Abu Dhabi, UAEFriday 3 July 2020

CORONAVIRUS

What quarantine was like in 1947: the fascinating story of the Middle East's cholera outbreak

The Trucial States' brush with the epidemic laid the foundations of much of our healthcare systems, and influenced the UAE's coronavirus response

The coronavirus pandemic may seem to be on a scale the Middle East has not seen before – and in many ways, it is.

But the world and the region is no stranger to outbreaks of disease.

In fact, the UAE's first brush with a potential large-scale epidemic may have been in 1947, the year cholera tore through Egypt, Iraq and Syria, and arrived in Dubai, then part of the Trucial States, which was under British rule at the time.

The disease caused panic among the British, who put people into quarantine, grounded flights, sent for huge stocks of vaccines from London and went door-to-door to ensure people were inoculated against infection.

Because of the 1947 scare, the country was well equipped to address the outbreak

Sara Farhan, historian

It was this outbreak that caused some of the first examples of large-scale border closures, travel restrictions, quarantine, contact tracing and flight groundings.

And while the two diseases are very different (cholera is a bacterial infection that is transmitted via excrement in water, and Covid-19 is a respiratory illness caused by a virus, and is transmitted by infected people or surfaces), the method in which outbreaks were dealt with 73 years ago provide a fascinating insight into how our healthcare has both developed, and remained the same.

The National has studied the 228-page report, A Outbreak of Cholera in the Trucial Coast, held by the British Library, and worked with a historian to determine how this could have informed the response to the 2020 pandemic.

"This is a lesson of how early state mitigation can prevent an outbreak," Sara Farhan, assistant professor of history, and medicine historian, at the American University of Sharjah, says.

"The scare prompted local officials to embark on an inoculation campaign, invest in advancing the health apparatus of their sheikhdoms, and ensure that should an outbreak occur, they would be adequately prepared to address it promptly and swiftly."

The spread of disease through trade

In September 1947, Egypt was experiencing a cholera outbreak that had yielded 20,804 cases and 10,277 deaths – a staggering 50 per cent mortality rate. The epidemic went on to reach Syria, and neighbouring countries such as Iraq and Palestine. August 1947 was also when India was partitioned; during which, a devastating cholera outbreak killed millions across India and Pakistan.

The El-Mursi Abul Abbas Mosque in the Anfoushi district of Alexandria, Egypt, 1944. The mosque was built in 1775. (Photo by G. Packham/Fox Photos/Hulton Archive/Getty Images)
Egypt's El-Mursi Abul Abbas Mosque in the Anfoushi district of Alexandria, pictured in 1944. Getty

This was all of great concern to the British, who wielded great influence over Egypt through its proprietorship of the Suez Canal, and were wary of the country's proximity to the Arabian Gulf and its trade routes. They feared that an outbreak in the Trucial States was only a matter of time.

"In the aftermath of the Second World War, British troops were in India, Iraq, Egypt, and the Trucial States to name a few. The connection between these areas facilitated a marvellous exchange of vibrant culture, people and ideas. These interactions also facilitated the communication of diseases," Farhan says.

"Cholera outbreaks emerged in the 19th century and quickly reached pandemic status through increased communication and improved transportation."

Much the same as Covid-19, cholera spread quickly through trade and ports, and caused economic and agricultural devastation.

Patient zero and contact tracing in the 1940s

The first case of cholera arrived in Dubai on November 4, 1947. In a letter, the residency agent of Sharjah informed the political agent in Bahrain of a case of cholera and two suspected deaths from the disease.

Immediately, demands were made to find out the patient's movements for the past 10 days, as well as their contacts. It was then requested that anyone the cholera patients had come into contact with, as well as the patient themselves, be isolated.

So, could this have been a very early form of contact tracing?

Perhaps, says Farhan. But it was also an instant and aggressive measure by the Brits to stymie the disease, as they "anticipated an outbreak similar to that reported in Egypt".

In Dubai, the report of the infected case outlined a servant dying after vomiting and purging. "He looked dried up," it says.

People who had come into contact with the deceased were moved to another house on the outskirts of the city.

"Under the circumstances, Dubai and Sharjah must be considered as infected localities and necessary quarantine restrictions imposed," the report says. "Till the contrary is proved by the non occurrence of further cases for a period of at least three weeks."

The next day, a letter to Bahrain outlined the fact the Trucial States had "limited resources to counter the outbreak" and a request was made for quarantine medical officer, Captain MLA Steele, to be permitted to fly to Sharjah by RAF plane "immediately".

In the following days, 20,000 cases of the cholera vaccine were sent for from Sharjah to London and a request was made that "inoculation is energetically carried out".

Quarantine worked much the same 73 years ago

Quarantine efforts and border closures across the Arabian Gulf came quickly afterwards.

On November 6, Iraq closed its borders to travellers from India, Pakistan and the Arabian Gulf.

The souk at Kuwait, Kuwait, circa 1940.  (Photo by Marian O'Connor/Royal Geographical Society via Getty Images)
Kuwait, circa 1940. Getty

In Kuwait, travellers arriving from Egypt were quarantined for six days.

"The main reason for the isolation of Kuwait and Bahrain from Iraq is fear that travellers may leak through from Egypt without undergoing quarantine," a letter dated November 14, says.

"A case of America Oil Company employees who went to Kuwait from Egypt by air, stayed there, 'passed a day or two' and then flew on to Baghdad where they did not reveal they had recently been in Egypt and stayed at a hotel in quarantine."

Later, as guidelines were updated, the residency agent in Sharjah was instructed to stop all passenger traffic by dhows or steamer heading to Bahrain. Boats from Karachi and Bombay were ordered to have cholera inoculation certificates.

The scare led to the inoculation of a quarter of the populations of Sharjah and Dubai – a cost-effective measure to dealing with the alternative – a devastating cholera outbreak

Other travellers were warned they may suffer four days' delay "due to steamers being placed in quarantine at the entrance of the [Iraqi] port".

Cholera inoculation certificates were later introduced as mandatory for other countries.

"The policies were indicative that local officials were specifically isolating areas where there was a cholera outbreak – Syria, Pakistan, India and Iraq," Farhan says.

And even 1947 wasn't immune from misinformation. As we are experiencing on social media amid the coronavirus outbreak, it isn't always easy to tell fact from fiction.

Fake news and conflicting reports in 1947

On November 8, Bahrain's political agent sent a seemingly contradictory report to all agents in the area, saying there was no cholera outbreak in Dubai as there was "bacteriological proof lacking".

"As a precaution Dubai is being treated as cholera infected and preventative measures are being taken," the same report says.

"The only means at our disposal of suppressing the epidemic is preventative inoculation and to try his best to inoculate every resident in Dubai."

Doctors then went door-to-door vaccinating the city's residents.

But to confuse matters further, at the same time, authorities in Dubai and in Bahrain were alerted to a report by the BBC that had "specifically mentioned Dubai as the port at which cholera had broken out". Questions abounded as to where the erroneous information had come from.

A report at the time from Sharjah to Bahrain reads: "The news about cholera was not sent by anyone from the Trucial Coast to BBC. On the 4th of November, the Officer Commanding, Royal Air Force, Sharjah, wired to Royal Air Force Headquarters informing them of the outbreak of cholera in Dubai as reported to him by the Medical Officer and it is very likely that the Royal Air Force or others passed on the information to BBC."

Farhan says this announcement "puzzled local health officials as only three cases were recorded and a handful of suspected cases".

"Nonetheless, local officials quickly adopted the policies of neighbouring countries. Sharjah grounded the Royal Air Force, and limited entry into the country."

Daily case counts were also enforced, much the same as they are today.

This came after a dressing down for the Bahrain resident from his counterpart in Kuwait on November 14 for his tardiness: "A report three days old is useless. I require an up-to-date daily telegraph report until Trucial Coast is officially declared free from infection."

Case counts were then sent each day.

Farhan says "it really forced local authorities to adopt preventive measures".

"The scare led to the inoculation of a quarter of the populations of Sharjah and Dubai – a cost-effective measure to dealing with the alternative – a devastating cholera outbreak."

How an epidemic was curbed

Subsequent daily reports from Sharjah to Bahrain outlined zero new cases until November 21, two weeks after the first case.

That was the day Iraq relaxed its quarantine restrictions and resumed some flights, except its Cairo to Baghdad route.

Dhows from Bahrain, Kuwait and the Arabian Gulf were once more allowed to enter Iraq's Shatt Al Arab port – after a traveller underwent one stool (faecal) examination. This was also on the understanding crew and passengers had been twice inoculated against cholera.

After another week of zero cases, as promised, Dubai relaxed its quarantine restrictions and Iraq relaxed all border restrictions.

An archival photo showing the Sharjah RAF airbase in the 1960s. Courtesy Taff John
An archival photo showing the Sharjah RAF airbase in the 1960s. Courtesy Taff John

However, people coming from Egypt were still required to undergo a stool examination and quarantine for six days.

In the end, the 1947 cholera outbreak in the Trucial States amounted to 12 suspected and three confirmed cases.

So how was a more sinister outbreak avoided? After all, this occurred a year before the World Health Organisation was formally founded, which put in place a more streamlined way of combatting and tracking infectious diseases.

Shortly after the inauguration of the WHO, all participating countries were required to report disease outbreaks, which were later published in the Weekly Epidemiological Record.

And it wasn't for another year, on January 1, 1949, that streamlined instructions for travellers arriving into the Trucial Coast were laid out.

"The scare in the Trucial States led to the delivery of a surplus of anti-cholera remedies as well as the inoculation of a quarter of the local population. It also led to the expansion of the public health apparatus," Farhan says.

"By 1949, the Trucial States began to take serious measures to advance its health apparatus. Hospitals, clinics, as well as vaccination policies and health protocols were implemented."

And the healthcare system in the region continued to be tested. Also in January 1949, Bahrain experienced a smallpox outbreak, which resulted in another contact tracing and quarantine drive.

What parallels can we draw to our response to Covid-19?

So, could the 1947 cholera outbreak have informed our response to 2020's Covid-19 pandemic? It certainly laid the foundations for our healthcare system and large-scale disease outbreak response.

And lessons learnt in 1947 certainly stymied a pandemic situation 23 years later.

Farhan points to August 1970, when another cholera outbreak reached the Trucial States.

"Because of the 1947 scare, the country was well equipped to address the outbreak," she says.

Much has changed in the past 73 years. The UAE's healthcare system has rapidly developed and modernised. But our basic response remains the same. Perhaps, 70 years from now, we will be looking back to the Covid-19 response as the event that shaped our response to the next pandemic. Because there will be another one.

Updated: May 31, 2020 03:58 PM

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