Did you know that most cholera infections are asymptomatic?
Only about 10% of people will develop severe illness from cholera, and even then it is completely survivable if you have access to clean drinking water. And yet, we changed our entire water and waste management systems to eradicate this disease.
Not dumping our poop into the same water we drink from seems like a smart idea now, but did you know that there was a time when people actually fought against these protective health measures? There were actual riots.
In fact, history is punctuated with disease and those who fought against their eradication. The recent ebola outbreaks are a great example of this. Eradication efforts are constantly hampered by misinformation, conspiracy theories, and suspicion of medical staff just doing their best to keep people alive. Basically, anytime you have disease, suspicion of science, medicine, and efforts to fight against them arise. And every time, when the dust settles, those folks look real silly.
I haven’t wanted to write this post because, well, I am not an expert in public health policy and so figured it was something better left to them to do. However, I have not seen much written about it throughout this pandemic and I feel like it’s very important contextual information for people to have.
I do have a background in public health policy, I would like to clarify, so writing this isn’t entirely outside of my wheelhouse. I have both studied it and worked in the field, and still contribute as a consultant from time to time, but it’s not my specific job at the moment.
So, with that disclaimer out of the way, I want to try to alleviate some of the confusion I’ve been seeing and hearing around the interplay between public health policy and government functioning. I know that a lot of you have been feeling uneasy. It’s hard not to. With our media and social media constantly shouting about ‘draconian health measures’ and ‘authoritarianism’, without the proper context and background as to why they’re actually very much not, it can be easy to feel like our country is sliding into chaos.
It’s not. At least not as far as these things go, anyway.
So, let’s take a look at why your freedoms aren’t actually at risk and nothing is actually being taken away from you, from a public health perspective.
There will come a time where we view breathing the same air in that other people exhaled out just as weird and gross as we view drinking the same water we dump our poop into now. Covid is just the cholera of the air. It will eventually force us to rethink our air management and filtration systems and all of this hoopla will seem real silly to future generations who study this period of time in school.
Public health policy has been around since the first quarantines began in the 1300’s. Surprise! Quarantines, lockdowns, public health mandates - all of these things have been used to control the spread of infectious disease for centuries. None of what is happening is new. New to you maybe, since vaccines and other medical advancements like antibiotics have either eradicated or made many infectious diseases not such a big deal, so you’ve likely never really had to deal with things like quarantine in your lifetime, but there are still plenty of diseases that are effectively managed by these types of public health measures.
Want a popular culture ‘for instance’? The mumps episode of Brooklyn 99 where Captain Holt and Jake Peralta catch the mumps and have to quarantine in Captain Holt’s house together for 9 days while they’re still infectious. The gym where they caught it was locked down too, the patrons contact traced, tested, and quarantined. Sound familiar?
That episode aired on January 19, 2016 - long before the pandemic.
Mumps, you’ll be interested to note, is an illness that we have vaccine mandates for as well that help to control its spread, but there are still sometimes ‘breakthrough cases’ and outbreaks of it because never has a vaccine protected you 100% from becoming infected, immunity wanes over time, and we all need boosters for it periodically. The difference is that we receive those vaccines when we’re kids so most of you don’t remember the mandated part, but almost all schools require that you’re vaccinated for it to be able to attend. You have to show proof of that vaccination or proof of exemption too (*cough cough - vaccine passport). The mumps vaccine is administered as a 2 dose regime in childhood.
Here’s an infographic explaining the routine childhood vaccines - notice how many require multiple doses.
Source: CDC
The covid vaccine is a multiple dose regime, like the multitude of vaccines that came before it, i.e., HepB and Polio. Want an interesting bit of knowledge? The DTaP vaccine requires (gasp) 5 doses. Multiple dose vaccines are not weird but rather the norm.
But I digress. This post is about freedoms and how yours aren’t actually, in any way, being taken away. Because public health policy has been around for a very, very long time. Because transmittable diseases have been around for a very, very long time. All of the things we’re experiencing now with covid, have been experienced before for all of the other diseases that came before it that we now have vaccines and treatments for. Our societies are all still here, our democracy still very much intact. This, too, will just become a footnote in history and life will carry on.
Vaccines help to keep those diseases from disrupting society now, but there was a time when society was quite disrupted by those diseases. Before vaccines, the other public health measures like quarantines, lockdowns, travel restrictions, social distancing, masks, contact tracing, etc., were how we controlled diseases. For hundreds, if not thousands, of years. They are still used to this day for diseases we don’t have vaccines for. We also have travel restrictions and vaccine mandates for all kinds of places where certain diseases are still rampant. Ever travel somewhere and have had to get certain vaccines before you go? Those things all had to start somewhere. We’ve been through all of these processes before. None of this is new - it’s taught in schools, people have careers in it - it’s just maybe new to you because you haven’t had to live through a pandemic before and so haven’t paid much attention to all of the ways public health measures keep you safe in your daily life.
How are these public health measures able to exist? Because of the way our Constitution and Charter of Rights and Freedoms is set up.
This is such an important thing for Canadians to understand so I’m going to put this in bold:
We are not America.
We do not have first amendment rights or free speech or the right to bear arms.
The rights and freedoms set out in the Canadian Charter of Rights and Freedoms are not absolute but rather can be limited to protect other rights or important national values. Section 1 of the Charter says that Charter Rights can be limited by law so long as those limits can be shown to be reasonable in a free and democratic society. For example, freedom of expression (not ‘free speech’ or ‘first amendment rights’, that’s American) may be limited by laws against hate propaganda or child pornography.
That’s why public health rules, mandates, and laws are able to function the way they do and not infringe on our Charter Rights. They have to be shown to be reasonable limits, of course, which is why certain proposed ideas - like the health tax on unvaccinated individuals - haven’t gone forward, but other ones - like the short term restricting of access of unvaccinated individuals during a global pandemic can only occur for non-essential activities, but not essential ones - are okay. It is a reasonable limit on your rights and freedoms given the circumstances. This comes with a huge caveat - there are specifics to these rules that make them reasonable versus not - their time-limited nature, the amount of disease prevalence, percentage of population vaccinated, alternatives for the unvaccinated to participate in essential services and activities (like working from home, wearing a mask and testing frequently, etc). All of these things are worked out with the Human Rights Commission of Canada, the various government levels and departments, and the court system to ensure that these limits are, in fact, reasonable. And sometimes they change over time.
And for the record, I get it - when you don’t have the context or the background in public health measures, constitutional law, or how our government system functions, some of these measures can seem like over-reach. There are, of course, nuances that would make them over-reach. If, say, a government were to exclude a group of individuals based on their ethnicity - something they can’t change about themselves - then yeah, totally, go protest the heck right out of that! If there was no disease and the government just decided to restrict your access to things - total problem right there. Maybe.
Let’s talk about seatbelts and not smoking in public spaces - both non-disease public health measures that limit your freedoms and have become laws because they did so in reasonable ways. The first one, seatbelts, was found to be a reasonable restriction because the scientific evidence says that they reduce the risk to the individual should that individual get into a car accident. Not smoking in public spaces was found to be reasonable because, though it may infringe on your right to smoke wherever you want, the scientific evidence says that your choice to smoke can harm the other people around you. You still have the right to smoke, but you do not have the right to endanger other people with your choice, so the reasonable limit on your freedom is to designate smoking areas that are far enough away from other people so as to not impact them negatively.
See how that works? Individual freedoms have to be balanced by the freedoms of those around you to not be negatively impacted by your choices.
You haven’t been free to spread a deadly disease for a very long time because it negatively impacts on the freedoms of those around you to not be exposed to a deadly disease. In some instances, knowingly spreading a deadly disease to others without their consent is actually illegal.
The laws that public health operates under have been around for a very long time. They actually pre-date the formation of this country. Again - there are entire professions dedicated to making decisions around infectious disease. If you’re truly interested in this stuff, take a course in it, go back to school, get a degree, work in the field. Your uneducated opinion is just that - an uneducated opinion. It does not change an entire field of research and policy. Nor should it. No matter how angry you may be at the inconvenience you feel having to do your part to stop the spread of a dangerous disease, your opinion on it doesn’t actually make public health rules null and void. Just be thankful we stopped shipping infectious people off to islands, i.e., leper colonies and during plagues. You having to wear a mask and wash your hands is actually pretty tame in comparison.
But I digress.
Here is a brief historical overview:
There’s actually a lot of biblical mentions about isolation and quarantine, but I’m not going to start there because dates are hard to pin down. So we begin our journey in the 1300’s with the European plague epidemic known as ‘the Black Death’ of 1347–1352 (it actually continued for like, 350 some years) that began in Italy, arriving on ships with rats, sailors and cargo, and spread to France, Spain, Austria, and central Europe. Since medicines to treat plague didn’t exist yet, the only option to prevent infection was to isolate the sick from the healthy and avoid contaminated objects. City-states began to impose restrictions on strangers entering the cities. ‘Sanitary Cordons’ were imposed by armed guards along trade routes and at access points to the city. Breaking it was punishable by death. Infected people were initially held in makeshift camps outside the city, but later (1377) these developed into ‘lazarettos’, or plague hospitals. These were located far enough away from cities to restrict the spread of disease but close enough to still transport the sick. Often, these hospitals were placed in areas where a natural barrier - like the sea or a river - separated them from the city (i.e., islands), but in areas where that wasn’t possible the hospital was surrounded by a moat or a ditch. In port cities, buildings were designated as quarantine zones and were used to house incoming passengers, crew, and cargo. The people working to intake these potentially infected individuals worked from behind glass barriers to stop the spread of ‘bad air’. They maintained a good deal of physical distance between themselves and others. Sound familiar? 1300’s. Before we even knew that microorganisms existed because the microscope hadn’t been invented yet. Because these measures actually helped to limit spread of disease even when we didn’t know yet how it was spread.
During this time, in addition to these measures to stop plague from travelling into cities from outside, measures were enacted to stop the spread within cities as well. Anyone deemed to be infected were confined to their homes, often under guard to ensure they did not leave. In some places, the sick were actually walled up inside their homes and left to die. Also interesting to note that the length of quarantines back then were 40 days and nights, likely a biblical reference, and this standard was maintained for over 300 years. Doubly interesting - plague has a disease course of 37 days, so the 40 days was actually pretty perfect.
Let’s fast forward a bit, because though many diseases sprung up during this time, the measures to contain them didn’t change much. I want to note that quarantine and isolation measures were first introduced to North America in New York and Boston in 1688 and 1691, respectively, to try to contain outbreaks of Yellow Fever. Under the new legislation, which was the responsibility of the individual states, people could be mandated to remain at home for 40 days if they were suspected of being infected.
Just want to take a moment here to point out that legislation around quarantines and isolation were introduced to what is now Canada in 1791 in a ‘British colony’ that is now the Province of Ontario. So when I say that you are not losing any freedoms here - you never had them. Some of these laws have been here since before Canada was even Canada. This is why, to someone who has a knowledge of public health history, all these protests and calls for your ‘freedoms’ to be returned to you are just… a part of the process. You’ll understand in a minute. But you didn’t lose anything. In fact, laws have been enacted around these original laws to limit their sweeping powers because the French Revolution happened and we began to recognize the rights of the person. Our laws around all of this did not begin with the rights of the person. They began with the rights of the people in the colony to be protected from the infected individual.
It may seem like a small distinction, but it is an important one. Your individual rights do not supersede the rights of others here. You are granted certain freedoms only as long as those freedoms don’t infringe on the rights of others. From the very beginning of our country. You may not like that, but the law says that you need to respect that, otherwise you face consequences. When some new disease comes along, it may seem like we’re making new laws, but those laws are actually just the same old laws being utilized in a new instance and are, again, more about protecting society from an infected individual than they are about protecting the infected individual. That’s partly how the Charter evolved - the old laws taking into consideration the new fancy ideas from the French Revolution that gained traction around the rights of the individual. How do we go about balancing those two main conflicting goals in a way that respects the individual so that society doesn’t become too authoritative? But also done in a way to ensure that society is still protected from the individual? Conversations around that happen every time we have to apply old laws to new situations. That’s supposed to happen. That doesn’t mean anything is wrong; it’s an important part of the checks and balances within the process to ensure that the rights of the individual are respected while the rights of everyone else are also respected. This is normal.
Understanding this fundamental part of how the formation of Canada differs from America - where that balance is shifted so that rights of the individual are more heavily weighed over the rights of society - helps to explain a lot of the friction we are currently experiencing in our country. We have a lot of American content, be it TV, social media, in the press, etc., and the way their society is structured is fundamentally different from ours in this way.
You can see it in the recent bail hearing for one of the Ottawa Freedom Convoy organizers, whose husband stated that he believed he was in Ottawa to protect their First Amendment Rights. 1) Wrong country. We don’t have ‘First Amendment Rights’. 2) Freedom of expression here, again, is limited by its effect on society and/or how it may impact other individuals, ie., hate speech and child pornography. We don’t look at it from the perspective of having to ‘protect’ free speech here. We look at it from the perspective of ‘is your speech infringing on other people’s rights/the rights of society?’ They’re actually quite different perspectives.
The same goes for our public health measures.
Okay, back to the history.
We’re going to jump ahead here to the emergence of cholera. Cholera spread all across Europe and North America in the 1830’s. It reached Quebec in 1832 and spread all along the St Laurence River. The first strategies used against it were essentially the same that had been used against the plague, but by this time things were becoming more coordinated and structured. Ships had “licences” that told ports where they were travelling from, which were used to determine whether or not the ship had to quarantine so the spread of infectious disease into North America had been fairly well contained for a while. People were used to ships and goods being quarantined, but generally hadn’t had to deal with sweeping quarantines of individuals within the colonies. But when cholera got here, all of that changed. Sick people were forced into lazarettos, and their contacts were traced and quarantined. Since it had been a while since a major disease had spread this quickly, people were unused to such harsh measures and, basically, it created widespread fear and resentment. Combined with the spreading notion of the rights of the citizen from the French Revolution that had happened in 1789 (news travelled slow back then), outcries of personal liberties being infringed upon began.
Social and political tensions created an explosive mixture, culminating in popular rebellions and uprisings in Europe and across North America. Conspiracy theories that cholera was really just the ruling class poisoning the poor were rampant. Some places used the cholera epidemic as a justification for increasing police power. “Anticontagionists” (real thing), who disbelieved that cholera was a communicable disease at all, protested quarantine measures, saying that the practices were a relic of the past, useless, and damaging to commerce. They complained that the free movement of travellers was hindered by sanitary cordons and by controls at border crossings. Local authorities were reluctant to abandon the protection of the traditional public health strategies because, despite this small vocal group’s opinions, they still provided an antidote to population panic, which, during a serious epidemic, can produce chaos and disrupt public order. Also, they still worked. Any strategy they tried to replace them with failed miserably.
The public became gripped with widespread fear of the disease and distrust of authority figures - most of all doctors. Unbalanced press reporting led people to think that more victims died in the hospital than at their homes, and the public began to believe that victims taken to hospitals were killed by doctors for anatomical dissection, an outcome they referred to as “Burking.” This fear resulted in several “cholera riots”.
Any of this sounding familiar? 1830’s and the ‘but the economy…’ crowd already in full swing.
Between 1852 and 1923, the world would see four more cholera pandemics. The third pandemic, stretching 1852–1859, was the deadliest. It devastated Asia, Europe, North America and Africa, killing 23,000 people in Great Britain alone in 1854, the worst single year of cholera.
In that year, British physician John Snow (his real name, not a Game of Thrones reference), who’s considered one of the fathers of modern epidemiology, carefully mapped cholera cases in the Soho area of London, allowing him to identify the source of the disease in the area - contaminated water from a public well.
You see, back in those days, it was believed that disease arose from ‘foul smells’, so sewage, rotting food, everything was just dumped into whatever water sources were close by to get rid of the ‘bad smells’. This, of course, led to widespread contamination of drinking water.
John Snow convinced officials to remove access to the public well and immediately the cholera cases in the area dropped. This discovery eventually led to improved sanitation, separation of waste water, and better drinking water supply and sanitation, but it took a long time to convince people that it was the water that was actually the problem. When they did manage to… Again, more widespread misinformation, distrust, panic, and a bunch of riots. People were really committed to the idea that the ruling class was intentionally poisoning the water supply to kill poor people. It got real ugly.
It wasn’t until 1883, when German microbiologist Robert Koch, the founder of modern bacteriology, studied cholera in Egypt and Calcutta. He developed a technique allowing him to grow and describe Vibrio cholerae, the organism that causes cholera, and then showed the presence of the bacterium in intestines, which can then be spread to others through poop contaminating drinking water supplies. Again - uproar, uprisings, people not believing that poop water was bad for you. People were real committed to drinking the poop water. People didn’t want to have to ‘change how we do things’, governments didn’t want to have to invest the money to make the changes required to make drinking water safe, people downplayed the dangers, more riots, you get the idea.
With that fun story, let’s go back to smallpox and discuss anti-vaccinationists. Would it surprise you to know that there has been an anti-vaccine movement since the first vaccine mandate against smallpox in 1853?
In Britain in 1853, the first law requiring mandatory vaccination against smallpox passed. Immediately after, the ‘Anti-Vaccination League’ arouse demanding an end to the mandate as it infringed upon their personal liberties and choices. There were, again, violent riots.
These laws extended to Canadian colonies. Canada wasn’t established until 1867. So our first mandatory vaccination laws actually pre-date the formation of our country. I want you to let that sink in for a second. Think about all the hoopla right now about vaccine mandates and how they somehow violate our Charter Rights and understand that this fight has continued since before our country even formed. Our laws around all of this have grown up right alongside our country and the development of that Charter and those rights and freedoms. So all of the horrible Nazis references and the Nuremberg Code and public experimentation conspiracy theories being spouted now like this is all some big new thing that only JUST happened for the first time ever… It isn’t. They’re just terribly misinformed people, using a horrible event in our past to somehow justify the fear they’re feeling and inflicting that rage upon the other people around them with zero regard for the folks actually connected to that event or how that horribleness may be affecting them. Which, for all you ‘but the Charter’ folks - is ACTUALLY against Section 1 of our Charter.
Interesting to note, during this era, French Canadians were generally much more suspicious of vaccination than English Canadians, although anti-vaccination sentiment could be found across the country. French Quebecers associated vaccination with British surgeons and while many of them lived in filthy, overcrowded conditions in the poorest neighbourhoods of Montreal, they were hostile to public health attempts to help them or to contain the disease. Homeopathic advocates called the vaccinators charlatans and many among the poor saw it all as a conspiracy of the rich and powerful trying to kill their children.
Again, before our country even formed. None of this is new. I cannot stress that enough.
Let’s move along to summer of 1906 and Typhoid Mary.
Mary Mallon was born in Ireland in 1869 and immigrated to the US in 1884. She was employed in 1906 as a cook by Charles Henry Warren, a wealthy New York banker, who rented a residence in Oyster Bay on the north coast of Long Island for the summer. Typhoid is a bacterial illness that can be spread through contaminated drinking water, much like cholera.
That summer, 6 of the 11 people in residence with Mary came down with typhoid, an illness that can also be fatal about 10% of the time. Mary was one of those infected. She recovered, but remained infected with the bacteria, becoming what is known as a “healthy carrier” - you feel fine, but you contaminate everything around you. By March 1907, Mary Mallon worked in Manhattan as a cook and served 8 families. That year, about 3,000 New Yorkers had been infected by Typhoid, and contact tracing revealed that Mary was the centre for the outbreak. Of the 8 families she worked for, seven of them had experienced cases of typhoid. Twenty-two people presented signs of infection and some died. Those 22 people spread the disease to 3000.
Since immunization against Typhoid was not developed until 1911, and antibiotic treatment was not available until 1948, a healthy carrier of typhoid was dangerous to the general public, so Mary was arrested and forced into quarantine on North Brother Island where she stayed for 2 years. In 1910, a new health commissioner vowed to free Mary and assist her with finding suitable employment as a ‘domestic’ but not as a cook. Mary was released but never intended to abide by the agreement. She started working again immediately as a cook under the name “Mary Brown” at Sloane Maternity in Manhattan. In 3 months she infected at least 25 people, doctors, nurses and staff. Two of them died.
Since then she was stigmatized as “Typhoid Mary” and became synonymous with the spread of disease, as many were infected due to her denial of being ill. She was the butt of jokes, cartoons, and eventually “Typhoid Mary” appeared in medical dictionaries as a disease carrier. Mary was placed back on North Brother Island where she remained until her death, 24 years later. She died alone.
Etc., etc., etc.
How we doing? Getting the idea? Do you need more examples? I have plenty. New disease happens, public health mandates come in to prevent the spread and protect the public from the infectious individuals. People are ostracized. People refuse to believe the disease is real. People flip out and demand their freedoms. People knowingly spread the disease in the name of those freedoms and denial of its existence. Vaccinations come along to stop the disease. People flip out and refuse to take them. Conspiracy theories abound. The press spread misinformation. Riots. Violence. Vaccination mandates. More flipping out. Then everything calms down, goes back to normal for awhile, new disease emerges and the cycle repeats. For centuries.
Know what’s going to happen with covid? The same thing as every other disease. We will eventually get on with it. Life will settle in to whatever the new normal is. People will get used to all the new air filtration advancements and laugh at how silly people were and how gross society was ‘back then’. And then it will all just happen again with whatever the new disease is.
Know what will remain exactly the same though? The public health measures that will be employed when that new disease emerges. They haven’t changed in centuries. Because they work. Your rights remain intact. You didn’t lose any freedoms. You never had whatever it is you think you lost in the first place. Because these public health measures actually pre-date our actual country. And without them, the germs win. Every time. So they’re not going anywhere anytime soon. They respect our Charter of Rights, the rights of the patient, all of it. Because they have grown up alongside the evolution of our individual rights and freedoms. Again, you haven’t lost anything.
To put a real fine point on it using the cholera example - you have the right to drink poop water yourself. Fill yer boots. (However, generally we now recognize the desire to drink poop water as the mental illness it is and you will likely be stopped for your own good.) You do not, however, have the right to dump your poop into other people’s drinking water. I think we can all agree that that’s fair.
So, if we’re thinking about covid as the cholera of the air - you have the right to get infected with covid and breathe your own covid air. You do not have the right to then dump your air into the air that other people breathe. You can get all Big Mad about that, but recognize that you’re just the folks in history who got Big Mad about not getting to drink the poop water anymore. You’re the folks who got Big Mad at the vaccines that eradicated smallpox and started anti-vaccine societies, harassed doctors, and claimed that everyone was just trying to kill your children. See how ridiculous that sounds from the vantage point of time’s passage? Do you really want to be remembered as being part of the ‘pro-freedom to breathe the covid air (aka drink the poop water)’ brigade? Cause I promise you, history is going to remember all those folks exactly that way. It will be taught in our schools as just another example in a long line of examples. I learned all of this twenty years ago. This is why public health officials remain unfazed by all the hoopla happening now. None of it is new. You’re not unique ‘freedom fighters’ who just ‘woke up’ to the ‘tyranny’ of public health measures, valiantly defending peoples’ ‘freedoms’. You’re just the folks from a point in time in history that decided to make life hard for everyone because you didn’t know what else to do during a pandemic. Like all the other people who did the exact same thing throughout history when confronted with the same.
As the saying goes, those ignorant of history are doomed to repeat it.
So, all of that said, make good choices. After all, isn’t life difficult enough?
Till next time, Folks! Be kind to one another!
For more reading on this, or to check out the sources I used to write this, here’s a list:
Conti AA. Quarantine Through History. International Encyclopedia of Public Health. 2008;454-462. doi:10.1016/B978-012373960-5.00380-4
Drews, K. (2013). A Brief History of Quarantine. The Virginia Tech Undergraduate Historical Review, 2. DOI: http://doi.org/10.21061/vtuhr.v2i0.16
Hillel Shuval, Badri Fattal, 15 - Control of pathogenic microorganisms in wastewater recycling and reuse in agriculture, Editor(s): Duncan Mara, Nigel Horan, Handbook of Water and Wastewater Microbiology, Academic Press, 2003, Pages 241-262, ISBN 9780124701007, https://doi.org/10.1016/B978-012470100-7/50016-9.
Institute of Medicine (US) Committee for the Study of the Future of Public Health. The Future of Public Health. Washington (DC): National Academies Press (US); 1988. 3, A History of the Public Health System. Available from: https://www.ncbi.nlm.nih.gov/books/NBK218224
Tognotti E. Lessons from the history of quarantine, from plague to influenza A. Emerg Infect Dis. 2013;19(2):254-259. doi:10.3201/eid1902.120312
Tulchinsky TH, Varavikova EA. A History of Public Health. The New Public Health. 2014;1-42. doi:10.1016/B978-0-12-415766-8.00001-X
This is Public Health, A Canadian History, interactive resource: cpha100.ca