Guenter B. Risse is a professor emeritus of the history of medicine at the University of California, San Francisco. He answered some questions about his book Driven by Fear: Epidemics and Isolation in San Francisco’s House of Pestilence.
(Read full version of the Q&A on the University of Illinois Press blog site HERE)
Q: What was the San Francisco Pesthouse and why was it unique?
Guenter Risse: So-called “pest houses” or lazarettos were mostly temporary facilities created to segregate and isolate individuals suspected or actually suffering from diseases deemed contagious and therefore capable of igniting an epidemic outbreak. Initially conceived during the Black Death pandemic in Europe, such secluded institutions and quarantine stations were preferably located in port cities or solitary islands. Unlike other institutions of forceful confinement such as hospitals, asylums, and prisons, they have been seldom studied. Delving into the spectrum of feelings that drove them to harsh measures like segregation and isolation is illustrative. Their role must be more fully explored and inform our current beliefs and behavior.
The San Francisco Pesthouse opened its doors after the Gold Rush to separate arriving migrants suffering from smallpox, notably Chinese. Given the perceived dangers of mass infection, the choice of location was a hillside in the largely rural Potrero Nuevo district, away from the city. Here it remained for almost a century, in spite of subsequent urban sprawl. Its uniqueness stems from the fact that beyond harboring infected people, the SF Pesthouse became an instrument of blatant racial segregation, confining not only Chinese suffering from syphilis and leprosy, but warehousing a host of other terminal patients with chronic ailments.
Q: In Driven by Fear, you show that we cannot solely understand reactions to San Francisco’s Pesthouse and its inmates by framing the problem in purely rational terms. What does the story tell us about the need to understand the role of emotions in shaping local responses?
Risse: California’s emotional landscape was shaped by environmental and cultural factors linked to the consequences of Gold Rush. Self-reliance, independence, and the pursuit of personal wealth favored narcissism and discouraged social cohesion. Distrust of government led to weak and corrupt political, administrative, and legal institutions. Health and illness were mostly private concerns in a world of intense social and economic competition requiring a great deal of physical and spiritual stamina. Threats to individual well-being lurked everywhere, sparking distress and fear of their implications for employment and survival. Often deprived of aid provided by family and friends, vulnerable newcomers easily panicked, blaming and lashing out at strangers. The results in San Francisco were not surprising: a profusion of private physicians with dubious credentials together with a corrupted and underfinanced municipal health department that provided their hospitals and the Pesthouse with insufficient funds compounded the inmates’ misery.
Q: How can we enhance public health history?
Risse: Traditional narratives of public health depict a successful rational enterprise based on successive scientific discoveries, progressive legislation, and their steadfast implementation in the service of government and the well-being of a population. Since emotions are essential forms of human experience, however, they are central for understanding human conduct and survival. Indeed, behavior and language expose an array of negative emotions surrounding threats or states of sickness, from anxiety to fear of contagion, disgust with deformed physical appearances, as well as contempt concerning cultural practices that create undesirable landscapes and unfamiliar odors. Since Pacific Coast cities such as San Francisco came to fear the scope and consequences of Asian migration, notably China, feelings of revulsion came to include persons suffering from “loathsome” diseases, especially smallpox and leprosy. The use of this code word was deliberate; it was part of a popular and medical vocabulary designed to instill aversion. Loathsomeness implied a broad range of revolting feelings, from physical repulsion to moral scorn, racial fears to outrage, odium to hate. Taken together, these emotions were instrumental in creating a political and social climate responsible for shaping the institutional trajectory and reputation of the SF Pesthouse.
Q: Can the history of emotions also offer assistance in understanding America’s persistent fears regarding recent threats of intrusive foreign diseases such as Ebola fever and Zika virus infections?
Risse: Prompted by xenophobia and overt racism, the United States has traditionally sensationalized “invasions” of foreign infectious diseases, blaming arriving weak or unhealthy “others,” for their appearance and transmission. Awareness of dangers, real or imagined, is largely based on assumptions derived from past exposures. Indeed, strong and negative emotions are rooted in experiences reaching back to the earliest conquest and colonization of what was erroneously believed to be a pristine and healthy continent. Unfortunately, the first contacts between indigenous people, conquerors, and settlers lead to the involuntary spread of deadly endemic European diseases conveyed by the new arrivals. These imported scourges—notably smallpox—quickly overwhelmed and decimated America’s adult population exhibiting genetic uniformity and immunological incompetence.
Empires declined or were destroyed, with depopulation forcing the introduction of slaves from Africa afflicted with their own equally fatal cohort of tropical diseases like malaria and yellow fever, all ostensibly sullying the Promised Land. It is therefore not surprising that since colonial times, fear, disgust, and paranoia have shaped responses to imported contagions. “Good health” enhanced the quality of life and became an integral part of the new nation’s identity; it was essential that all risks and threats with the potential of impairing wellness needed to be forcefully thwarted. Similar prejudices about foreign health threats have persisted over the centuries. The 1918 flu pandemic was blamed on a surge of European migrants. Tuberculosis was associated with arriving Jews while Italians and Polish arrivals were held responsible for spreading poliomyelitis. For a while, Haiti was incriminated in the origin of HIV/AIDS. SARS came from China. Not to be excluded were Mexican newcomers, repeatedly denounced for bringing tropical scourges into the United States.
Q: Stigma and scapegoating play powerful roles in your narrative. What made them so critical in San Francisco?
Risse: Stigma in San Francisco resulted from a unique combination of powerful nativist, racial, medical, cultural, and economic ideologies. The term, originally employed in ancient Greece, sought to highlight the presence of certain cutaneous markers or blemishes suggestive of hidden internal defects based on a popular premise that the skin could “speak” and thus mirror troubles of the body and soul. Such a concept easily led to racial profiling and social distancing, misogyny and cultural conflict. Indeed, “stigmata” revealed much about a person’s identity, moral and social standing, as well as health status. The latter could be quickly recognized and diagnosed for a group of infectious diseases with obvious facial lesions that posed a serious danger of widespread contagion.
Given the presence of a substantial number of migrants from China, San Franciscans eagerly discredited Chinatown residents, considering them as potential purveyors of deadly contagious disease such as smallpox, leprosy, syphilis, and plague. Blaming this ethnic population for each epidemic outbreak and threatening to close the district by forcefully returning the inhabitants to their homeland became routine. The vehemence of this critique and blame was exacerbated because of San Francisco’s 19th century reputation as one of the most healthful U.S. cities, a welcome and profitable destination for convalescents, notably those suffering from tuberculosis. With mild weather and tonic breezes, the “city of refuge” worried about the impact of Chinese casualties on their low mortality rates.
Q: Finally, the rather sad story of the shunned and poorly funded San Francisco Pesthouse has a much happier ending. What convinced San Franciscans—a breed known as rugged individualists, to say the least—-to change their approach in fighting contagious diseases?
Risse: The devastating 1906 earthquake and fire with its vast panorama of urban ruin prompted a dramatic shift in outlook. With large populations of homeless and unemployed, the citizens of San Francisco rallied to display solidarity and empathy, adopting a true communitarian approach to deal with all aspects of the catastrophe. The new emotional tone was aided by the attendant rise of progressivism with its plea for political reform, honest government, and respect for scientific achievements. Moreover, San Francisco’s traditional apathy with regard to public health measures was further shaken following another outbreak of bubonic plague in May 1907 that, unlike its 1900 predecessor, afflicted mostly non-Chinese residents.
At the Pesthouse, expanded operating budgets and a brand new ward for plague cases reversed decades of neglect. Federal demands for an anti-rat campaign—the rat was widely believed to act as host for the plague bacilli—led to the creation of a Citizen’s Health Committee, a broad coalition of civic, commercial, transportation and academic interests in January 1908. In the face of feeble municipal resources, the organization pledged to provide funding for a grassroots drive to educate the public and eliminate rats and their sources of food and shelter. This preventive endeavor succeeded admirably within a few months, leading to the elimination of this scourge, allowing civic leaders to proclaim San Francisco “the healthiest large city in the United States.”
This essay completes the analysis of the recent quarantine imposed on West Point, a district of Liberia’s capital, Monrovia, by exploring the present and past emotional dimensions of epidemic outbreaks and quarantine measures. This approach is timely given recent remarks made by the Liberian president explaining her reasons for ordering the failed closure of an entire neighborhood. Human feelings have become an important subject for interdisciplinary inquiries since they offer valuable assistance and further insights into past events, including the danger posed by epidemics and the imperative to segregate and isolate the sick. Historical recollections--from the quarantines imposed on Chinatown in San Francisco during 1900 to the recent Ebola fever scare illustrate as well as help explain the importance of negative sentiments such as fear and disgust for understanding new epidemic threats and aggressive public health measures.
Previous essays The Ebola Outbreak: Historical Notes on Quarantine and Isolation (August 26, 2014) and The Ebola Outbreak: History Repeats Itself: Another Failed Quarantine (September 22, 2014) discussed the establishment and subsequent lifting of a total quarantine around Monrovia’s northern township of West Point in the capital city of Monrovia. The drastic and ineffective action occurred between August 20 and 29 of last year. Ordered by Liberia’s President, Ellen Johnson Sirleaf, the 2011 Noble Peace Prize winner, the operation was promptly executed by members of an Ebola Task Force in riot gear and armed with automatic weapons. In response to inquiries from local and foreign health officials, the Liberian military leaders insisted that the quarantine was designed to restore community order and cooperation. After the failed blockade was hastily raised, a presidential board of inquiry justified the intervention and accidental killing of an adolescent boy as rational and necessary given the current atmosphere of chaos and rioting, a rationale strongly challenged by an independent Liberian Commission on Human Rights. The irony was not lost on local and international observers: human rights advocates chastising a world peace-prize winner for her actions. In a recent interview granted to the New York Times, Sirleaf changed her story, seeking to defend her decision: “We did nor know what to do. We were all frightened. It was an unknown enemy. People attributed it to witchcraft. I was personally frightened.” Her instinctive intent had been to stop the transmission of the Ebola virus at all costs: “we went into a security approach,” she admitted, closing the borders between the healthy and the sick, and thus triggering confusion, anger, and mistrust instead of cooperation. Sirleaf sounded subdued: “Now I know that people’s ownership and community participation work better in a case like this. I think the experience will stay with us.”
Perhaps, but our emotions usually have the last word. In Africa and around the world, the pervasive fear concerning Ebola persists with regard to other potential killers, like avian flu, malaria, cholera, and plague. This sentiment is frequently mentioned but rarely analyzed. To be sure, awareness of dangers, real or imagined, is mostly based on assumptions derived from past experience. Self-preservation is intuitive and we observe examples of emotion-driven behavior in response to an ever-more complex sequence of risks around the world. Feelings are essential forms of human experience; they are central for understanding human communication and survival. With the help of disciplines like cognitive neurobiology, anthropology, as well as evolutionary, social, and clinical psychology, new insights are emerging concerning a broad range of sentiments and their influence on human decision-making and behavior. Negative emotions seem to operate as an early warning system, monitoring and detecting environmental dangers and social threats. While gruesome images provide physical, aesthetic and moral appraisals, smell and touch offer their own impressions and language to reinforce such aversive emotions. Such sensory cues trigger or reinforce repugnance. Trumping reason and knowledge, fear and disgust prompt protective responses meant to be beneficial for survival.
Emotion-driven aversion and protection tend to flourish in crowded urban settings. Early medieval quarantines—envisioned as forty-days of rest and renewal sanctioned by the Scriptures—were first established near key Mediterranean seaports and trade centers. Since the Black Death, so-called “lazarettos” flourished in Europe, together with secluded facilities for sufferers of leprosy and syphilis. German “pox houses,” British “lock houses and “fever hospitals,” as well as American isolation facilities or “pest houses” testify to a far from benign tradition of institutional segregation and isolation. America’s persistent fears regarding threats of epidemic disease from abroad and their evasion through protective public health measures are particularly noteworthy. During the bubonic plague scare in March 1900, the leading Republican newspaper, the San Francisco Chronicle, launched into an attack on the city administration claiming that even a suspicion of the disease “is sufficient to terrify the community, paralyze commerce, turn away strangers and prevent even the visits of neighbors and friends.”
As described in my recent book Plague, Fear and Politics in San Francisco’s Chinatown, (Johns Hopkins, 2012), one of William R. Hearst's newspapers, the New York Journal, issued a special Sunday “Plague Edition,” leading with a headline that announced “The Black Plague Creeps into America.” The accompanying news story painted a sensational scene of the purported epidemic with men collecting bodies of plague victims in the streets of Chinatown. These fictitious accounts, based on biblical and historical descriptions and medieval iconography, painted a picture of dread and panic among San Franciscans. Even interviews with Chinese residents uncovered “much fear.” Some of these feelings were directed at American physicians said to poison their children. No one played in the streets; mothers were afraid of leaving their homes since “doctors are going to send all Chinese away far out to sea on rock; no room. no place. Chinese must all leave Chinatown.” There was also fear of “Mexican” soldiers invading the district and forcing all inhabitants to be inoculated with deadly poison.
Today, globalization and the formation of pluralistic societies seem to enhance feelings of aversion directed at virtually all aspects of human relationships: we are said to be a fear and disgust-obsessed species. Deviance is a social construction employed to define, separate, and marginalize certain categories of individuals or groups believed to threaten the order, morality, and conformity of an established majority, including those supporting public health and safety. As my new book Driven By Fear: Epidemics and Isolation in San Francisco’s ‘House of Pestilence’ makes clear, a highly charged rhetoric frequently employs emotional imagery and language to assert cultural superiority and achieve social separation. Under such circumstances, dread and revulsion help develop prejudice and stereotyping, especially around issues of morality, ethnicity and nationality—but also with regard to religious beliefs, gender roles, and bouts of sickness.
Since its inception, people in the United States have displayed a singular emotional style: constant fear of contracting diseases brought to its shores by immigrants coming from all over the world. According to the modern Western sanitary gospel, the newly arrived “unwashed” were expected to adopt hygienic values on their road to assimilation and eventual citizenship. In fact, dread has recently been called “one of the dominant emotions in contemporary American public life.” By the end of the summer 2009, as fears of a lethal and catastrophic pandemic of H1N1 influenza outbreak escalated, Fox News aired a television segment with flashing signs of “Mass Quarantines” and a repetitive sound track declaring “Be Very Afraid.” Similar warnings were expressed during the 2003 worldwide SARS outbreak.
Last spring, residents in a small Southern California town angrily protested the illegal arrival of refugees--notably children from Central America. Amid howls of “invasion” and references to other calamities, the question “what happens when they come here with diseases?” revealed this deeply imbedded cultural fear. In fact, replaying a sequence of events linked to the 1900 outbreak of bubonic plague in San Francisco, several US cities near the border with Mexico passed resolutions banning illegal aliens “suffering from diseases endemic in their countries of origin” from their communities.
Ebola’s association with the poverty, filth, and backwardness of underdeveloped Africa, similarly offends the eye and generates widespread dread and repugnance. These anxieties are compounded by the disease’s horrific terminal bodily disintegration, including the messy discharge of bodily fluids. Given Ebola’s lethality, and with no obvious cure or vaccine as yet available to protect sufferers, a revolting foreign invader threatened last summer to slip across America’s borders and cause mayhem. Fear mongering thus became ubiquitous; rumors, print media, and an ever-expanding Internet succeeded in transforming the presence of a few cases of an exotic killer in the homeland not only into an urgent national problem but also an international security crisis.
With barely disguised racial, class, and ethnic overtones, the “pandemic fear” reached nearly apocalyptic levels in mid October 2014 when two hospital nurses caring for the dying Liberian patient also contracted the highly lethal scourge. The reaction was immediate: ”letting the unknown into the country” was totally unacceptable. Perhaps all Ebola suspects should be placed on offshore hospital ships. Moreover, a relentless media blitz went viral, distorting the scientific information concerning the true risks posed by the disease. In word and image, America’s journalists magnified the danger, creating a veritable panic widely characterized as “hysteria.” With Its proximity to Halloween, the drama seamlessly melded Ebola fright with entertainment. Trick or treat revelers featured beaked medieval plague doctors and space-suited—hazmat--health workers. Freaked out by the threats, “who could blame you for deciding to remain indoors, alone in bed, indefinitely,” caustically observed one New York Times columnist.
Humans have always framed their reaction to the presence of disease by employing military metaphors. Because mass disease posed an existential risk, forceful, coercive responses powered by aversive emotions employed police or military force. According to the Centers for Disease Control and Prevention, quarantine and isolation are still considered effective “police power” functions designed “to protect the public by preventing exposure to infected persons or to persons who may be infected. In emergencies, the Department of Defense plays an important role in mobilizing troops while state, local, and tribal law continues to guide the implementation of similar protective measures to control the spread of infectious disease within their borders. After the Ebola outbreak, a presidential executive order urged the Defense Department to prepare for a call up of reservists from the National Guard, and set up a rapid reaction squad. The so-called “Ebola SWAT team” was envisioned as a specialized group of experts in logistics, epidemiology, medicine, and specialized caregiving, assembled by the CDC and ready for deployment anywhere in the US to assist local authorities and healthcare systems in safety and infection control.
Near panic, a majority of the public demanded a more muscular response. A national poll suggested that over 80% of the population favored stringent measures to deal with the Ebola outbreak. Several governors--some engulfed in reelection campaigns—obliged “out of an abundance of caution,” ordering strict and mandatory 21-day home quarantines. The seclusion targeted all health care workers returning from West Africa after an emotionally draining tour of duty attending Ebola patients. Tracked by police, the potentially infected were to monitor their temperature but were not allowed to contact family members or receive visitors. “You can’t take chances on this stuff,” commented the New Jersey’s governor, in reference to an arriving nurse who despite negative tests and lack of symptoms was summarily confined.
Yet, suspicion and apprehension about militarized federal interventions linger, notably in an American culture proud of its organizational prowess and “can do” resolve. Detention can often be counterproductive; violations of human dignity humiliating and degrading since they frequently tend to encourage resistance and evasion. Like their predecessors centuries ago, contemporary public health authorities dealing with Ebola admitted that aggressive monitoring and watching can trigger “perverse incentives” to evade the quarantine. Historically, suspects or sufferers of particularly “loathsome” diseases were expected to cope and adjust to their stigmatized status as pariahs. Medieval castaways were forced to dispose of their properties and leave homes and communities. Shamefully concealing their disgusting appearances, suspects and sufferers were often forced to abandon occupations, break up relationships, seek admission to special institutions, or simply go into hiding. Yet coercion always compromises human dignity, a complex religious and secular concept closely linked to identity and social status. For many in America, the crass inhumanity of such an exile was obvious.
With the advent of civil rights, so-called “social distancing” in private homes or hospital isolation are now seldom involuntary. Yet, the psychological effects of strict social isolation can be serious. Anxiety and fear of contagion--even the possibility of death--could leave many suspects traumatized, lonely, and depressed. In SARS, some observers claimed that, following their ordeal, quarantined persons suffered from post-traumatic stress disorder. In the Ebola crisis, Kaci Hickox, the nurse in New Jersey, found her experience “painful and emotionally draining.” After a tough tour of duty in Africa attending the sick and dying, she was isolated across from a Newark hospital in a drafty tent equipped with a potable toilet. Deprived of her clothing and outfitted with skimpy paper scrubs, the involuntary patient rightly questioned the inhumanity of her virtual imprisonment. Appalled, she was quoted as saying “I don’t plan on sticking to the guidelines” before seeking legal recourse, a rebellion that galvanized the country and led to her eventual discharge, thus illustrating the deeply emotional plight of those subjected to quarantine. Every unwarranted abuse of power can easily heighten and spread the very fear it was meant to suppress. While emotions will always dominate the advent of mass sickness, we must be aware of their influence and power in shaping our behavior and therefore seek to moderate all responses towards a fair way to not only protect the public health but also the suspected or sick victims of disease.
Guenter B. Risse, Plague, Fear and Politics in San Francisco’s Chinatown, Baltimore: Johns Hopkins University Press, 2012.
Rick Gladstone, “Liberian Leader Concedes Errors in Response to Ebola,” NY Times, Mar 12, 2015.
Peter N. Stearns, American Fear: The Causes and Consequences of High Anxiety, New York: Routledge, 2006.
Paul Rozin, Jonathan Haidt and Clark R. McCauley, “Disgust,” in Handbook of Emotions, ed. M. Lewis, J. M. Haviland-Jones, and L. Feldman Barrett, New York: Guildford Press, 2008, pp. 757-76.
William I. Miller, The Anatomy of Disgust, Cambridge, Mass.: Harvard University Press, 1997.
David Gentilcore, “The Fear of Disease and the Disease of Fear,” in Fear in Early Modern Society, ed. William G. Naphy and Penny Roberts, Manchester, Manchester University Press, 1997, pp. 184-208.
Guenter B. Risse, “Epidemics and History: Ecological Perspectives and Social Responses, in AIDS: The Burdens of History, eds. E. Fee and D. Fox, Berkeley: University of California Press, 1988, pp. 33-66.
Guenter B. Risse, Driven by Fear: Epidemics and Isolation in San Francisco’s ‘House of Pestilence,’ Champaign, Illinois: University of Illinois Press (in press)
Cassandra White, “Leprosy and Stigma in the Context of International Migration,” Leprosy Review 82 (2011): 147-54.
Judith W. Leavitt, “Public Resistance or Cooperation: A Tale of Smallpox in Two Cities,” Biosecurity and Bioterrorism: Biodefense Strategy, Practice and Science 1(2003): 185-92.
George J. Annas, “Pandemic Fear,” in Worst Case Bioethics: Death, Disaster, and Public Health, New York: Oxford University Press, 2010.
Lawrence Downes, “When Demagogues Play the Leprosy Card, Watch Out,” NY Times, Jun 17, 2007.
Center for Disease Control and Prevention, Legal Authorities for Isolation and Quarantine, http://www.cdc.gov/quarantine
Jeffrey M. Drazen et al., “Ebola and Quarantine,” New England Journal of Medicine--on line--(Oct 27, 2014)
Noam N. Levey and Kathleen Hennessey, “Obama Tells CDC He Wants Ebola SWAT Team Ready to Go,” NY Times, Oct 15, 2014.
Interview with Kaci Hickox, Dallas Morning News, Oct 25, 2014.
Karin Huster, “Don’t Let Fear Drive Response,” The Seattle Times, Nov 2, 2014.
As predicted earlier, another fiasco! After lasting less than ten days, the quarantine of Monrovia’s West Point neighborhood was suddenly lifted on August 29, 2014 by orders of Liberia’s President Ellen Johnson Sirleaf. Everybody will remember that she had imposed this draconian measure on the advice of military security officials in spite of warnings from international public health experts who stressed its futility. As noted in my previous blog, the isolation came in retaliation for an attack from panicked residents on a new makeshift center for the treatment of suspected Ebola sufferers collected from other districts of the capital. The violent assault on the temporary facility occurred as tempers flared in the township. The measure, made without local consultations, was considered highly discriminatory, reinforcing notions that the slum was a favored dumping ground for misfits and undesirables.
Already infamous for living in their overcrowded, unsanitary dump, West Pointers did not wish to be further stigmatized by hosting potentially infected outsiders that could spread contagion and death. The assault of the center forced the dispersal of its seventeen detained patients and their belongings, all possibly incubating the dreaded disease. When the quarantine took hold on August 20, the heavily armed security forces managed to block all entries into the township, ordering its residents to return and remain in their hovels. Resisters were beaten with the isolating ropes, others sprayed with tear gas and finally greeted with live bullets that resulted in the death of a child. “We were treated like prisoners,” commented one denizen. Officials announced that the isolation would last 21 days, the average incubation time determined for Ebola fever.
From a historical point of view, the West Point quarantine eerily followed in the footsteps of San Francisco’s second shutdown of Chinatown in early June 1900. Unlike the seclusion of entire villages with their intact infrastructures, mass urban quarantines create an immediate problem: who and how will the isolated dwellers be supplied with vital necessities such as food and water without violating the isolation rules imposed to prevent contagion? High-density areas preclude the creation of backyard plots for cultivation and the raising of chickens. Residents depend almost totally on products imported from surrounding suburban farms. In San Francisco the new city charter made no provisions for the Health Board to provide food. Fortunately, as demonstrations and riots threatened, legal rulings days later lifted the embargo on food shipments of rice and milk.
Another problem was unemployment: many Chinatown residents nursed menial jobs in the rest of the city and their inability to show up for work had led employers to prompt dismissals. Loss of commerce forced shops and restaurants to close. Desperate Chinese openly expressed their willingness to bribe officials, eventually agreeing to pay $10,000 for raising the quarantine of Chinatown but the offer was somehow botched and never accepted. By the time it was over, more than 1,000 Chinese had managed to leave San Francisco and California.
With existing provisions rapidly dwindling and often looted, ostracized West End residents turned to outside family members and friends to smuggle them across the lines encircling the segregated Township. Except for some food supplies donated by the United States, Monrovia’s leadership failed to organize any assistance. Neighbors scrambled for the remaining scraps in garbage bins. Some business owners living elsewhere tried to check on and resupply their starving employees. Local clinics ran out of medicines. Increasingly hungry, frustrated, and unemployed, the trapped inhabitants — estimated at more than 10,000 people — reacted in desperation, throwing stones at the soldiers guarding the exits. Confrontations between residents and security forces turned into running battles. Others simply bribed the soldiers and police officers, or, most often, “sneaked out.” escaping from the sealed up “Ebola Jail” thus rendering the purpose of the quarantine meaningless.
Officials invariably defend their actions. In San Francisco, the coerced segregation was justified because of the unclean habitations of the Chinese. They deserved to be locked up and “suffer from the consequences of their own acts after constant notice.” The quarantine was not only a form of punishment but also a reasonable way of dealing with an incipient epidemic of plague. It was designed to prevent “promiscuous communications” between persons living in the district — all previous plague victims were Chinatown residents — and the people living outside. Moreover, officials claimed that the rules were being enforced without distinctions of race, age, sex, and nationality, a blatant and obvious lie since it exempted white businesses at the edge of Chinatown. Therefore, it was time for the Chinese leadership to take responsibility, cease to deny the presence of plague and cooperate with the authorities. For this purpose, the Heath Board passed a resolution promising to raise the quarantine twenty days following the last confirmed case of plague.
In Monrovia, the government similarly explained its intent: the quarantine would give West Point residents an opportunity to accept the presence of Ebola fever in their district, then mobilize their own local leadership and, finally devise a local surveillance plan that would contribute to the national effort towards Ebola’s containment. A businessman explained that the quarantine was not a punishment, just an effort to save the isolated population from Ebola. The government was protecting the Township from the ravages of a deadly fever. It was unfortunate that such noble intentions appeared to be misinterpreted by the local and international media that only seemed to stress the hardships inflicted by mass segregation. Instead of protesting, citizens should consider it a privilege and be appreciative; it was time to cooperate with the authorities. However, West Point residents, already deeply distrustful and even hostile of government — they were refugees from previous civil wars in Liberia — viewed the quarantine as an attempt to deflect Ebola fever towards the Township and allow it to burn itself out there as one successful measure to grapple with the epidemic crisis.
The same was true in San Francisco’s Chinatown regarding the plague outbreak. Everybody seemed aware of the fact that the quarantine actually exposed the isolated population to the disease. Medical experts testifying in court spoke on behalf of the beleaguered inhabitants, warning that the artificially created confinement of about 20,000 people created a potential “plague center,” ready to spread throughout the rest of the city. Instead of such a drastic and dangerous mass quarantine, traditional public health experience suggested the “strict quarantining of particular rooms or houses supposed to be infected.” A failure to individually isolate the plague-infested houses enhanced the danger, especially if the inhabitants were not allowed to leave the district. No new cases of plague were discovered during the quarantine period.
Like in Chinatown, the West Point quarantine was lifted well before its original deadline. Amid traffic jams, shops opened, long queues of hungry residents formed at distribution centers issuing rations of rice from the United Nations Food Program. With the military finally out of sight, people were free to move around. A community leader and student was quoted saying: “The majority of people in West Point are happy for the fact that they just got out of a dungeon of hardship and the dungeon of being dehumanized.” Indeed, “most of our people went to bed on wrinkled bellies. “Like in San Francisco’s Chinatown, the mood turned festive; celebrations were in order after more than a week of deprivation and suffering. Ironically, there were apparently no cases of suspected Ebola fever among them although given the pervading climate of suspicion, dead bodies could have been hidden anywhere or spirited away. Nevertheless stigmatization and scapegoating persisted. “We have been called all sorts of names. People point fingers at us labeling us the Ebola patients. We want the government to tell the public that the people from West Point are indeed Ebola free.” Whatever remnants of confidence residents retained towards their government, the quarantine had delivered the final, crushing blow.
Given such circumstances, fearful and leery Monrovians were surprised when a local resident, a Harvard-educated epidemiologist, sought to personally reverse this trend. Acting alone, Mosoka Fallah began to crisscross the capital, seeking to encourage cooperation with the authorities by acting as an intermediary between anxious and often desperate residents and local officials. “Ebola will keep spreading,” he said, unless trust was restored. Time was of the essence. As an unpaid advisor to the Health Ministry, Fallah started performing heroic acts of compassion and empathy, facilitating the transport of abandoned sick residents lying in the streets to treatment centers. Moving from one neighborhood to another, the former member of Doctors Without Borders systematically visited every block and hut. In West Point, where he had previously resided, Fallah went back to a pre-civil war arrangement that had divided the Township into separate zones, prodding community leaders to establish food supply lines and voluntary surveillance teams that could identify potential Ebola victims and remove them. Such grass–roots community efforts continue to be essential in public health work but they can only be achieved through mutual respect and collaboration. As previously noted, the Liberian government had similarly sought to stimulate such local efforts but decided to achieve its goal through coercion, imposing a heavy top-down, military-assisted quarantine.
Nevertheless, Lewis Brown, the Minister of Information, reiterated the previous claim: “this (quarantine) was a tool intended to help the community to help themselves.” President Sirleaf was more cautious. Although she insisted that the measure was necessary to control the spread of the epidemic, Sirleaf ordered Browne Samukaim, the Minister of Defense, to set up a board of inquiry for the purposes of investigating all the circumstances and events that took place during the West Point Township quarantine. This move preceded a daily brief from Human Rights Watch, an independent, international organization devoted to the support of human rights around the world. The September 15, 2014 summary stressed the notion that protection of such rights was crucial for the control of Ebola fever in West Africa, and that the use of quarantines. A day later Human Rights Watch issued a lengthy statement, reiterating its stance on quarantines. The foundation noted that such tools had been imposed in several West African nations including Liberia, thus “restricting peoples’ rights to liberty and freedom of movement.” Indeed, these quarantines were inadequately monitored, “making them ineffective from a public health perspective and disproportionately impacting people unable to evade the restrictions, including the elderly, the poor, and people with chronic illness or disability.” In the Ebola crisis, better results could be achieved through community engagement and cooperation combined with social support that included home-based care and food aid. Perhaps the lessons from the West Point Township fiasco will endure.
New York Times, Aug 29, 2014.
James Butty, “Liberia’s West Point: Life After Ebola Quarantine,” Voice of America, Sep 01, 2014.
The New Dawn (Monrovia) Sep 04, 2014.
Guenter B. Risse, Plague, Fear and Politics in San Francisco’s Chinatown, Baltimore, Johns Hopkins University Press, 2012.
Human Rights Watch, “West Africa : Respect Rights in Ebola Response,” Sep 16, 2014.
“Fear remains the most difficult barrier to overcome”
Margaret Chan WHO Director General
Recent headlines immediately drew my attention. Dispatches from Monrovia, the Liberian capital, reported that under presidential orders, armed riot police and soldiers from the Ebola Task Force in riot gear and equipped with automatic weapons had quarantined West Point, a northern township of the city, on August 20, 2014. To physically cordon off the district, makeshift barricades were erected using red rope lines, wood scraps, and barbed wire. Ferry service to the peninsula was cancelled and the coast guard started patrolling the surrounding waters, turning back people attempting to flee in their canoes. A subsequent image depicted a quarantine violator, summarily detained under the chassis of a car.
Segregation and detention of people suspected or suffering from lethal contagious diseases has a long past. In an era of globalization, “contagious anxieties” become ubiquitous. Responses towards an ever-more complex sequence of biological dangers tend to flourish especially in overcrowded urban settings like Monrovia. In despair, the lessons of history are conveniently ignored. Blaming the victim continues to be a common survival skill, employed for self-defense and preservation. Appealing to basic human instincts of survival, successive Western societies developed regulations and erected institutions designed to cope with incoming diseases. Like in Monrovia today, much was judged to be at stake: catastrophic mass dying, social breakdown, political chaos, economic decline, and, at times, even national survival.
Since the Renaissance, the term quarantine came to designate spaces for the temporary detentions of residents, travellers, and cargo suspected of carrying infection. This tactic differs somewhat from another traditional public health scheme: the sanitary cordon or blockade that closes checkpoints, roads, and borders with the similar purpose of preventing the spread and contamination of deadly infectious diseases. In both cases, groups of individuals previously marginalized on the basis of age, sex, race, religion, and class were blamed for epidemic outbreaks. The favorite scapegoats are often strangers, newcomers, and ethnic minorities. I am particularly sensitive to issues of stigma and isolation because of my recent research and completion of a book manuscript on the San Francisco Pesthouse, now under academic review. My thesis is that both fear and disgust historically managed to frame coping behaviors and drive actions. In my opinion, anger and revulsion explain the heartless, even brutal nature of the responses.
In Liberia, Monrovia’s crowded and dilapidated slum with its narrow alleys and rickety shanties had long been a public health nightmare: neglected by authorities, residents were without sewage disposal and only obtained their water in wheelbarrows. Ebola was only the last and perhaps the most dangerous disease to visit this community of an estimated 75,000 people. With hospitals closing to prevent further institutional contamination—some health workers were already dead or dying, potential victims had not place to go. Without consulting residents, the government decided to use a former schoolhouse in West Point as a makeshift neighborhood center for the purpose of concentrating, isolating, and managing all Ebola cases reported in the city. This decision only stoked the growing local panic, leading to protests and violence. Perhaps Ebola was only a “government hoax.” The building was stoned and its patients—presumed to be infectious-- forced to flee. The attack led to widespread looting of furnishings and medical equipment, including blood-soaked bedding believed to be contagious.
Enforced by police and even military units, indiscriminate segregations often prove counterproductive: historically they fostered mistrust, fear and panic, resistance and aggression, while encouraging flight, concealment, and social chaos. Paradoxically, while often unsuccessful in curbing an epidemic, such containment policies contribute to the suffering and risk additional fatalities. Since the Black Death, families and isolated populations trapped in their homes and neighborhoods suffered severe hardships ranging from a lack of water, food supplies, and a higher risk of cross infection. Loss of employment and economic ruin followed. When an outbreak of plague in Rome occurred in 1656, the entire city was immediately closed with temporary stockades placed in front of two gates for screening supplies and people. Police patrols enforced the sealing of homes suspected to house victims of the disease. Individuals considered tainted through contact with the sick and who failed to follow isolation procedures were arrested and often condemned to death. In fact, contemporary iconography depicts public executions by firing squads or hanging from gallows erected in various city piazzas. In Monrovia, a crowd of desperate residents sought to break out of their prison by storming the barricades, hurling stones and attacking their jailers, only to be greeted with live ammunition firepower that managed to kill one boy and injure others. One dweller caught in the crossfire sarcastically asked ”you fight Ebola with arms?”
Risk fluctuates; it can be subjected to reevaluations within shifting social contexts and sanctioned by experts, then amplified by information systems for the purpose of mobilizing public opinion. This is particularly true if uncertainty, rumors, and a sensational media stoke fears of contagion, causing societal support systems like Monrovia’s public health departments and hospitals to break down. In the United States, three such intra-city quarantines were imposed in response to a pandemic of plague: Honolulu (1899-1900), San Francisco (March 1900) and again (May 1900). None proved beneficial.
Like Monrovia’s township, the targets were overcrowded and impoverished enclaves, unsanitary urban slums largely populated by Chinese migrants. In Hawaii, faced with a confirmed case of plague, the Honolulu Health Board issued an order to quarantine the Chinatown district on December 12, 1809 by roping it off with the help of rifle-toting National Hawaiian guardsmen. To avoid losses for white businesses, the perimeter was gerrymandered to exclude them. The afflicted neighborhoods, home to about 5,000 people--half of them Chinese--featured crumbling shanties with cesspools planted on stagnant marshy land strewn with refuse. In such circumstances, potentially plague-carrying rats posed an unacceptable risk.
Based on work by my colleague and friend James C. Mohr, frequent medical inspections and a search for new cases ensued. Disinfection, garbage removal, and the burning of “infected” lodging that had sheltered the sick began. The rationale for burning houses to kill plague germs stemmed from recommendations adopted by Hong Kong’s Sanitary Board during an epidemic in 1894 involving the walled-in and overcrowded and dilapidated district of Taipingsshan. While the official quarantine boundaries in Honolulu were constantly patrolled, security remained lax and direct contact with residents through the influx of food supplies and services continued. Yet, angry denizens protested the seclusion with threats, concealment, and flight. Businesses suffered, exports dwindled, and a paucity of new cases created pressures for the Health Board to terminate the quarantine six days after its initial decree. Reinstated on December 28 after the appearance of new cases, Honolulu’s quarantine was responsible for reducing Chinatown to ashes on January 20, 1900. With orders to burn down additional rat-infested housing, the local Fire Department misjudged the weather conditions: strong winds spread the flames to nearby buildings and a church, forcing residents to flee the district. The fire eventually scorched thirty three acres of the city and destroyed 40,000 homes. Rejected by dwellers from the outlying neighborhood, the Chinese were forced into makeshift detention camps, initially under monitored by national troops but soon replaced with Hawaiian Republic guardsmen. While the accidental fire and destruction of Honolulu’s Chinatown contributed to the eradication of plague, this episode remains a stark remainder of the adverse consequences of coerced mass segregation.
Given plague’s relentless march across the Pacific, and the close commercial ties with Honolulu, particularly the extensive sugar trade, San Franciscans braced for its arrival. Indeed, the events in Honolulu had already prompted an inspection of the city’s Chinatown by Health Board officials in early January 1900. The subsequent story is told in greater detail in my recent book Plague, Fear, and Politics in San Francisco’s Chinatown (2012). Not surprisingly, the death of a Chinese laborer on March 6 with a presumptive diagnosis of bubonic plague encouraged health officials to immediately impose a quarantine of the entire district. The enforcement was quite similar. Early Chinatown risers, including cooks, waiters, servants, and porters heading for their jobs outside the district, discovered that ropes encircled the space between Broadway and California, Kearny and Stockton Streets. Two policemen on every corner demanded that everybody turn around and return to their homes. Traffic was blocked and streetcars crossing through the area were not allowed to stop. Massive confusion ensued as frantic Chinese escaped across rooftops or sneaked through the lines, fearful that outside employers would dismiss them if they remained absent. In the confusion, stores closed although some provisions were passed across the lines. The quarantine hampered the movement of Western physicians living outside the district, preventing them from attending the sick at the Oriental Dispensary. Chinese passengers could not board river and coastal steamers to leave the city. Many managed to cross the Bay in small boats and find shelter in vegetable gardens of suburban friends and laundries. Others hid with Chinese cooks in private residences. Crowds quickly assembled in the streets, stunned by the encirclement. Rather than respond forcefully, the Chinese at first aimed for a restoration of harmony. For them the quarantine constituted an operation designed to impress the district’s ethnic population that the local health department and police were, after repeatedly faltering, up to their jobs.
Bacteriological confirmation of plague’s presence, however, remained elusive. Facing growing skepticism, the Health Board—like in Honolulu—unanimously voted to lift the “preventive” quarantine a few days later. No further cases of plague were found. The temporary encirclement of Chinatown, widely characterized by the press as “bubonic bluff,” turned into a setback for sanitarians: with regular scavenger service suspended, mountains of rotten food littered the streets, creating an unbearable stench while providing further food sources for its hungry rats. With the Honolulu experience vivid in their minds, Chinese residents expected another possible razing or burning of their homes. In a series of patterns replicated in the months ahead, laboratory findings and quarantine threats would be announced, manipulated, and denied in a climate of profound political and economic divisions. In the meantime, the reported mortality rate in Chinatown had dropped dramatically.
When cleaning and disinfection operations failed and an anti-plague vaccination program fizzled, San Francisco’s authorities decided to rent a number of grain warehouses at Mission Rock, a small island near the city’s port, converting the facilities into a temporary detention facility for Chinese suspected of suffering from plague. However, an empowered Chinese leadership hired prominent local lawyers and challenged the plan in federal court. Soon thereafter, in a landmark decision, the presiding judge ruled that all public health measures, while lawful, were not totally immune to judicial scrutiny. Inasmuch as they impaired personal liberties, totally arbitrary measures could not be permitted to stand. In this particular case, the quarantine was also racially discriminatory and harmful since confinement actually increased the risk of infection in the district.
Within hours, however, business leaders and health officials from San Francisco and California met to deal with a growing trade embargo against the state because of the presence of plague. The only proper response: reassure the trading world by sending a clear signal of California’s determination to control the presumed foe. Thus the Health Board was authorized to proceed immediately and once more close down Chinatown, again a “merely precautionary” move. Instead of ropes, a large police force and workmen descended on Chinatown, erecting a veritable fence around the district with wooden planks, posts, cement blocks, as well as barbed wire, creating an enclosure to seal off the entire area. The issue of detention centers for suspected plague victims raised, once more, its ugly head. To force the issue, San Francisco’s mayor refused to take responsibility for feeding the blockaded population.
By June 5, the Chinese leadership filed another judicial request in US District Court to stop the planned deportation. The federal judge immediately lifted the embargo on food supplies to Chinatown. He also delayed the removal of Chinese to the Mission Rock detention camp, but granted a continuance, further infuriating residents of the district. Many had already lost their jobs and were without food and other supplies. Because of growing shortages, prices for the remaining merchandise were skyrocketing. Thousands would soon be destitute and a serious disturbance was expected. While the case continued to be debated in court, protests and demonstrations escalated. Attorneys for the Chinese argued that by confining thousands of residents, the quarantine had, in effect, created a potential “plague quarter” capable of spreading disease to the rest of the city.
Ten days after the filing, the judge handed down his decision in favor of the Chinese plaintiffs. Like the previous ruling, the court employed the legal standards of due process and equal protection to grant the injunction against quarantine. Morrow ruled that the San Francisco Board of Health acted “with an evil eye and unequal hand” in an arbitrary and racially discriminatory manner, actually increasing rather than lowering the risks of infection in the isolated population. The siege of Chinatown was over. A defiant ethnic community with the help of the federal judicial system had managed to thwart two quarantines in the course of a few months. Municipal workers began taking down the makeshift fence that had encircled the district for sixteen days, allowing more than one thousand trapped Chinese residents to pour across the breached fences. Wagon after wagon of supplies arrived. After two weeks of fright, deprivation and protests, euphoria descended on Chinatown. Numerous celebrations marked the passing of the “fake” quarantine. During this judicial proceedings, only three additional deaths had been bacteriologically confirmed as caused by plague.
The above historical examples illustrate the challenges, hazards and futility of mass quarantines, their adverse economic impact and human toll. Public health is ill served when brutal coercion exacerbates mistrust and triggers hostility. Moreover, like in the Chinatown examples, forceful segregation was totally out of synch with the contemporary epidemiological understanding regarding disease transmission. In plague, the vectors were mostly fleas and rats instead of humans while Ebola fever is originally contracted from handling and cooking contaminated bush meat. Monrovia’s quarantine, imposed on an overcrowded population already burdened with poverty is unconscionable: the slum already shelters some ill and dying cases of the disease. Their contagious body fluids will only magnify the outbreak already in progress. As provisions dwindle in West Point, food prices will skyrocket, making them unaffordable and soon unavailable. Faced with a standoff, hunger and desperation will lead to further skirmishes with the military units guarding the township. Interviewed by a CNN reporter, one residents admitted: “The hunger, the Ebola, everything. I’m scared of everything!”
Liberian News, August 17, 2014.
Margaret Chan, “Ebola Virus Disease in West Africa—No Early End to the Outlook,” New England Journal of Medicine.org, August 20, 2014.
Guenter B. Risse, “Pesthouses and Lazarettos,” in Mending Bodies, Healing Souls: A History of Hospitals, New York: Oxford University Press, 1999, pp. 190-216.
Alison Bashford and Claire Hooker, eds. Contagion: Historical and Cultural Studies, London: Routledge, 2001.
New York Times, August 21, 2014.
CBC News and CNN News, August 26, 2014.
Howard Markel, “The Concept of Quarantine,” in Quarantine!: East European Jewish Immigrants and the New York City Epidemics of 1892, Baltimore, Johns Hopkins University Press, 1997, pp. 1-12.
James C. Mohr, Plague and Fire: Battling Black Death and the 1900 Burning of Honolulu’s Chinatown, New York: Oxford University Press, 2005.
Guenter B. Risse, Plague, Fear, and Politics in San Francisco’s Chinatown, Baltimore: Johns Hopkins University Press, 2012.