"among those who escaped from Caffa by boat were a few sailors who had been infected with the poisonous disease. Some boats were bound for Genoa, others for Venice, and to other Christian areas. When sailors reached these places they mixed with people there, it was if they had brought evil spirits with them: every city, every settlement, and their inhabitants, both men and women, died suddenly...We Genovese and Venetians bear responsibility for revealing the judgements of God."
Gabrille De"Mussi, A Genovese Lawyer writing in late 1348
In the same year, 1348, that De’Mussi wrote his commentary a Report of the Medical Faculty of Paris, commissioned
by King Philip VI of France, examined the probable causation of the outbreak of Bubonic Plague in Europe and came
to a very different conclusion. The august members of the Faculty blamed the ‘Black Death’ on the celestial
conjunction of Saturn, Jupiter and Mars that had occurred on the 20 march 1345!!!
Venetian Plague-Doctor's mask with Jani Beg and the
depiction of Mongol mangonels in action.
The real explanation for the lethal pandemic which ravaged Europe and decimated
half the population of the Mediterranean basin (estimates of 75-200 million) of
course was the presence of plague-carrying rats that had devastated the Mongol
armies under Jani Beg, Khan of the Golden Horde, which had besieged the
Genovese port of Caffa (Feodosia) in the Crimea in 1345. Jani Beg, in
frustration at having to break off the siege, ordered the catapulting with
mangonels of the rotting corpses of his dead soldiers into the city. Escaping
Genovese ships, loaded with grain, people and rats brought the Yersinia pestis bacillus (Plague) first
to Constantinople, then Sicily and then to all ports beyond from Mid-October
1347 – mid-March 1348, thereby rapidly accelerating the spread of the disease
beyond the lands of the Golden Horde.
Dubrovnik (Ragusa) – Approaching from the South
Early Quarantine Stations for Republic of Ragusa 1377
In 1377 the
Republic of Ragusa (Dubrovnik), a rich maritime state which depended almost
entirely on the flow of commerce through its city, to try and prevent outbreaks
of plague in the city, introduced as a public health initiative the Trentina Ordanance which mandated that
all ships and their crew, goods and passengers from plaque infected areas must
lay-up at the islands of Mrkan and Bobaro (off Cavtat) for thirty days. A
similar facility for land-based arrivals existed outside the city walls and for
these a period of forty days, the Quarantina
was imposed. Ragusa established its first purpose-built quarantine facility or lazzaretto for maritime traffic on the
island of Mljet in 1397 and this subsequently moved to a land-based facility on
the Danče peninsula to the west of the city in 1430.
"Be it therefore
determined that our Provveditori al Sal shall by the authority of this Council
cause a hospital (locum) to be built on the Vigna Murata (Sant’Erasmo), as they
see fit, and those who have left Nazareth (Lazzaretto Vecchio) after being
cured must go to this hospital and remain there for forty days before they
return to Venice."
Venetian Senate
Decree 18 July 1468
Ragusa’s
overlords since 1205, the Most Serene Republic of Venice (when the returning Venetian
fleet of the IVth Crusade and the new Patriarch of Constantinople Tommaso
Morosini took control) established its own quarantine facility on the small
island of Santa Maria di Nazareth (renamed the Lazzaretto Vecchio) off the Lido
with a Senate decree in 1423 and a further convalescent facility, the
Lazzaretto Nuovo in 1468 on the island of Sant’Erasmo. The finance for the
building of these came from the commercial Proviveditori al Sal (Salt Office)
and were then subsequently overseen by the Health Office who could issue their
own ordanances.
In practice the
lazzaretto vecchio was run as an isolation (from isola or island) unit, where infected people were brought, and people
who had died from the plague both on and off the island were buried. An individual
could only be transferred to the Lazzaretto nuovo, a true quarantine facility
i.e. where non-infective or cured people were detained once his cure was
confirmed. The management of plague outbreaks was aggressive and highly
proscribed. A cure was determined if the individual had survived the disease
and had had his buboes or abscesses lanced and healed. Once this was determined
he would be transferred to the lazaretto nuovo but could take no goods with
him, and had to spend fifteen days in the pra part of the facility, then
fifteen days in the sanita part before being let go home where he had to spend
another ten days in quarantine under a ban on outside movement. At the height
of the plague outbreak in 1575 some 6000-8000 people languished and died in the
lazzaretto vecchio.
Pieter Bruegel-the-Elder's depiction of the Black Death attendants
and their modern Ebola equivalents.
The white shrouds have not changed much!!!
The difference
between quarantine as a preventative measure and isolation as a treatment
measure continues to be blurred. In the US, the Centers for Disease Control and
Prevention (CDC) define isolation as “separating ill persons who have a
communicable disease from those who are healthy” and quarantine as “separating
and restricting the movement of well persons who may have been exposed to a
communicable disease to see if they become ill.”
On the 24th
October 2014 the Governors of New York and New Jersey, Andrew M. Cuomo and
Chris Christie in response to the case of a medical doctor returning to the US
with established Ebola infection, imposed a mandatory quarantine of 21 days on
all medical workers returning from West Africa if they had had contact with
Ebola patients. The first person detained under this edict, a nurse Kaci Hickox,
who is asymptomatic and has tested negative for Ebola, has been detained in an
unheated tent on the grounds of the University Hospital in Newark, New Jersey.
This resurrected
Ragusan Trentina edict of the two Governors has created an enormous ‘civil
liberties’ outcry but does, because two States have made a conjoint decision,
have a basis in Federal Law but only it appears if the US Secretary of the Treasury
has given the go-ahead.
Article I,
section 8 of the US Constitution (the so-called Commerce Clause) grants
Congress the power to “regulate Commerce” with foreign Nations, States and the
Indian Nations. Using the remit of the Commerce Clause the US Congress passed
its first federal quarantine law (to contain Yellow fever) in 1792. The law did
not allow federal authorities to promulgate quarantine procedures of their own
but allowed those authorities to assist State officials, upon request, in
enforcing their own quarantine measures. The Act was repealed in 1799 to be
replaced by slightly more robust measures and transferring authority for its
implementation to the Secretary of the Treasury (Act Feb 25,1799, ch 12, 1 Stat
619).
A US Supreme
Court judgement in 1886 ( 118 U.S. 455) in Morgan’s Steamship established that
quarantine in the maritime context was to be subject to the federal Commerce
Clause and in 1890 an Act to Perfect the Quarantine Service was passed which
granted the Secretary of the Treasury power to develop regulations beyond just
the maritime context. Further and further court decisions re-enforced the
federalisation of quarantine and in 1921 New York State was the last state to
transfer its quarantine facilities to federal control.
In a 1942
decision in Wickard v. Filburn (317 U.S. 111 [1942]) the US Supreme Court
determined that any activity that would have an economic effect on inter-State
commerce was subject to the Commerce Clause. Two years later the Public Health
Service Act (PHSA) was passed invoking these powers. The segment of the Act
devoted to civilian quarantine and isolation is codified at 42 U.S.C. § 264 (d)
(1) and states:
Regulations
prescribed under this section may provide for the apprehension and examination
of any individual reasonably believed to be infected with a communicable
disease in a qualifying stage and (a) to be moving or about to move from a
State to another State; or (B) to be a probable source of infection to
individuals who, while infected with such a disease in a qualifying stage, will
be moving from a State to another State.
The PHSA thus
legislated for the potential of any individual to disrupt directly or in a far
more draconian fashion, vicariously inter-State commerce, by having quarantine
regulations enforced. In most decisions since 1944 the US Supreme Court has
been consistent in holding that the quarantine provisions in the PHSA as
enabled by the Commerce Clause are constitutional but they do imply a volition
or activity on the part of the individual that could disrupt that commerce.
The notion of
activity, inactivity and compulsion as defined by the threat to inter-State
commerce have yet to meet the challenge to constitutionality presented by a recent
Supreme Court in National Federation of Independent Business v. Sebelius (2011)
which held that the Commerce Clause does not regulate for “inactivity”.
According to the decision, and to use a rather broad example, Congress and by
extension the Federal authorities under the Commerce Clause cannot legislate
for ‘breathing’ but only for breathing in certain places.
New York and New
Jersey States have decided to go their own way for now and not wait for a federal
mandate. New Jersey has decided to allow quarantine at people’s homes for 21
days but this leaves Kaci Hickox, who lives in the State of Maine in limbo.
Under Commerce Clause authority New Jersey has decided to quarantine her, as a
non-resident and therefore a risk to interstate commerce, in a tent on a New
Jersey medical facility. The mere fact that she might make the effort to go
home means that her actions are no longer considered ‘inactive’. You can be
sure that State lawyers are already preparing for a constitutional challenge
with this authority in mind. Unlike Kaci Hickox, in 1664 the famous Turkish
traveller Evliya Çelebi was very impressed with the conditions and management
of the quarantine facility he visited in Ragusa (Dubrovnik).
Piri Reis' Dubrovnik
From Ragusa,
Venice and France in the 1370s, to New York and New Jersey in 2014, from Black
Death to Ebola, the management of pandemics are certainly a public health issue
and in our ever shrinking world requires a world-wide response which does not
certainly include punishing volunteer medical and non-medical staff for
responding to that need. The basis for the quarantine of the well, the legality
or illegality of detention, is not a medical issue but a commercial one.
Quarantine has always been driven by commercial concerns and used law as a tool
to protect those concerns.
Now that the
Trentina has been re-entrenched in New York and New Jersey 650 years after it
was first introduced in Ragusa, and 220 years after the powers to institute
quarantine began to be removed from State to Federal control, perhaps those
States are now determined to re-establish some quarantine facility on an
offshore island. To be renamed the lazzaretto cuomo-christie no doubt! Guantanamo
Bay in Cuba would probably suffice as such a site, given that its current
quarantined detainees under the War Against Terror powers of the Patriot Act,
are already governed by the constitutional provisions of the Commerce Clause!!
UPDATE: 27th OCTOBER 2014
The New York and New Jersey State threat to Federal control of quarantine provisions has forced the Obama administration and the CDC to issue guidelines and by extension regain that control.
Kaci Hickox has gone home to Maine where she has also run into conflict with the Maine Governor's quarantine regulations. New Jersey Governor Chris Christie said that if she wishes to sue him for infringing her civil rights, she should "Get in line."
References:
http://www.cdc.gov/quarantine/specificlawsregulations.html
http://www.huffingtonpost.com/2014/10/27/un-ebola-quarantine_n_6054592.html
http://www.nj.com/politics/index.ssf/2014/10/chris_christie_to_maine_nurse_go_ahead_sue_me_over_ebola_quarantine.html#incart_story_package
http://www.nytimes.com/2014/10/30/us/kaci-hickox-nurse-under-ebola-quarantine-threatens-lawsuit.html?
http://www.cdc.gov/quarantine/specificlawsregulations.html
http://www.huffingtonpost.com/2014/10/27/un-ebola-quarantine_n_6054592.html
http://www.nj.com/politics/index.ssf/2014/10/chris_christie_to_maine_nurse_go_ahead_sue_me_over_ebola_quarantine.html#incart_story_package
http://www.nytimes.com/2014/10/30/us/kaci-hickox-nurse-under-ebola-quarantine-threatens-lawsuit.html?