3—
Cholera:
The Epidemic of 1831 and Later Invasions
Cholera became a constant threat to Egypt during the nineteenth century as expanding and accelerating ocean transport increased the traffic of Muslim pilgrims along the Egyptian coastline and overland across the Nile valley.[1] At least half of the ten epidemics that erupted between 1831 and 1902 have been traced to pilgrims returning from the holy cities in the Hijaz, but this connection was not recognized until 1865.[2] No one inside or outside Egypt early in the nineteenth century was aware of the country's extreme vulnerability to cholera infection because of its dependence on a single source of water. The danger of contaminating the water supply always existed, but we know today that running streams are automatically self-purifying unless grossly polluted. Egypt's nineteenth-century map indicates that urban as well as rural communities drew their drinking water mainly from the Nile or its branches and from groundwater wells.[3] The cholera pandemics threatened Egypt precisely at the time when the country was changing from basin to perennial irrigation, enormously multiplying the number of canals that diverted the Nile into agricultural areas and that became potential health hazards because of the likelihood they might be drawn on for drinking water. Towns like Tanta and Damietta were at great risk because an influx of visitors to a fair in June or July periodically depleted the normal water supply just before the annual Nile flood when all water courses were at their lowest level.
In Egypt as in Europe, many saw an association between cholera and poverty, but nowhere were the reasons for the disease's more rapid spread among the lower classes understood. Since it is necessary to ingest the vibrio cholerae , which is exposed through the dejecta of those attacked by the bacillus, the most common mode of transmitting cholera has been through polluted water. But since any contact with materials contaminated by cholera sufferers' feces is dangerous, personal cleanliness also is necessary for protection against the disease. Cleanliness was difficult to achieve and maintain, however, among large groups of people assembled for any period of time in makeshift circumstances—whether they were European barracks or British slums, pilgrimage sites along the Ganges, or the shanty-town huts of workers in Alexandria's Arsenal.
The central fact in the nineteenth-century's collision with cholera was the lack of any effective therapy or even palliative treatment and consequently the overriding importance of preventing invasion by the disease. Dr. Robert Pollitzer, the World Health Organization's first specialist in communicable diseases, identified five initiatives considered necessary today for effective cholera controls: adequate intelligence services, sufficient facilities for isolating patients, a sanitary engineering service to deal with contaminated water supplies, measures to control flies and to ban the sale of potentially dangerous food or drinks, and a large-scale public information program alerting the public to take necessary precautions.[4] Except for the control of flies and sanitary engineering competence, which did not exist anywhere at that time, Muhammad Ali's government eventually took steps toward the controls Pollitzer listed. The viceroy probably sanctioned these initiatives on the advice of Europeans, but he utilized indigenous institutions—some old, like the local police, and some new, like the government Gazette —to contain an epidemic in 1848.
Of the ten cholera epidemics Egypt suffered between 1831 and 1903, I describe briefly the outbreaks of 1831, 1848, and 1865. Each posed the problem of disease invasion in different circumstances with varying contributing factors, illustrating the mounting difficulty of maintaining effective defenses as Egypt was drawn more closely into the network of international trade. In 1831, the Egyptian government and Egyptian society were taken unaware by the first cholera pandemic, and the country suffered devastating fatalities. Muhammad Ali's primary concern was to protect the armed forces, poised at that
time for a campaign in Syria, and it appears that government measures may have minimized losses among the military to a certain extent. When cholera broke out again in 1848, Egypt's armed forces had been reduced to a nominal level, but the government shifted attention to a wider population and enlisted the medical corps in civilian service. In 1865, cholera entered the country with pilgrims using two new rapid means of transport, the steamship and the railroad. Because this epidemic traveled on to Europe from Egypt, the quarantine establishment in Alexandria became a focus of international attention and efforts that in general seem to have had positive effects in barring the entry of disease. Last, the technology for excluding epidemic outbreaks could not keep pace with population growth, deteriorating environmental sanitation, and the rising volume and speed of maritime traffic following the opening of the Suez Canal. After an absence of almost twenty years, cholera reentered Egypt in 1883 and spread quickly in shockingly unsanitary conditions resulting from neglect by successive Egyptian governments preoccupied with other problems. Because mounting urbanization and population density made environmental sanitation control increasingly difficult, it was imperative to keep cholera out of the country; once the streams became polluted, widespread infection was almost inevitable.
The Cholera Epidemic of 1831
The first visitation of cholera in 1831 was one of the most murderous epidemics in Egypt's history. Within two months, the disease killed about 150,000 of the estimated population of three and a half million; some 36,000 of Cairo's quarter million inhabitants are believed to have perished in only twenty-eight days.[5] The Egyptian government was completely unprepared for this first invasion of cholera. It was a new scourge in the lands of western Asia, first appearing in Muscat with an expeditionary force from India in 1821. The disease also entered Basra and traveled to Baghdad and Mosul; carried by caravan to Anatolia and the north Syrian coast in 1822, it struck Aleppo and Alexandretta and disappeared by the end of 1823. We are told that Arabian chroniclers confronted by the outbreak in Oman had no name for cholera; seeing the healthy struck
down suddenly as if by a simoom blast, they thought cholera was carried by a pestilential "yellow wind" (al-rih[*] al-asfar or al-hawa al-asfar ).[6]
During the epidemic in Syria in 1822, Muhammad Ali had sought advice from the French Supreme Council of Health, exchanging correspondence on quarantine procedures for about a year.[7] But his interest waned as the disease failed to reappear in the Levant, and when cholera struck again in 1831, it caught him off guard, coming suddenly from an unexpected quarter in the Hijaz. In spring 1831, an estimated 25,000 to 50,000 pilgrims had converged on Mecca for the communal ceremonies of Qurban Bayram. Early in June, the Egyptian military Medical Council in Cairo received reports from the chief army surgeon in the Hijaz of great ravages of disease among the pilgrims. An epidemic, "analogous to the cholera morbus of India," had broken out in Mecca in March, subsided, and flared again with the arrival of new pilgrims in May. The outbreak had been aggravated by the simoom wind, a severe shortage of potable water, and drenching rain to which thousands were exposed during their overnight encampment on Mount Arafat. It was believed that 30,000 sheep sacrificed the following day also must have added to the "poison" in the atmosphere. Estimates of mortality from the epidemic ranged from 12,000 to 30,000, and among the victims were reported the leaders of the Damascus and Cairo caravans and the governor of Mecca himself.[8]
Although the Egyptian government hoped that the disease would be confined to the Hijaz, a report that 4,000 pilgrims had set out from Mecca for Qusayr and Suez caused a flurry of anxiety and official activity. Well equipped with troops to apply the standard defense measures against epidemic diseases—military cordons and detention stations for travelers from the infected area—the viceroy ordered Suez and Qusayr encircled and all travelers from the Hijaz quarantined. When the physicians dispatched to Suez returned, reporting that pilgrims had broken through the blockades, a battalion of regular troops moved to intercept them. As news arrived that cholera had broken out in Suez and claimed 150 victims in three days, Ibrahim Pasha organized a military sanitary administration in Cairo which promptly established detention stations at Old Cairo and at Birkat al-Hajji for travelers from Qusayr and Suez. The sanitary authorities also ordered a lazaretto set up near Suez for travelers already stricken with cholera and assigned 300 Bedouin to strengthen the military cor-
don.[9] Before these precautions went into effect, a courier brought news that the great caravan from Mecca had bypassed Suez and was on its way to Cairo. The governor of Cairo immediately dispatched 200 Bedouin to intercept the caravan and order the pilgrims to set up camp in the desert; meanwhile, a cordon of line troops cut all communications between the camp and city.[10]
It appears that these measures were too little or too late. Pushed by fear, several hundred pilgrims had already entered Cairo; several days passed before most were rounded up and interned, and some remained at large in the city. John Barker, the British consul general who had witnessed the cholera epidemic of 1823 in Aleppo, was scornful of what he considered the perfunctory quarantine of a thousand pilgrims who arrived in Alexandria early in August. Although they had left Mecca while cholera was still raging, they were allowed to proceed further after only "a slovenly quarantine of 15 days."[11]
According to Barker, the fact that the disease did not break out during the two-week quarantine period lulled the people and the government of Cairo into a "fatal security." On the sixteenth of August, they were aroused by simultaneous outbreaks of cholera at several sites in the city,[12] and within three days, the disease claimed 335 victims. When two days later the number of dead rose to 450, panic seized the city. There was a mass exodus of Europeans fleeing in terror to the suburbs, to Fayyum, or to the western bank of the Nile bordering the desert. The Nile swarmed with craft of every description filled with refugees from the stricken city. As the disease spread throughout Cairo, the Franks' quarter became a scene of mass rout. In the streets, a continual file of camels carrying the fugitives' effects passed sad bands of peasant laborers returning home to the provinces. Within a few days, funerals for the victims of the epidemic filled the streets with a steady train of mourners. Although religious-minded Muslims believed the scourge was an act of divine vengeance, according to Dr. Clot, fatalistic resignation was not conspicuous among them. Muslims who had never been convinced that plague was contagious fled Cairo or withdrew to their houses, taking precautions they had scorned in the past.[13]
The news that 335 had died in Cairo within three days paralyzed Alexandria with fear; consular and commercial agents' offices closed and business came to a standstill. At this point, Muhammad Ali proposed that the European consular corps organize a board to protect the port city from the epidemic. According to the consuls' reports,
the viceroy placed at their disposal 20,000 troops in the area, extended carte blanche for expenditures, and promised to execute any measures they recommended for the common welfare. Seventeen consular representatives assembled and named a five-man committee as the first Quarantine Board in Alexandria: the consuls general of England, France, Austria, Tuscany, and Russia. The board's first move was to order a double cordon around Alexandria and to post European physicians as inspectors at stations on the cordon and in the markets.
The Quarantine Board survived only about a week, for cholera broke out in Alexandria, in spite of the double cordon, with the same explosive force it had exhibited in Cairo. Deaths mounted quickly, and by the end of August the daily mortality in Alexandria exceeded 100.[14] The consular Quarantine Board had resolved to take full advantage of the extraordinary powers the viceroy had granted them, but their efforts were in vain, and within ten days, they admitted defeat at their last session. Since 800 soldiers in the hospital were without medical attention because of the death or desertion of many physicians, the board recalled all physicians stationed on the cordons and designated only a few observation points to be maintained for detaining travelers from Cairo and for fumigating mail. And since both cordons, which were preventing the delivery of provisions to the city's markets, had become infected, the board abolished the blockades. Finally, the members abandoned their commission and dissolved the board itself.
At the time the Quarantine Board prorogued its sessions, the cholera epidemic had peaked and was claiming more than 100 deaths daily in Alexandria and between 500 and 650 in Cairo. During the following two weeks before the disease began to decline, it spread into new quarters at a terrifying rate. There was a rising toll among troops, in the naval barracks, and on shipboard. Cholera penetrated most of the ships of the fleet and eventually broke out on board the viceroy's own frigate, where the staff made every effort to conceal the fact from him. Muhammad Ali returned to Alexandria precipitately and took over the governor's residence. lbrahim Pasha had already fled Cairo for Upper Egypt when cholera broke out in his harem.[15]
Although Upper Egypt had not been touched by the epidemic, people in the capital feared that pilgrims en route to the Saïd would reignite the disease when they passed through Cairo on river craft;
those who appeared at Bulaq or Old Cairo ports were intimidated and forcibly prevented from disembarking.[16] In Lower Egypt, cholera had spread in all directions, attacking Rosetta, Boulos, Damietta, and almost all the villages of the delta. Fuah, at the entrance to the Mahmudiyah canal where many pilgrims had stopped, was particularly hard hit, and an army regiment garrisoned there was almost wiped out.
Sending conscripted peasant laborers back to their home villages appears to have been the only government-initiated measure for the civilian population during the cholera epidemic. Muhammad Ali had enforced the Quarantine Board's proposals to draft gravediggers for Alexandria and to remove burial grounds outside the city, but he refused to sanction the destruction of cholera victims' corpses by quicklime, which, he said, was forbidden by the precepts of Islam.[17]
The government's primary concern centered on the military forces, stricken with a devastating disease on the eve of their departure for Syria. According to observers' estimates, about 2,000 sailors and 5,000 troops of the 90,000-man army died during the epidemic.[18] It appears that isolating the sick was the principal expedient adopted to contain the disease among the armed forces. As soon as cholera broke out in Cairo, the minister of war ordered cavalry and infantry regiments to the border of the desert to isolate them from the urban population.[19] When regimental infirmaries soon proved inadequate for the growing number of patients, extra tents were set up to separate the stricken from healthy men in their units. In one case where the regiment had no facilities for the sick, the War Ministry approved housing them temporarily in a local caravansary. Government communications invariably emphasized economy, even during an epidemic, but there were some concessions to medical opinion. A regimental commander who requested instructions for disposing of the effects of soldiers who died was directed first to record the amount realized by selling the effects; however, it was then declared preferable to burn the clothing of those who died of cholera. The War Ministry also surprisingly upheld a second lieutenant who appealed his dismissal for failure to follow his regiment while he was recuperating from cholera.
But there was no clemency for medical officers who had deserted their posts during the panic of Egypt's first cholera epidemic. The viceroy ordered all medical personnel who had fled dismissed, because they had failed in their duty when they were needed most.
European physicians' names were stricken from the payroll; they were obliged to return the swords issued to them and to reimburse the treasury for the mount and saddle they had received.[20] The flight of European members of the medical corps had apparently created a serious shortage of trained personnel, for Dr. Clot acknowledged there was mass defection during the epidemic.[21]
By the middle of September, cholera was on the wane and the mortality bills for Cairo and Alexandria had dropped back to pre-epidemic proportions. The official figures forwarded by European consuls reported the number of dead from cholera between August 19 and September 15 as 2,000 in Alexandria and 10,000 in Cairo, including army and navy personnel.[22] The French consul general questioned these figures and suggested as a more accurate toll 4,000 for Alexandria, 30,000 for Cairo, and perhaps 100,000 for all Egypt. Confirming his estimate for Alexandria, he reported the following mortality figures:
|
Complaining that reliable statistics were exceedingly difficult to obtain, the French representative offered the following information about the epidemic's toll in different localities. In Cairo, the governor estimated the mortality at 32,000, but European physicians believed the toll was closer to 40,000. Rosetta had lost 4,000 of a population of 15,000, and Damietta reported 5,000 to 6,000 deaths among its 15,000 inhabitants. Suez had lost 300 of 500 inhabitants; Qusayr had practically no survivors; Fuah was virtually depopulated, and Abu Zabel had lost one-half of 2,000 inhabitants. Upper Egypt also suf-
fered losses; according to a French archaeological expedition in Luxor, cholera almost decimated the population of villages around Thebes. Therefore, Mimaut believed that the death toll for all of Egypt must have been between 150,000 and 190,000.[23]
Everyone expected that the country would be slow to recover from its first invasion of cholera, but by mid-October, when forty days had passed without a recurrence of the disease, Egypt appeared to have recovered good health. Ibrahim Pasha successfully carried off the expedition to Syria, and the epidemic began to fade in memory. By the end of November, the anticipated long drawn out recovery period had diminished miraculously; prosperity had followed a cotton crop that surpassed all expectations.[24]
Cholera Again in 1848
In the interim between the first cholera pandemic in 1831 and the second pandemic in 1848, several important changes had occurred in Egypt. Most dramatic had been Big Power intervention to thwart Muhammad Ali's challenge to the Ottoman sultan in Syria, forcing him to withdraw his armed forces from the Levant and curtail their number to a nominal level. Reducing the armed forces led to cutbacks in government agencies serving the military establishment and called for replacing relatively highly paid foreign employees with Egyptians who received lower wages than either Turkish officials or European specialists. Retrenchment thus significantly strengthened the trend toward the formation of a professional Egyptian civil bureaucracy.
In the same way, demobilization of the military medical corps permitted their redeployment in an evolving network of civil hospitals and clinics, which will be examined later, as well as in the quarantine service directed by the consular board in Alexandria. Deemphasizing the military establishment also fortified the educational character of the Egyptian Gazette, the official organ founded to inform government officials about political, economic, and administrative developments. Abandoning the heavy emphasis of the 1830s on Ibrahim Pasha's military exploits, the Gazette became a channel for explaining to local government functionaries innovations in public affairs, such as government activity in new areas like public health. Under the capable direction of editors who had studied abroad, notably
Shaykh Rifa'a Rifai al-Tahtawi, it disseminated among government officials the specialized information and recommendations of the viceroy's technical advisers, including the Medical Council in Cairo.
Finally, Muhammad Ali was keenly aware that stripped of his military power, he was completely dependent on international goodwill for the free, uninhibited flow of Egyptian commodities in overseas commerce. Adverse public opinion abroad regarding the allegedly poor state of health and sanitation in Egypt was a major factor in the prolonged periods of quarantine that ships carrying Egyptian produce had to undergo in European ports. Muhammad Ali's concurrence in all the restrictions imposed on traffic by the Quarantine Board in Alexandria therefore aimed not only to protect Egypt from epidemic invasions but also to demonstrate his resolve to uphold the recognized standards in international cooperation for disease control.[25] To gain the confidence of his international trading partners and ensure free-flowing traffic in Egyptian goods, the viceroy was ready to take additional steps to disarm their objections to sanitary conditions in Egypt. As early as 1835, he had commissioned the British consul general to head a committee that would recommend sanitary improvements in Alexandria, but it seems not to have undertaken any concrete projects.[26]
An outbreak of plague in Alexandria in 1841 provided the incentive and the occasion for the viceroy to issue a model sanitary code for the city.[27] The lengthy decree invoked the etiological principles held by Europe's sanitary reformers and laid down comprehensive regulations covering every then-known locus of dirt and possible infection. One set of orders dealt with periodic purification, fumigation, and whitewashing of all residential premises; another series assigned similar duties to those in charge of quarters for the troops, seamen, workmen in the Arsenal, apprentices in government schools, and all hospital employees. Street repair, street cleaning, maintenance of drains, disposal of waste from privies, and ventilation of bazaars and markets were all responsibilities assigned to specific functionaries. Food inspection became one of the new duties for former military medical officers who were to accompany the municipal market inspector (muhtasib),[28] examine all comestibles and the food prepared by public cooks, and deliver any suspect commodities, together with their vendor, to the police. Severe penalties for noncompliance with the regulations were threatened in each chapter of the Sanitary Code. Finally, since cleaning Alexandria alone would
not benefit the general welfare of the country, the decree announced the viceroy's intention to extend the regulations for urban sanitary policing to Cairo, Damietta, Rosetta, and other cities in Egypt.
It is likely that the presence in Alexandria of merchants and consular representatives of the trading nations whose confidence he wished to win influenced Muhammad Ali's publication of these comprehensive and exemplary regulations. But two points concerning Alexandria's sanitary code are worth noting. First, since the regulations include miasmatist recommendations for ventilation and elimination of noxious exhalations, as well as contagionist stipulations for fumigating effects and filling cracks and holes in walls, it appears that the viceroy had felicitously combined the best practices of two rival schools of thought on prophylactic public hygiene. Second, the comprehensiveness of the regulations probably doomed them to nonenforcement. Only another autocrat concerned, as Muhammad Ali was, to safeguard the health of government employees who were the instruments of his policies as well as to impress Europe favorably by sanitary reform in Egypt would execute such a thoroughgoing program. If, as the viceroy indicated, Alexandria's sanitary code had been extended to Cairo, Damietta, Rosetta, and other cities in Egypt, it might have mitigated some of the tragic losses the country suffered to cholera.
But, above all, at mid-nineteenth century, rigorous vigilance was necessary to prevent the deadly cholera infection from penetrating the country's inhabited areas. In spite of Alexandria's sanitary code and an elaborate quarantine establishment, Egypt did not escape the second cholera pandemic in 1848. The mortality that year was nothing like the frightful toll in 1831, according to official reports: 3,793 deaths from cholera in Alexandria and 6,028 in Cairo during the two months from mid-July to mid-September. Damietta, Rosetta, and Qusayr also reported high losses, many villages in the delta suffered severely, and at the end of the year, the total number of deaths from cholera stood at 30,000 for all Egypt.[29]
The epidemic in 1848 illustrated two factors that aggravated Egypt's vulnerability during the nineteenth-century cholera pandemics. First, because environmental sanitation was so poor, any large assembly of people could overtax the water supply and put the entire area at risk once cholera had entered the country. Second, the evidence of widespread evasion and defiance of quarantine regulations indicated that neither the elite nor the masses were willing to
submit to detention, while medical authorities were at odds over the value or futility of preventive measures.
Ironically, the government had been on the alert in 1847, anticipating the infiltration of cholera with pilgrims from the Hijaz, and had issued comprehensive regulations to control their passage through Egypt. Pilgrims arriving by sea either at Suez or Qusayr and those traveling overland via Aqaba were required to undergo five or ten days' quarantine, depending on whether they were well or sick on arrival. Food, drink, tents, and troops to enforce detention were dispatched from Cairo to all three sites. Enforcing the regulations evidently proved difficult, however, because none of the pilgrims showed any signs of cholera and they all resisted detention. So it appears from the Gazette, which reported that although 7,000 pilgrims died at Mecca and Medina, nothing occurred among the returnees to Egypt except that the huge crowd fleeing the epidemic swamped one of Ibrahim Pasha's boats at Jiddah. Since the pilgrims arriving in Egypt all seemed to be in good health, the viceroy spared them the well-known vexations of quarantine.
Although the Gazette announced in January 1848 that the government had authorized funds to expand the lazaretto in Alexandria,[30] that overtaxed facility failed to screen the pilgrims who carded cholera into Egypt later that year. As Chief Physician Grassi of the Quarantine Service admitted, it was simply inadequate to accommodate large agglomerations of men and goods without hazard to health. At one time during the pilgrimage season, the facility held 1,300 persons "with all their filthy effects," who were crammed into rooms "closer than in a ship." It was no wonder that cholera appeared in the lazaretto, he declared, since "noxious vapors and miasma" undoubtedly emanated from the stagnant air. In June, two deaths occurred at the lazaretto which the chief physician and his colleagues suspected to be caused by cholera; however, they were not permitted to examine the bodies to determine the cause of death because the deceased were Muslim women.[31]
Some of the stricken apparently traveled unhindered from Bulaq port to Tanta, where a semiannual trade fair held on the feast of Sayyid Ahmad al-Badawi was attracting thousands of visitors from all over Egypt and the neighboring countries. Within a few days, a full-scale epidemic was raging, and the panic-stricken visitors stampeded out of the town in all directions, carrying cholera with them. The outbreak in mid-July 1848 occurred under optimum circum-
stances for the spread of the disease. Ramadan, the month of fasting, was about to begin; hot weather had set in with temperatures ranging between eighty-five and ninety-five degrees; the river was rising, but water was very low in the canals in the delta. Tanta had no resident medical or sanitary officer and was not noted for cleanliness, according to a Russian physician who visited the town shortly before the epidemic broke out. The water supply was patently inadequate for the influx of people and livestock during the fair, and people might be tempted to draw water from a poorly maintained canal encircling the town. This would be extremely hazardous, the visiting physician observed, when the water level was low, as it was when 150,000 to 200,000 visitors to the fair descended on the city of some 17,000 people in July 1848. Instead of continuing for a week as it did in normal times, the fair broke up in confusion and panic on the fourth day.[32]
Although the information available is slim, government communications in 1848 indicate an evolution in official attitudes toward responsibility to the public since the first cholera epidemic in 1831. Then, the only government initiatives had been segregating sick military personnel and returning fallahin laborers to their home villages. In 1848, high-ranking functionaries still retired to seclusion,[33] but government agencies issued directives urging observance of the public and personal hygiene measures detailed in Alexandria's sanitary code of 1842, described earlier.
In Cairo, the chief physician attached to the Police Department was ordered to enforce rigorously regulations for inspecting slaughterhouses and for cleaning streets and public places in the metropolitan area. Above all, he must prohibit the sale and consumption of green, unripe fruit.[34] Schools received special instructions from the Ministry of Public Instruction, which exhorted school supervisors in general terms to safeguard the students' health and specifically urged the following: maintain cleanliness of the school premises and of students' clothing and bedding; assure good ventilation, but do not permit students to sleep uncovered or with windows open at night; forbid the purchase and consumption of all unripe fruit; forbid students to leave and outsiders to enter the premises; forbid games that will tire the students because fatigue and perspiration may predispose them to the disease; if any student is stricken with cholera, place him in isolation and provide medical attention immediately; if cholera spreads to other students, send the healthy home at once.
Although some of these instructions were irrelevant, some were good advice representing empirical hygiene practices of the day. Since no one knew how cholera was transmitted from man to man, the most important ruling was isolating sick students. Quite rightly, the instructions also stressed cleanliness, a sovereign prophylactic against many infections. In keeping with nineteenth-century views, fatigue, perspiration, and sleeping exposed to the night air were all considered predisposing causes of illness and were to be avoided. At this time, Europeans also commonly believed that eating pulpy vegetables and green, unripe fruits would cause dysentery; one observer expressed certainty that in 1848 cholera made the worst inroads among Muslims who "stuffed their stomachs" with watermelons and cucumbers after breaking the Ramadan fast. The prohibition was a step in the right direction for other reasons: pulpy vegetables and fruits like cucumbers and watermelons may harbor several microorganisms responsible for enteric disorders.[35] As for the general public, it appears that the central authorities directed local government officials to utilize the provincial health service created in 1842 and to refer promptly any cases of cholera to district physicians. In Cairo, the government instructed police to urge stricken residents to go to the city's ten health bureaus, where they would receive treatment and medication free of charge.[36]
There were conflicting reports, however, about the availability of medical assistance in Alexandria. The British consul general reported that strict quarantine regulations were enforced only to safeguard "the precious life of Ibrahim Pasha and members of his family," and as soon as he sailed for Rhodes, all suspected cases of cholera were turned out of the lazaretto. The poor of the town were totally neglected, he reported; out of 284 deaths in one day, 214 were listed "found dead," that is, they died without any medical attention. Francesco Grassi, Chief Physician of the Quarantine Service, described the release of detainees in the lazaretto as a considered decision to abandon quarantining and crowding people in cramped quarters after the epidemic was already under way in Alexandria. If many had died without medical aid, he stated, this was due to the speed with which victims succumbed to the disease and to many Muslims' lack of faith in medicine, for the quarantine administration had provided physicians and medicines without charge in every quarter of the city. The French consul also reported that free emergency health stations had
been created in Alexandria on the model of those that operated in Paris during the cholera epidemic in 1832. Similar arrangements apparently were available in the provinces.[37]
True to its didactic purpose, the Gazette tried to rouse local officials to the danger of failing to notify district physicians immediately when cholera broke out. Cholera appeared in Fariskur, one of the rural rice-growing communities in Sharqiya, it reported, and attacked fifty-five people on the fifteenth of Ramadan. Where the district physician was summoned without delay, he treated them immediately and God cured them all, the Gazette asserted. However, it warned, one whose family did not notify the physician promptly departed for the hereafter. During the epidemic, the Gazette kept government functionaries informed on the course of the disease with such edifying examples and exhortations. Early in the epidemic it reported that the viceroy had requested scholars at al-Azhar to read Bukhari's Sahih publicly, divinity students to read the holy Koran to influential persons, and all the people to pray for deliverance from the scourge that afflicted Egypt. It also reported the epidemic's decline and declared the waning was God's response to the people's humble prayers.[38]
Although the daily routine of life continued normally, government business slowed down with the ministries' adoption of quarantine, and the lack of Muhammad Ali's strong hand was evident, according to observers. The viceroy had retired from government affairs in December 1847, and Ibrahim Pasha had fled Cairo for Alexandria and ultimately Constantinople as soon as cholera appeared in Egypt. The duties of government thus passed to Abbas Pasha, who, being no more ready to risk infection than Ibrahim, boarded ship and sought safety in Upper Egypt. Bagi-Bey, the governor of Cairo, was an early victim of the epidemic, and the capital city was left without a chief executive.[39]
Clot's experience in disciplining the staff of Cairo's civil hospital, Qasr al-Ainy, offers an example of the lack of a central coordinating authority. He claimed that while inspecting the hospital, he found the supervisor, physicians, instructors, and medical students all neglecting cholera patients. He reported his finding to the Ministries of War and Public Instruction and demanded exemplary punishment of the entire staff. The Ministry of War complied, but the Ministry of Public Instruction objected that it was contrary to Islamic law to
inflict punishment during Ramadan and therefore ordered the prisoners released.[40]
Clot's experience demonstrated the pitfalls of overlapping bureaucratic spheres of responsibility, but it also illustrated the Egyptian government's good fortune in failing to adopt officially and exclusively his anticontagionist views on communicable diseases. Clot had expressed scorn publicly for the "inhumanity" of physicians who were cautious in attending plague patients, and he held similar views on cholera. His hostility toward quarantine procedures was so well known that the British consul's report that quarantine was "grossly neglected" in Cairo seems plausible; Clot probably was responsible for not detaining the travelers who carried cholera from Bulaq to Tanta.
Observers of the epidemics in 1831 and 1848 remarked that the Egyptians were terrified of cholera; while they scoffed at precautions against plague, they fled or secluded themselves at home in Frank fashion when cholera appeared.[41] Medical staff members at Qasr al-Ainy hospital whom Clot observed neglecting cholera patients were acting on sound, if selfish, instincts, given the dubious hygiene standards of the day. Clot would have preferred that Egypt follow the example of Malta, where the government officially adopted the idea that cholera was a disease transmitted by vitiated air loaded with miasmatic emanations. Citing renowned medical authorities in Paris, a government notice condemned those who upheld "the cruel and unfounded doctrine" of contagiousness and stipulated that such opinions would disqualify medical practitioners who became candidates for government posts. According to the medical historian of Malta, the official stand "fostered an irresponsible familiarity toward the fatal illness" at a time when techniques for handling communicable diseases were wholly inadequate.[42]
In Egypt, however, neither one of the two medical factions prevailed completely at this time. In his observations submitted to the Sanitary Commission of London, Dr. Grassi unequivocally stated his belief that cholera was communicated from man to man. As evidence that cholera was "portable and catching," he pointed to the concentrations of cholera outbreaks at sites along the waterways where travelers stopped. Bulaq port had suffered proportionately far more than Cairo, and two villages that faced each other at the entrance to the Mahmudiya canal, where Muhammad Ali had relocated all the poor people's huts, were struck much harder than Alexandria itself.[43]
The Cholera Epidemic of 1865
The lack of vigilance which had allowed cholera to pass through Egypt in 1848 continued, but two additional contributing factors appeared for the first time in the epidemic in 1865.[44] Most dramatic was the epidemic's easy and rapid progress from the Hijaz to Egypt to Mediterranean Europe, facilitated by new rail and ship transport. Equally disturbing was the discovery that ships' captains were falsifying declarations on the state of health of passengers traveling to and from the Mecca pilgrimage.
Completion of the Alexandria-Cairo-Suez railway line had added the link connecting steamship transport in the Mediterranean with that in the Red Sea in 1858, but pilgrim traffic on that line did not attract attention until 1865. In that year, the feast of Qurban Bayram occurred on a Friday, making the pilgrimage a "Hajj al -
At the end of April, the Quarantine Board in Alexandria learned that cholera had appeared in Mecca and Medina. Two Egyptian physicians dispatched to the Hijaz confirmed the outbreak as cholera and described a scene of mass mourning as hundreds of pilgrims died on all sides each day. The Ottoman Commission of the Hijaz estimated the mortality at 15,000, but observers held the death toll must have been twice that number. According to an investigating committee, cholera was imported to the Hijaz at the end of February by two ships from Singapore carrying almost 1,200 Javanese, Malaysian, and Indian pilgrims. During the voyage, 143 persons on board the ships had died of cholera, but the captains declared that the disease had appeared only after they had put in at Mokalla, a port on the southeastern coast of the Arabian peninsula.
Within a period of three weeks, ten steamers, each carrying nine to twelve hundred passengers, arrived at Suez. The ships' official statement declared the passengers' health perfect and indicated that the few deaths that had occurred were due to "ordinary" diseases. A port physician at Suez boarded each of the vessels, reported no evidence of illness, and authorized free entry for the ships. Thereupon, twelve to fifteen thousand hajjis landed and boarded the Suez-to-Alexandria rail line. When cholera broke out among those newly
debarked in Suez, it became evident that all the ships' captains had falsified their declarations.
Investigation revealed that each of the ships had cast overboard passengers who died of cholera, and one in fact had lost to cholera more than 100 out of 2,000 passengers. In the meantime, the pilgrims traveling by rail had arrived at Alexandria and camped close to the Mahmudiyah canal. Egyptians in the area who hastened to welcome their coreligionists from the holy cities were the first to be attacked by cholera. The first case occurred on June 2, but through wishful thinking or self-deception, the Quarantine Board authorities failed to acknowledge the nature of the disease until June 11. From that date until July 23, cholera swept over Egypt, causing more than 60,000 deaths, 4,000 in Alexandria alone.[45]
Seized with panic, foreigners in Egypt rushed to any vessel available to carry them away from the epidemic, and an estimated thirty to thirty-five thousand persons scattered from Alexandria to all the chief ports of the Mediterranean—Beirut, Cyprus, Malta, Smyrna, Constantinople, Trieste, Ancona, Marseilles, Valencia—carrying the disease with them. By the time the fourth pandemic ended in 1874, it had circled the globe from the Malayan peninsula back to Java. It had hit European population centers hard, causing an estimated 200,000 deaths on the continent.
Following the European exodus, business came to a virtual standstill in Alexandria and Cairo; all government offices, banks, and commercial establishments extended leaves of absence to employees who requested them and adapted to skeleton staff work. The government suspended all public works projects in Cairo and Alexandria, and the dockyards adopted a reduced work schedule to allow long rest periods for their workers.[46]
As had been the case in Tanta in 1848, communities that drew on sources other than the Nile were at greatest risk from contaminated water supply. In Upper Egypt, villages close to the Nile escaped the epidemic, while those a half-mile or even a quarter of a mile inland suffered seriously. An English resident in Luxor reported that only one death suspected to be caused by cholera occurred in that town, while at Qina, 250 persons allegedly died in one day. "Shaikh Yussuf laid the mortality at Keneh to the canal water, which the poor people drink there," she wrote.[47]
In the poor quarters of urban communities, where the cholera epidemic made the worst inroads, the quarantine service initiated
rigorous measures to contain the disease. But the epidemic was out of control before they realized the danger, and their efforts came too late. It is worthwhile describing the quarantine service's procedures, however, to understand the resistance they aroused and the fact that entire villages fled at the mention of a possible quarantine. The community that had become infected was cut off from communication with the rest of the country by a military cordon; no one was allowed to leave or enter, and all provisions, including medicines, were passed through the line of soldiers. The markets, slaughterhouses, and public privies were policed. Fresh fish, vegetables, and fruit were seized; stale fish, hides, and bones were deposited outside the town, and rags and soiled clothing were burned. Drains emptying into the canal were closed and disinfected with quicklime, as were the latrines of mosques, prisons, barracks, schools, and other public places. People were driven out of their houses into tents and sheds; the worst hovels were destroyed, and other houses were cleaned and whitewashed.
In Cairo and Alexandria, government authorities ordered what had become routine measures to clean up the municipality: obstructions were demolished, the streets were swept and sprinkled, and rubbish was deposited outside the city; market supervision was tightened, and the sale of produce considered harmful for any reason was banned. Emergency medical stations were set up at strategic points within the two cities; physicians were assigned to each station on 24-hour call to dispense medication and to move quickly to any place in the city where they might be needed.[48]
Like his predecessors, the Khedive Ismail fled with his retinue and harem, this time to Constantinople. Many considered his sudden departure irresponsible and believed it contributed to panic and to general demoralization. Some Egyptians openly criticized his precipitate flight, the British consul wrote: "They now say it is one more plague which has visited Egypt in two and a half years since his accession."[49] Nevertheless, Ismail's fear of epidemic disease caused him to uphold what some called "needless" quarantines on transport between the Hijaz and Egypt as long as he held the khediviate. Regrettably for Egypt, fear as a motivation in public health policy disappeared, causing relaxation of quarantine controls.
The principal reason for extreme variation in opinions about cholera transmissibility from person to person was the widespread confusion about possible modes of transmission of what was obviously an
alien imported disease. The nineteenth century was trying to deal with cholera by measures earlier ages had devised in their straggle with another exotic and fearsome affliction, the Black Death. Egyptians and Europeans differed in their reactions toward cholera because their attitudes had been conditioned by historical encounters with plague. We turn now to that dread disease, which had longtime associations with Egypt.