Overview

Public health, as a science and as a domain of public policy, was born out of infectious disease surveillance. From plague in Venice in 1486 to typhus in Upper Silesia in 1848 to H1N1 influenza in Mexico City in 2009, epidemics have continually galvanized research and provoked policy responses. Disease surveillance is one of the few weapons in the public health arsenal of 150 years ago that is still relied upon today. However, disease-specific etiologies and the identification of microbial pathogens in the laboratory, which are essential to infectious disease surveillance today, played no role prior to 1880. This chapter explores the debates and controversies that marked infectious disease surveillance in the years just before the Bacteriological Revolution (roughly 1880–1900), when the germ theory of disease transformed medical knowledge and public health policy. The institution of maritime quarantine was especially controversial, and debates about its operation provide a revealing glimpse of the important role played by surveillance in nineteenth-century public health. Notwithstanding advances in microbiology and laboratory techniques, careful observation and correlation of disease patterns remain essential to epidemiology and public health.

Introduction

In the mid-nineteenth century, diseases were understood as dynamic and variable processes with an array of causes operating at various levels, rather than as distinct biological entities with specific microbial causes. Historians have generally dismissed the practice of quarantine as unscientific and ineffective, because in their portrayal it was based on an erroneous belief that diseases like plague, yellow fever, and cholera were contagious—that is, transmitted by direct person-to-person contact [1–5]. In fact, contagion was not the premise on which quarantine was based; many physicians and health officials who vehemently opposed the belief in contagion nevertheless advocated quarantine. Moreover, quarantine was based on rigorous observation of disease outbreaks and their systematic—even scientific—correlation with a wide range of events and circumstances.

In the centuries following the establishment of the first permanent board of health in Venice in 1486, maritime quarantine was the foundation of public health policy (Box 4.1). By the nineteenth century, every major seaport in the Western world had a quarantine station, or “lazaretto,” where incoming ships, passengers, and cargo were inspected, and where they were detained for varying periods of time if signs of danger were detected. These stations owed their existence to imported epidemics, and were designed to prevent any transmissible disease from entering and gaining a foothold in the port city. In the United States, recurring and deadly visitations of yellow fever which spread among populations from Boston to New Orleans between 1793 and 1878 prompted a tightening of quarantine regulations in many ports and sparked lively debates about the contagiousness and prevention of the disease. Three examples from these debates in the decades immediately preceding the Bacteriological Revolution illustrate the anecdotal but systematic method that generated useful public health knowledge at a time when viruses and vectors were not part of the discussion.