the sea route, which is so singularly free from cholera, is subject to a never-ending interference. [Sanjeev: Here’s the other HUGE problem with the theory of quarantine. It could not be imposed on land borders, being extremely impractical. So the transmission of disease could never be stopped anyway (and it CAN’T be stopped – except in one or two cases). Pure harm, these quarantines.]

If all this be the truth—as I believe it is—it is abundantly clear that these boards have really no basis whatever on which to form an opinion, and that their action—harassing and annoying as it is to trade, and the cause of serious loss to shipowners—can be of no practical benefit to anyone. It would be much better if the time and money expended in quarantine arrangements were devoted to cleansing the towns of Egypt and other countries where the conditions are so favourable for disease. [Sanjeev: Great to see yet another rational argument being canvassed by the sanitarians. unningham elicits the opportunity cost argument – that you can get far better “health” bang for the buck via sanitation than via quarantine which doesn’t work and only imposes costs.] The maritime nations of Southern Europe are no doubt fully impressed with the belief that quarantine can protect them—especially from cholera. There can be no objection to give in to their prejudices in any reasonable way. The Constantinople and Vienna Conferences both expressed a decided opinion that the period of incubation of cholera did not exceed eight or ten days; and if this statement were acted on in practice, the prejudices of all who believe in quarantine would be respected, while trade would suffer no injury; for the instances in which cholera has appeared on board ships going from Indian ports to the Red Sea are so extremely rare that they need hardly be taken into account.

There is yet another, and, if possible, greater evil still which results from the views regarding the causation of disease so common in the present day, and that is that the importance of sanitary improvement does not receive that attention which it ought to do. If disease be due to a specific germ, then there is no danger to the community so long as that specific germ is not introduced. The place may be in the most unsatisfactory condition, both as to its conservancy, its drainage, or its water-supply; but, if the specific germ does not find entrance, these conditions are of little or no importance. But if, on the other hand, it is believed that disease is in the main the product of insanitary conditions, the community will be much more likely to bestir itself to improve them. They will feel that it is not sufficient to put their water-supply, or their drainage, or their conservancy in a proper state, lest some germ should be introduced; but that it is absolutely necessary, if they are to maintain a good standard of health, that they should have these requisites at all times. There is, no doubt, something which is acceptable to the human mind in the theory which ascribes disease to somebody else; which is satisfied with the explanation that the mysterious “it” was brought by some one else; which is willing to blame others, instead of blaming oneself, for the neglect of sanitary arrangements. The one idea that seems in the present day to pervade the minds of many men in regard to sanitary matters, is that if a person is suffering from a so-called contagious disease he should be immediately isolated, or, in other words, put in a sort of medical prison. The improvement of sanitary conditions is to them a matter of singularly little moment: and yet the only safe and practical sanitary creed is that disease is not to be prevented by any such means; that it is due to causes existing chiefly in the locality where it occurs; and that it will continue to exist until these causes have been removed.

In regard to small-pox, no doubt we have a special means of precaution in vaccination; but even with regard to smallpox it seems extraordinary how the danger arising from, the sick person seems to overshadow everything else: In India more especially, such procedure is attended with very lamentable results. We endeavour to persuade the natives of India that vaccination is an admirable protection against small-pox, and yet the moment a case of small-pox is heard of there is the greatest alarm, just as if vaccination were no protection whatever. The natives are not slow to reason from the facts which come under their observation, and are little likely to place reliance in vaccination when they see that those who applaud it so loudly believe in it so little themselves.

People seem to think that if a germ could be discovered as a cause of every disease a great advance would be made not only in our knowledge, but in our means of preventing disease. Knowledge on all points is much to be desired, and if it should appear hereafter that diseases are really due to germs, the question will then arise, What action can be taken in regard to them? But it seems to me that the discovery of disease germs, which people hail with so much satisfaction, would be very far from a gain to the human race. For, if a germ can only be distinguished and discovered by a high-power microscope, it seems hardly probable that it can ever be dealt with in practice by a sanitary police. Cleanliness in every form, cleanliness of the air, of the water, and of the soil, are the great ends to be aimed at. [Sanjeev: Yet another masterful comment by Cunningham:  What if germs are finally found?  Can we ever use quarantine to stop germs visible only via a microscope? (This is the information problem of PH that I’ve alluded to.) SANITATION & VACCINATION IS THE BEST DEFENCE.] The great lessons I would draw from the-experience of India in such matters are: 1. The importance of ascertaining the facts, both those respecting the localities immediately concerned and the general history of disease at the time, and of recording them all fully, instead of recording only those which tell either on the one side or on the other. 2. Having collected all the facts, we must assume nothing, and draw from them no conclusions except such as are strictly logical. 3. That, however the questions may be affected by further research, the doctrines of germs or contagia communicated from the sick to the healthy will not account for Indian epidemics, and especially not for epidemics of cholera and prevalence of enteric fever among European soldiers serving in India. 4. That to diminish fevers of all kinds, to diminish cholera, and to diminish small-pox—the three greatest forms of Indian disease—the real and only practical remedy is the improvement of local sanitary conditions, largely aided in the case of small-pox by vaccination.

In illustration of what I have said I might give many examples derived from an experience of nearly twenty years in the Sanitary Department of India, but I have already detained you long enough. I am well aware that the views which I have expressed are not those which are generally accepted or which are generally acceptable to the medical profession, but I can say that they are the result of an honest endeavour made during many years to arrive at the truth. I advance them in no spirit of dogmatism, for I feel that the subjects to which they refer are beset with difficulty, and that it is only by a patient and persevering analysis of the facts that we can ever hope to frame those wise measures which are best calculated to prevent disease.

Postscript.—Here my-paper, as I wrote it some days ago, ended, but since then news has arrived that cholera has broken out in Damietta and in other parts of Egypt, and all that I have said acquires an immediate importance which I had not anticipated. I prefer to leave what I have written untouched; but there are two questions which the cholera in Egypt suggests, and to which I would ask your attention for a very few minutes. How did the cholera appear in Egypt? and secondly, What can be done to arrest it? In reply to the first question, the believers in the cholera germs will no doubt say that it must have been brought from India somehow or other. We shall see hereafter what proof can be advanced in favour of this idea. Certainly there is nothing very tangible, or we should have heard of it long ere this, and the British Government would have been upbraided, as it has already been, for allowing the cholera to get out of India. If the Sanitary Boards are to justify their very existence, they must prove that cholera was brought from India, either directly or indirectly, and that their quarantine failed only because it was not sufficiently stringent. It will be time enough to examine the supposed facts when they are announced, but there is one important fact which is worth all the theory in the world, and that is, that the cholera broke out not at Suez or along the Suez Canal, or at any port of the country through which the Indian traffic passes, but at the remote and decayed port of Damietta, where there is no Indian traffic at all. And there is another fact, that all along the line of Indian traffic from Suez upwards, so far as we yet know, there has been no cholera at all. But the second is the more important question, and that is, What ought to be done? Results have already shown this, as I knew they would, that quarantine cannot keep out cholera, and that sanitary cordons, as they are miscalled, are perfectly power less to isolate it. The misery, and alarm, and mischief in every form that must be caused by all that is being done in Egypt under the misnomer of sanitation is sad to think of. It is indeed lamentable, in this nineteenth century, to read of soldiers with fixed bayonets attempting to stay the cholera; they might just as well attempt with fixed bayonets to stay the wind, or the rain-cloud, or the thunderstorm. These Sanitary Boards are indeed, I firmly believe, doing more harm than the cholera itself. The only real preventive of cholera, as I have already said, is sanitary improvement of every kind, and I trust that the lesson which this epidemic so forcibly teaches may not be lost. Every effort should be made to put our house in order in case the storm comes, and to collect information to guide us in future epidemics. If the cholera should come, it will come first in isolated cases, and it is of the highest importance that the most complete account of these cases should be recorded.

 

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Sanjeev Sabhlok

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