Abstract
Two centuries ago, quarantine measures were used to combat the yellow fever epidemic in Gibraltar, a colonial outpost and garrison town. These measures foreshadowed similar practices used today to mitigate Covid-19. Authorities took advantage of a highly compliant population to impose measures which many today would consider draconian in nature to control, monitor and contain the population during the five-month epidemic. Statistics drawn from official day-to-day reporting show that the policy of the forced encampment of the vulnerable was effective in lowering both yellow fever sick and death rates. The yellow fever mortality rate for those in the Town was significanly lower with43.73 per 1000 living compared to 21.06 per 1000 living in the encampment (Z = 7.68, p = <0.0001). The morbidity rate showed a similar differential with 233.17 sick with the fever per 1000 as opposed to 43.14 per 1000 for those in the camp (Z = 38.11, p = <0.0001).
Keywords
Quarantine; Yellow fever; Sanitary cordon; Fever passport; Encampment.
CITATION
Sawchuk LA (2024) Quarantine, Epidemic Containment, Infected and Safe Spaces: Yellow Fever in Gibraltar, 1828. SM J Fam Med 2:1-6.
INTRODUCTION
Prior to the bacteriological revolution, state authorities resorted to the adoption of an imposed quarantine during an epidemic to preserve the health and well-being of its citizens. Most early inter-state quarantine regulations specified an isolation period of forty days, and the term quarantine is derived from quarantenaria, referring to this length of time [1]. Describing a universal statement on quarantine practices, however, is no easy task for as Coleman has observed that the practice varies from nation to nation as well as from disease to disease [2].
The Gibraltar case study uses a historical example to illustrate novel quarantine measures that were implemented by colonial and health officials to limit the spread of yellow fever (YF) disease that was endemic to the Iberian Peninsula during the 19th century [3-5]. The similarities of the quarantine strategies during Covid-19 and 19th century YF warrant considered reflection given the two centuries difference between the two epidemics.
The YF virus remains today as a public health challenge owing to global climate change and to the result of under immunization [6-9]. There remains no treatment for YF with symptomatic relief only for the pain and discomfort in the patient. Presently, 90 percent of cases occur in endemic areas in Africa and the remaining are found in endemic areas in Central and South America [10].
In severe cases, YF causes liver damage and death within days. The yellowing of the skin was a byproduct of liver damage while the black vomit, bleeding from the nose and mouth, and bloodstained stool, resulted from gastric bleeding and capillary damage. Fatality rates from this acute viral haemorrhagic disease range from 30 percent to 60 percent.
THE SETTING: GIBRALTAR
Gibraltar is a peninsula of oblong form, what Aldrich and Connell [11] have referred to politically as a continental enclave.Connected with the southern tip of Andalusian Spain by a flat sandy strip of land, the limestone outcrop known as Gibraltar is some 3.2 miles in length and a total of about 7 miles in circumference [12]. The density of the population residing in the Town was 2,211 persons per square kilometre of habitable space based on the 1829 census.In addition to Gibraltar’s densely packed population, the climate played a role in complicating household security and health, particularly in the hot drought months. Like most of the Iberian Peninsula, Gibraltar receives most of its rainfall from November to March. Thereafter, there is a long period of drought lasting from June to August [13,14].
Gibraltar is a peninsula of oblong form, what Aldrich and Connell [11] have referred to politically as a continental enclave.Connected with the southern tip of Andalusian Spain by a flat sandy strip of land, the limestone outcrop known as Gibraltar is some 3.2 miles in length and a total of about 7 miles in circumference [12]. The density of the population residing in the Town was 2,211 persons per square kilometre of habitable space based on the 1829 census.In addition to Gibraltar’s densely packed population, the climate played a role in complicating household security and health, particularly in the hot drought months. Like most of the Iberian Peninsula, Gibraltar receives most of its rainfall from November to March. Thereafter, there is a long period of drought lasting from June to August [13,14].
It was during the hot drought period when the inhabitants of Gibraltar were likely to endure water insecurity. Water security is seen as having access to safe and sufficient supply of potable water that can be assessed through availability, access, and usage [15]. The oldest and simplest means of obtaining water was by catching or ‘harvesting’ rainfall and storing the water in vessels, barrels or other such containers. While such an approach was accessible to everyone, the more vexing issue was one of storage. Here, the wealthier inhabitant had a distinct advantage as they could afford to buy water as needed or they had access to a cistern located underneath their place of residence. By contrast, the working classes typically resided in buildings which lacked a cistern or access to a private well and did not have the means to pay the elevated prices for water when there was a drought [16]. The scarcity of water also affected personal cleanliness and its use for purposes such as flushing and cooking.
HISTORIC YELLOW FEVER IN GIBRALTAR
Gibraltar experienced its first YF epidemic in 1804 [Table 1]. It was catastrophic event where upwards of one third to one half of the civilian population died within four short months. By 1828, the notoriety of ‘Gibraltar Fever’ with YF was firmly set in the mind of the health authorities and the public with several signature features [17]. First, the disease had a distinctive symptomology characterized by a severe headache, back pain, general body aches, nausea, vomiting, and the sudden onset of fever. Second, epidemics began in the summer/autumn months and disappeared as the cold weather set in.Third, everyone, rich or poor, was susceptible to that first attack, though the very young were often spared from severe attacks. Finally, those who had passed through an epidemic and survived benefited from life long immunity in subsequent epidemics [18].
QUARANTINE IN GIBRALTAR
Quarantine practices in Gibraltar and Spain differed materially with the lack of coordination between the two countries such that numerous problems were commonplace. In Spain, there was two forms quarantine: one of observation and one of strict quarantine. In the former, it was not necessary that cargo be discharged. In the latter case, before certain specified articles could be landed fumigation was to take place. In Gibraltar vessels could only undergo a quarantine of observation and infected vessels with access to a lazaretto could not be dealt with at all.
Further differences arose, as the ports of Spain were not closed against ships coming from the West Indies at periods, as was the case in Gibraltar. Additionally, vessels with cases of sickness, such as yellow fever, plague and cholera, were excluded from Gibraltar while the practice in Spain was to receive them and place them under quarantine. Finally, vessels arriving in Spanish ports with foul bills of health from cholera ports without sickness during the voyage were subject to 10 days strict quarantine, and 15 days if there was sickness on board. Vessels from ports adjacent to places where cholera, plague and yellow fever exists were subject to 3 days of observation. Vessels from places where these diseases prevailed were subjected to quarantine sometime after the disappearance of the disease has been officially notified; for example, 30 days for ordinary cases of plague, 20 for yellow fever, 10 for cholera. Whenever the Spanish government felt that quarantine measures in Gibraltar were insufficient, there was no hesitation in establishing quarantine against the British port. The lack of conformity of Gibraltar’s quarantine principles to that of Spain invariably lead to conflict, which ultimately terminated with a protracted state of imposed isolation and economic depression for the inhabitants of the Rock.
THE SANITARY CORDON
While the sea made an adequate barrier and ports natural checkpoints for movement via water, quarantine control was more complex on land routes. Sanitary cordons, a term describing a land barrier where only those with clean bills of health can pass, were set up. Such cordons were generally temporary measures assembled for the duration of a perceived threat and consisted of medical inspectors, bureaucrats and a military presence for enforcement. The administration of sanitary cordons required organization, co-operation and freedom from corruption to function properly. Smuggling could and would undermine these regulations as poorly paid civil servants were responsible for the maintenance of quarantine and could be easily corrupted.
There were generally two kinds of stations, those for the passage of goods only (such as letters, money and small goods) and larger stations for the movement of imports and for the movement of people. To make the cordon effective, contaminated and uncontaminated people were kept separate and merchandise was handled with iron tongs. Goods that could be laundered were exposed to the air and then fumigated with sulfur. Bulky goods such as cotton and wool were opened and aired for the required length of time and servants were hired to sleep atop the bales. If the servants remained healthy, the goods were given a clean bill of health. Money was immersed in vinegar for disinfection.
During the outbreak of yellow fever in Gibraltar in the late August of 1828, Spanish authorities quickly responded by establishing a cordon sanitaire in the Neutral Ground on September 6th and persisted to December 28th [Figure 1]. Upwards of 3,000 Spanish troops were stationed at the border or what was called ‘the Lines’. Those attempting to breach the cordon would be shot. The economic consequences to Gibraltar and its inhabitants of the isolation and policing of the border brought about anxiety, loss of freedom of movement and economic distress.
DISTRICT HEALTH INSPECTORS AND CORPS OF EXPURGATORS
By 1828, disease surveillance had been fully developed with the Town and the South areas being divided into administrative Districts; each with its respective health inspector, which totaled fifty-four men in the Town and sixteen men located in the South [21]. The health inspectors were men who had passed through the fever. During the 1828 epidemic, daily information on the sanitary status, crowding, and health of residents during the epidemic was conveyed to Gibraltar’s Principle Medical Officer of Health (PMOH) via the district inspectors. Those who contracted YF would have two military sentinels placed at the door of the house, thereby placing the population under surveillance as well as isolation. Another task of the health inspectors was to obtain lists of all who have passed through former epidemics with the view that they may be permitted to remain in the Town. Once the list was compiled, authorities ordered the ‘unseasoned’ and their families to the civil encampment. Epidemic measures were taken to prevent mass gatherings; all places of worship were closed on September 7th, 1828. On September 20th all schools were shut and the public were cautioned against assembling in the streets. A special Corps was created on September 21st which was specifically designed to whitewash and fumigate houses where YF infection had occurred. The Corps of Expurgators was headed by the Director of the Scavenging Department.
THE PALLENQUE
Linked geographically and economically, Gibraltar could not escape the consequences of the imposition of a protracted state of quarantine from its larger, dominating Spanish neighbour. It was a common practice under epidemic conditions for Spanish authorities to visit the Gibraltar and report back to Madrid on sanitary and health status of Gibraltar. Until the true status of health of the garrison could be determined, Spanish authorities gave orders for the usual supply of meat, vegetables and other necessities to be furnished to the British garrison through the pallenque held at the border between Spain and Gibraltar. The origin of the novel marketplace dates to autumn of 1810 when sporadic cases of yellow fever appeared in Gibraltar.
A newspaper account from The Times [22] illustrates the protocol used at the marketplace. Under this scheme, provisions were passed through a designed space at the Lines, set off by two lines of posts and ropes, about 200 feet apart. This special marketplace permitted a highly regulated means of communication between the two trading parties. The exchange of goods was straightforward; to begin, Spaniards would place provisions in the middle of this area and then retire to their side. The merchant dealers of Gibraltar would then haggle a suitable price. Money would then be left in small packages to be picked up by Spanish police with tongs and dipped in vinegar before handing to the seller. Vegetables, fruit, fowl, straw and charcoal were all exchanged in this manner, From the British side, Gibraltar’s Director of Police would oversee the transactions keeping a watchful idea for any improprieties. Direct communication across the border was accomplished similarly by yelling or through the exchange of letters. All mail, however, was first dipped in vinegar before passing through the sanitary cordon. After passing through the cordon envelopes of letters were pierced and then fumigated. The pallenque remained an important mitigation strategy used until the last cholera epidemic in Gibraltar in 1884.
THE CIVIL ENCAMPMENT
Another novel quarantine measure introduced during the YF epidemic in 1828 was the creation of a designated area called the civil encampment located on the Neutral Ground that possessed ‘purifying airs’ [24]. While the logic of using the Neutral Ground was based on the principle of clean fresh air as having protective qualities, the diminished transmission of the disease may have had more to do with the winds limiting mosquito flight and their role as a vector- borne disease. There was also the possibility that the brackish water pools found in the area were unfavorable breeding sites for the mosquito.
Individuals who had not ‘passed through the fever’ in previous epidemics were ordered to enter that controlled space [Figure 3]. The controversial and draconian measure imposed by Gibraltar’s colonial authorities on thousands of inhabitants to the civil encampment began on September 6th and was lifted on November 24th,1828.
The scale of the problem was enormous given that the number of distressed persons in the encampment was put at 3,941 and another 1,200 within the walls of the garrison and aid had to be given over three months. Nearly one-quarter of Gibraltar’s civilian population existed in dire conditions and unable to escape poverty amplified by the epidemic.
With military precision, the encampment was under constant surveillance with movement in and out by the camp residents strictly regulated with Inspectors of Police and of Health passing through the streets of the camp daily. Three civil practitioners, paid from government funds, provided health care to the inhabitants of the encampment. The government appointed Chairman of the Committee for the Relief and Regulation of the Civil Camp was responsible for solicitating donations from persons local and abroad as well as receiving each day in the morning returns of sick and dead from the fever. The encampment also served as a center for aid relief. Food was provided by private charitable donations, and shelter was provided by the Colonial Government.
Those who contracted the fever were required to hoist a yellow flag over their shed or tent and their children were placed in tents of observation in a state of quarantine. Members of their family would be removed to the tents of observation and remained there for a fortnight. The bedding and clothes of the sick and dead were burned in the nearby beach in the evenings.
Accommodation for the civilians in the encampment consisted of either sheds or tents with the former allocated to the more privileged. The encampment had a total of 3,941 inhabitants where 73 percent of the residents living under canvas. There were 186 sheds which housed 1,063 individuals. There were 544 males and 519 females of adults and children. The wooden buildings are stained brown, and those of masonry are stained red. The typical size of the shed or wooden hut was fourteen square feet. Larger sheds were also available and turned into apartments that were occupied by different families. There were 775 tents inhabited by 2,878 individuals, 2,043 men and 1,898 women. The tents were placed at distance of 3 to 4 feet from each other and formed streets ten to 12 feet wide. Each street had number and every tent its number. Each tent was meant for 5 individuals and that number could vary from 3 to 8 individuals.
It is difficult to appreciate how those forced to reside within the confinement of the encampment coped, as in the view of many of the locals the consequences of cordons were worse than the disease itself [26]. Yet, there was the occasional sign of normalcy as resident adjusted to their confinement. For example, shed [#30] was used as a synagogue and another was used for a small schoolhouse for young children (Shed # 85).Shed (# 55) was surrounded by a large border of flowers. Pets and other domestics were also allowed in the camp with at least one family residing there with their pet monkey (Shed # 90),
THE FEVER PASS
Movement into the Town was initially confined to about 3,000 men who had obtained from a physician or a reputable person, a ‘fever certificate’ of having YF in former years [Figure 4]. These men were allowed to enter the garrison, and they were allowed back into their tents without any precaution. At the close of the day, evening gun fire, the workmen would return in crowds with shed doors shut at eight in the evening.
The fever passes were issued to those who had passed through previous YF epidemics. This measure was novel to the 1828 epidemic. Individuals with such certificates were allowed to enter the garrison to work. Fever certificates were also recognized by the Spanish neighbours because they were also fully convinced that the infection could not be communicated a second time, such that the disease was a sufficient passport through the cordon [27]. By 1828, there was general consensus that the “Gibraltar fever, in its former visitations, has rendered one porportion of the population, the invlunerable protectors of the other portion from future attacks” [28]. The principle of non-liability to a second attack played an important role in mitigation strategies in disease prevention despite the imperfect knowledge of YF aetiology.
Another of the important measures implented was that authorities required that the local newspaper, the Gibraltar Chronicle, was to provide daily counts of the sick and dead for the general public. Using the census numbers taken on March 22nd, 1829, we can construct a population at risk for those in the Town (N= 12,463) and those in the encampment (N=3,931). The major limitation is there are no precise numbers given to exactly who had and not passed through the fever. With that cavaet, the YF mortality rate for those in the Town is estimated 43.73 per 1000 living compared to 21.06 per 1000 living based on the dead reported in the Gibraltar Chronicle. The YF death rate was significantly lower among inhanitants in the camp versus those who remained in the Town (Z = 7.68, p = <0.0001). The YF morbidity rate showed a similar differential with 233.17 sick with the fever per 1000 as opposed to 43.14 per 1000 for those in the camp (Z = 38.11, p = <0.0001). Based on these approximations, individuals confined to the encampment showed the benefits of this mitigation strategy.
ECONOMICS AND THE WELL-BEING OF A COMMUNITY IN EPIDEMIC TIMES
The impact of quarantine measures had considerable adverse effects on Gibraltar’s export business and its status as a port of call. With the additional expenses incurred because of quarantine, the problems of delay, and a general diminution in trade activity, profits waned accordingly. Further economic hardships were created as business was lost to Spanish merchants taking direct shipment from England, effectively removing Gibraltarians, the traditional middlemen, from the economic loop. Middle to small retail dealers in Gibraltar saw their trade fall in direct relationship to the foreign traffic arriving at the Rock daily. Those employed by the petty bourgeois, such as clerks, journeymen, porters, and carters were also hit by the decrease in business. The resultant decrease in the spending power of the population fell as the downturn in business rippled through the local economy. It was the poor and labouring classes who suffered the greatest when the cordon restricted the flow of food and other provisions into Gibraltar.
Beyond the economic upheaval and lack of employment, there were other important issues that had an impact on the wellbeing of the civil inhabitants confined to the encampment over the four-month confinement. The psychological impact was amplified by anxiety, worry, depression and helplessness as they became totally dependent on the state. The separation of family from their extended kin and neighbours would have contributed to the lack of social support that was critical in times of crisis. Individuals who once inhabited places of choice and relative privacy would be faced with enforced confinement and the absence of privacy as sheltered in tents and sheds in very close proximity to each other. Finally, the day-today monotony of camp life would add to mental health burden of the civil inhabitants.
CONCLUSION
Gibraltar’s last yellow fever epidemic in 1828 illustrates how authorities managed and controlled the spread of an infectious disease that had been acquired with previous encounters with a pathogen that had social, economic and health consequences in a small-scale society. The measures taken two centuries ago show how echoes from the past can help understand the present moment with greater clarity and a deeper sense of appreciation of living in epidemic times.
ACKNOWLEDGMENT
We would like to thank Dr. Clive Finlayson, Director of the Gibraltar Museum, for granting access to photograph the permits.
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