Quarantine at the Eastern gate. The Italian Perspective in Alexandria, 1899-1905

At the end of the nineteenth century, Egypt was probably the main gate to European colonialism, and an important checkpoint for plague and cholera. In order to secure public health in the Mediterranean, European powers established the Conseil Sanitaire Maritime et Quarantenaire in Alexandria. This international body soon became an arena where national interests competed with public health. Archival documents from the Italian delegation show that this was also the case for the newly formed country, aspiring at playing a role in European imperialism. However, Italian geographical advantage was jeopardized by sanitary concerns: a difficult balance between public health and international diplomacy had to be maintained in front of infectious diseases travelling through Suez.


Introduction
The introduction of steam-powered ships in the second half of the 19 th century, as well as the opening of the Suez Canal, increased the importance of the Red Sea route, making Egypt pivotal in the prevention of epidemics in the Mediterranean area. The Conseil Maritime, Sanitaire et Quarantenaire, based in Alexandria, was an international council where European delegates sat together with local representatives, and supervised the prevention and management of epidemics in Egypt, with a special focus on plague and cholera. These diseases periodically arrived at the Eastern and Southern shores of the Mediterranean with the thousands of pilgrims that every year travelled to Mecca and Medina for the Hajj, the visit to the holy sites of Islam that every Muslim should do at least once in a lifetime. The control of caravans crossing the Arabian Peninsula and of ships sailing towards the Mediterranean through the Red Sea was of paramount importance for the control of epidemics and the protection of Europe. At the same time, to European powers with colonies in South-East Asia and East Africa, the free circulation of people and goods through Suez represented a vital interest.
In the last two decades of the century, in the recently created Kingdom of Italy a series of interests of the middle and the upper classes converged in pushing the country to join the other European powers in the colonial expansion towards Africa. As Antonio Gramsci pointed out, it was during the governments of Francesco Crispi that colonial expansion was boosted. According to Gramsci Crispi was obsessed to maintain the recently acquired national unity, and in order to contrast the separatists in the former Kingdom of the Two Sicilies, denied any agrarian reform. A Sicilian himself, Crispi wanted indeed to secure the loyalty of the Sicilian landowners to the Kingdom of Italy. Thus, he diverted the claim for land of the poorest peasants especially in Southern Italy towards Africa [1]. With the acquisition of the Assab bay in 1882 the Italian colonial expansion focused on the Horn of Africa and Egypt became therefore crucial. Italy, however, could not play the same role as France, Britain, Germany, or Russia did. Alliances had been vital for the House of Savoia to unify the Peninsula. The Kingdom of Sardinia had been able to create a nation-state by coupling its interests with those of major powers and by establishing different alliances at different times. Alliances were still needed to protect national interests -trade and public health -and sometimes the specific advantages sought by Italy in Alexandria were at odds with other diplomatic negotiations. Historians of medicine are inclined to look for uniform national approaches in facing epidemic diseases. Baldwin has argued that in the nineteenth century the states started diverging in their prophylactic approaches, ranging from the British radical sanitationism to the Prussian strict quarantinism [2]. In Baldwin's view, the British aimed to avoid restrictions on trade from the Suez Canal, whereas the Austrians, the French, the Germans, and the Italians were concerned that epidemics could reach Europe [2]. In the following sections we will see that the picture was much more articulated. We will show some examples of how different interests prevailed at different times, creating shifting balances and alliances. In this context, the focus of the biomedical actors on science-based public health appears to contrast with that of the political actors, who saw it more as an instrument in a global game, rather than as a goal to be pursued. The separation between the two kinds of actors was not so strict.
This short text focuses on the years between the plague epidemic of 1899 and the aftermath of the cholera epidemic of 1902. These two epidemics were the first ones to be fought with at least some knowledge of the microbiological agents of the diseases, which had helped to inform the International Sanitary Convention adopted in Venice in 1897. This agreement, while providing for physical-chemical disinfection and the active control of rat populations, still relied largely on the quarantine system. The Convention also regulated the sanitary control of the annual Hajj, creating several quarantine stations for ships and pilgrims at the South-East border of the Mediterranean area. In 1903, after the cholera epidemic, a new International Sanitary Conference was held in Paris, and an updated convention was signed. At the same time, the Italian colonial expansion came to a halt, as a consequence of the Adowa defeat in 1896.

Italy, epidemics and the sanitary council of Alexandria
The unification of Italy had been promoted by the British to contrast both the French and the Russians in the Mediterranean. Any move in the Horn of Africa by the Italians was negotiated with the British until the invasion of Ethiopia in 1935. At the same time as early as 1882, Italy joined the central Empires in the defensive Triple Alliance, which protected its northern borders. Peter Baldwin argues that Italy slowly abandoned its initial quarantinism for a more modern sanitationist approach after the failure in contrasting the 1884 epidemic (Baldwin, Snowden). Mark Harrison in his historical reconstruction of sanitary regulations in the Mediterranean ranked Italy among "Britain's chief supporters". As we shall see, on the contrary, on sanitary matter the interest of Italy often clashed with those of Britain. In the last years of the 19 th century, British authorities pushed to avoid restriction on trade from India and regularly complained about the severity of quarantine regulations in Italian ports. In 1899, after plague struck Egypt, Italian port authorities imposed restrictions on incoming ships -including the long-range steamers sailing from India. The restrictions affected both people and goods, including the postal correspondence embarked during the stop-over in Port Said on the Red Sea. Brindisi harbor was the terminus for the Peninsular and Oriental Steam Navigation Company (P&O) ships calling from Bombay, so the Brindisi port authority was SHS Web of Conferences 136, 0 0 (2022) MATTERS OF CONTAINMENT 2020 https://doi.org/10.1051/shsconf/202213602005 20 5 repeatedly criticized by the British that year because of the strict regulations it imposed upon ships. International conventions stated, for example, that correspondence from plaguestricken areas should be transported within tarry bags: as in Port Said this was not the case, P&O ships were subject to restrictions. Italian health officers were also authorized to board on the steamers sailing to and from Egypt.
The British representative complained about these lengthy procedures that disrupted the service, but the inability to control what happened in the Red Sea stopovers resulted in a threat to Italian public health, hence the adoption of sanitary restrictions. The incident would soon be followed by commercial retaliation. A year later, while in negotiations with the Italian government on the use of the new railway terminus in Brindisi, the Agent of the P&O navigation company duly remembered to the Italian Ministry of Interior that: "During the last epidemic, a quarantine of ten days was imposed on all arrivals at Italian Ports from Egypt with the result that the large passenger traffic from that country, as well as that from the Far East, was diverted to Marseille, where solely a medical inspection was imposed". [3] In 1899 and 1900, with plague present in Egypt [4], restrictions based upon the 1897 international convention were supposed to be applied throughout the Mediterranean. Italian authorities found themselves in the worst possible situation. Due to geographical proximity, southern Italy ports had no option but to enforce emergency measures. Meanwhile, according to a report from Ministry of Interior to the Ministry of Foreign Affairs [5], France thought to exploit the longer distance of Marseille from Egypt to actively refuse any effort to impose stricter regulations to vessels from that country. The Rules approved by the Conseil in June 1897 in fact established that a vessel coming from a port where a case of infection was found had to wait ten days before entering a European port [6]. Thus, vessels could disembark in Marseille without any quarantine. It was, of course, an ungrounded belief, rooted in political and trade reasons. In 1894 Yersin had proved that plague was a contagious disease and that rats were its most likely carrier. During the plague epidemic in Hong Kong Yersin had found plague bacilli 4-5 cm deep in the soil of houses where infected people lived [7]. It is worth noting that for cholera the French had already abandoned rigid quarantinism and rather relied on sanitation measures (cleansing, inspection of passengers, disinfection and isolation of the ill) [2]. The Egyptian government had not officially reported the case of plague, and the author of the report suspected that it was due to the pressure of the French delegates on the Egyptians. While the Venice Convention provided the Egyptian Government with a relative freedom for establishing restrictions against European ships, Italy failed to convince other European powers in Alexandria to support reciprocity in this regard. All the representatives at the Conseil Sanitaire (except for the British delegate) agreed on the need to impose disinfection and a strict medical exam on ships leaving Egyptian ports, but commercial interests prevailed in the end. Italy brought up the case to the French Embassy in Rome and to the French Government through the Italian Ambassador in Paris, failing as well to impose its views.
The Conseil often was in a difficult situation. In the spring of 1896 suspected cases of cholera had been found in deaths in El Tor. The clinical observations and the epidemiological data did not confirm it, but the microbiological analysis did. The Conseil did not take, therefore, extraordinary, measures. Writing to the Consul in Alexandria, the Italian delegate, Dr. Torella, remembered that the Conseil was in an embarrassing situation, because of lack of the necessary means to enforce extraordinary measures. Torella and the city's Municipal Sanitary Inspector Felix Gotschlich, however, remembered that alternative forms of the vibrio -already observed in 1895 -were causing the epidemic, with individuals carrying the germ showing no clinical symptoms (his research eventually proved right in 1905, see below) and pushed for the Conseil to take severe measures. The French delegate, Legrand, who was SHS Web of Conferences 136, 0 0 (2022) MATTERS OF CONTAINMENT 2020 https://doi.org/10.1051/shsconf/202213602005 20 5 personally persuaded that no measure had to be taken, called for a meeting and announced that the French government wanted to enforce extraordinary measures, which in the end were not approved [8].
Conflict within the Conseil broke out again when cholera ravaged Egypt in 1902 (in less than six months, the disease killed almost 35,000 people, according to official figures). Gotschlich was targeted with heavy criticism by several European delegates, including Gotschlich's fellow German national von Humboldt. The accusations focused on the poor collection and reporting of cases in Alexandria and elsewhere, with the Egyptian Board of Health failing to communicate properly with the Conseil. The British delegate was silent about this, and teamed with the Russian delegate, during the epidemic and its aftermath, to relax quarantine regulations. The French delegate criticized the local government acting under the so-called "veiled protectorate" by Great Britain. The British President of the Conseil was obviously not so explicit against the Egyptian government, but repeatedly expressed his doubts about Gotschlich's microbiological approach. The other European powers within the council were accused of being overprotective. Although the last cases of cholera were diagnosed in Hedjaz and in Yemen in November 1902, restrictive measures were kept. When in January 1903 the Ottoman delegate requested their termination, a new suspect case -later confirmed but with some uncertainty -emerged. At a meeting on January 25, 1903, they were confirmed, and on 7 February a new meeting was opened by a long lamentation by the Ottoman delegate. [9] After criticizing the British-Egyptian government, the other European powers went on to show the weakness of the Ottoman Empire, unable to control Muslim pilgrims in the large Hedjaz area and to implement basic sanitation programs in Mecca, Medina and Jeddah.
In this context, Gotschlich's emphasis on alternative forms of the vibrio -less virulent, but still able to create epidemics -may be seen as a defensive strategy for Egypt. Pilgrims travelling through El Tor quarantine station and respecting all the regulations imposed by the European-controlled Conseil, could still trigger cholera epidemics when entering the country. The British representative, Dr. Ruffer, while criticizing his excess of faith in microbiology, was most likely happy with Gotschlich's approach. On the one hand, it supported the action of the British government in Egypt, and, on the other hand, it showed that traditional methods of protection from epidemics were of no use if the laboratory could not reliably identify the true cholera germ. In this way, Ruffer could safely keep his loyalty to the British sanitationfirst tradition.
Political convenience drove diplomatic efforts and the conduct of Italian representatives in Alexandria and elsewhere. If quarantine was to be strictly enforced on foreign ships, especially in Italian ports, a more liberal approach was adopted when Italian vessels were involved in the contagion. Shortly before the International Sanitary Conference held in Paris in 1903, for example, an Italian diplomatic note discussed the possibility of allowing free pratique in a port if a ship got infected by an epidemic active in the harbor city. A similar case had happened to an Italian vessel in Alexandria, and the document raised the possibility of presenting the case to the Paris conference, since the 1897 Venice Convention did not cover this category of events. The author of the note was thinking about the possibility of moving goods to and from the moored infected ship -while tending to the diseased on board the ship or in the city hospital. Free pratique should not be revoked, according to the note, because it may cause severe damage to trade. Avoiding restrictions on the ship was thus considered "as the most reasonable and the best intended practice, regarding the sanitary aspect as well as the commercial interests". [10] Discussions about the changes to be made to the Venice Convention also involved the provision for the duration of isolation in case of infection on board. Navigation companies were pushing the Conseil in Alexandria and its twin institution in Constantinople to reduce the number of days following the departure of ships from an infected port that were required SHS Web of Conferences 136, 0 0 (2022) MATTERS OF CONTAINMENT 2020 https://doi.org/10.1051/shsconf/202213602005 20 5 to consider that ship again as "clean". The Conseil refused to do so, and particularly the Italian delegate, for whom such reduction would have been a clear breach in the Venice Convention. [11] Furthermore, the Italian representative argued that regulation of such a matter was not in the hands of the Conseil, nor should be decided according to the wishful thinking of the navigation companies: it was the domain of science, and, as such, the decision was up to scientists. However, a report most probably written by Italy's Director General of Public Health, Rocco Santoliquido, in 1903, remarked that: "Within the [Alexandria] Council, a lot of politics is practiced, and much less public health". According to the perception of the Italian physician and politician, the Council was used as an instrument for the political and commercial interests of Great Britain, for trying to loosen the constraints imposed by the international conventions (and particularly that of 1897): "Several variations and innovation proposals made to the Council were not motivated by sanitary reasons, and they were the product of the stubborn efforts by some Power (the Great Britain) to mortify at their own pleasure, and in an extremely important area (the Suez Canal), the dispositions of the Venice Convention, using the Quarantine Council as an instrument to this aim". [12] In fact, Ruffer had not a high opinion of Venice convention. In a paper presented at the London Epidemiological Society in 1899, he argued that "the united wisdom of Europe sitting at Venice has produced a set of regulations in which the same paragraph orders two contradictory measures" and concluded: "I am of opinion that all measures for ships going through the Canal in quarantine should be abolished". [9] [13] The Italians had to remember what happened in 1884, when in spite of the enforcement of rigid quarantines and sanitary cordons in Italy cholera had reached Naples [14]. They were aware that cholera had to be stopped in the Middle East and that the key to its control was the access to clean and unpolluted water. Writing to the Consul of Italy, the Italian delegate in Alexandria, Dr. Andrea Torella, remembered that doctors were following the pilgrims and monitoring the situations in Mecca and Medina [15]. Thus, the Italians welcomed better control in the Middle East, where the Ottoman Empire was failing to implement appropriate actions. According to an Italian report regarding the Sanitary Council of Constantinople (probably written in 1903), the main cause of cholera for the Muslim pilgrims was the polluted water in the holy sites. Every attempt by the Ottoman government to supply Jeddah and Mecca with clean water was thwarted by local populations selling precious water from local wells and reservoirs. The report complained that "it is intolerable that a continuous threat looms every year on Europe's public health, solely because of the inability to face the perturbation of the economy of a limited semi-barbarian population". [16] Furthermore, Italian diplomats in Egypt were convinced of the need to detach the Conseil from control duties over the Egyptian sanitary administration. In their opinion, the separation would have implied a substantial economic advantage -the Conseil was quite expensive to maintain -and it would have put an end to the rivalry between European countries, so that "competition is replaced by nationality in the choice of officers". [17] The attitude of the Italian delegate, Dr. Andrea Torella, was no exception, though. In 1905, the Conseil printed a report by Felix Gotschlich calling for stricter microbiological surveillance, after he successfully isolated what is currently known as the El Tor biotype of Vibrio cholerae. The Pfeiffer phenomenon as well as serum reaction proved that the isolated microorganism behaved as a true cholera vibrio in the laboratory but did not cause clinical symptoms. As a result, otherwise healthy individuals could be considered "porteurs du cholera" (asymptomatic carriers). [18] Gotschlich's conclusion was the target of harsh criticism by several delegates in the Conseil, but the Italian delegate was particularly upset because of national pride. Gotschlich was in fact appointed by Ruffer as the head of the scientific mission to investigate cholera in El Tor quarantine station, while the Italian SHS Web of Conferences 136, 0 0 (2022) MATTERS OF CONTAINMENT 2020 https://doi.org/10.1051/shsconf/202213602005 20 5 Giovanni Zirolia was sent to the same encampment for investigating the less fashionable dysentery. Despite the Italian attack, Ruffer showed no mercy towards Gotschlich's findings. In a report published in 1907 in the British Medical Journal, the British representative stated that "epidemiologically there is no evidence to show that the vibrios found at El Tor were true cholera vibrios". [19] Furthermore, he repeatedly underlined that alternative forms of the vibrio had been previously reported -privately, though -in 1896 by the Italian doctor Giovanni Galvani. [20] In this case, dr. Torella proved more interested in defending field interests -the career of dr. Zirolia -than public health.