DUBROVNIK QUARANTINE ESCMID-What Canonline We Learn Lecture from the Library History ESCMID Mobility and Infection, 16-17 October 2014 Ljiljana Betica Radić

Presentation outline

• Introduction • Public health measures in old Dubrovnik ©• byDubrovnik author quarantine ESCMID Online• Major Lecture ethical Library issues Presentation outline

• Introduction • Public health measures in old Dubrovnik ©• Dubrovnikby author quarantine ESCMID Online• Major Lecture ethical Library issues • Each culture has its • We live in the age of predominant disease cancer, cardiovascular (Cipola, Grmek) diseases and psychotic disorders ... , but also in • The early Middle Ages the age of fear of struggled with leprosy bioterrorism and and later, plague emerging and prevailed © by authorreemerging infections diseases

•ESCMID The Industrial RevolutionOnline Lecture Library was the age of tuberculosis

20.07.1969 The crew of Apollo 11 in quarantine 21days after returning to Earth, visited by Richard Nixon

• This practice continued for two more Apollo missions, 12 and 14, • before the Moon was proven to be barren of life and the quarantine process dropped

• Cholera • Yellow fever • Diphtheria • Viral hemorrhagic • Infectious fevers tuberculosis • Severe acute • Plague respiratory • Smallpox © by authorsyndromes • Flu that can cause a ESCMID Online Lecturepandemic Library

Twelve Diseases That Changed Our World Irwin Sherman, professor emeritus of biology describes in his book

smallpox, tuberculosis, syphilis, AIDS, influenza, plague, cholera, malaria, yellow fever, two noninfectious diseases (hemophilia and ©porphyria by author), and the plant disease behind the Irish Potato Famine— haveESCMID altered historyOnline Lecture Library by Irwin Sherman It's often taught that the course of history hinges upon great battles Time line

• The practice of quarantine—the separation of the diseased from the healthy—has been around a long time

• As early as the writing of the Old Testament, rules existed for© isolating by author lepers ESCMID Online Lecture Library • It wasn't until the Black Death of the 14th • In the mid-20th century, the advent of antibiotics and routine vaccinations made large-scale quarantines a thing of the past

but • Today bioterrorism© by and author newly emergent diseases threaten to restore the age-old ESCMIDcustom Online Lecture Library

After the first outbreaks of plague in 1348, governments in some cities legislated measures according to the classical theories measures according to the classical theories

• They tried to clean the • They ordered the putrefying air by setting sprinkling of houses fires with sweet-smelling with vinegar and rose herbs odour water and enforced more rigorous measures of cleanliness (removal of © by authordecaying animals and of human wastes) ESCMID Online Lecture Library

Dr. Zlata Blažina Tomić, McGill University, Toronto,1981 and 2007 • These measures helped in improving the general sanitary conditions, in the cities, but they did little for the prevention of plague epidemics

• Other governments tried to isolate the sick from the healthy© on by the author basis of contagion ESCMID Online Lecture Library

Dr. Zlata Blažina Tomić, McGill University, Toronto,1981 and 2007 Presentation outline

• Introduction • Public health measures in old Dubrovnik ©• Dubrovnikby author quarantine ESCMID Online• Major Lecture ethical Library issues • The citizens of Dubrovnik were aware of the significance of the latest public health and hygienic achievements for the development of their city

• Dubrovnik has,© everby author since its foundation, been connected with ESCMIDmedicine Online Lecture Library

Slobodan Lang & Ana Borovečki studied public health measures in old Dubrovnik and published A GUIDE TO THE HISTORY OF MEDICINE IN OLD DUBROVNIK, 2007

The beginnings of medicine in Dubrovnik

Rector’s palace- on the capital there is a figure of Aesculapius who has a long beard and a typical hat. He welcomes the patients in his alchemy laboratory. His servant (a citizen) leads © by authorhis patient (a peasant) who has in his hands a chicken ESCMID Online Lecture(the Library traditional fee of physicians) to Aesculapius.

• The traditional medicine was mainly based on herbal medicine

• The help of the saints was also often sought in the case of an illness. The votive tradition and the cult of St. Blaise, a medicine man himself, are just a few examples of this© by author religious medical tradition

–ESCMID The church of Saint Blaise Online is dedicated toLecture Library the patron of Dubrovnik Saint Blaise. His blessing is considered to have protective powers against the illness of the throat basic principles

1. Freedom 2. Patriotism 3. Justice © by author

ESCMID Online Lecture Library

The respect for human dignity and ethical awareness were always of a high standard in old Dubrovnik

Lovrijenac fortress Old inscriptions on fortresses and palaces 1. FREEDOM

• ESCMIDOver the entrance Online to Lovrijenac Lecture fortress Libraryan ancient inscription reads as follows: NON BENE PRO TOTO LIBERTAS VENDITUR AURO. In translation: Freedom is not sold for all the gold in the world

RECTOR’S PALACE 2. PATRIOTISM

© by author ESCMID Online Lecture Library Inscription at the entrace to a Small Council - RECTOR’S PALACE OBLITI PRIVATORUM PUBLICA CURATE (Forgetting your private business, concern yourselves with public affairs)

SPONZA PALACE (Dubrovnik’s archive) 3. JUSTICE

The fact that the city measures were true is captured on© the by inscription author on the arch: FALLERE NOSTRA VETANT; ET FALLI PONDERA: MEQUE PONDERO ESCMID CVM MERCES: Online PONDERAT Lecture IPSE Library DEVS (Our weights do not permit cheating or being cheated. When I measure goods the Lord measures with me)

© by author ESCMID Online Lecture Library Dubrovnik’s archive is considered to be one of the best-preserved archives for the research of all aspects of life in a city including the research of its public health conditions

The statute of the city of Dubrovnik from 1272 is one of the oldest Croatian legal documents Although its main significance is connected with the Croatian legal history one can find a number of regulations © by authorconcerning medicine and the quality of life ESCMID Online Lectureof the Library population of Dubrovnik

What we know from these documents

• In 1336 people were forbidden to keep animals in the city

• In 1407 a regulation was introduced that all the streets in Dubrovnik should be paved and in 1415 the first city street- sweepers were introduced

• From 1407 to 1436 a sewage system was introduced © by author

• In 1436 a 20km water system supplyESCMID was constructed Online Lecture Library

The Republic of Dubrovnik was very inventive regarding laws and institutions that were developed very early

• In 1301 Medical service was introduced

• In 1317 The first pharmacy (still working) was opened

• In 1347 The Asylum for Elderly people © by author • In 1418 Slave trading was abolished ESCMID Online Lecture Library • In 1432 The orphanage was opened Presentation outline

• Introduction • Public health measures in old Dubrovnik ©• Dubrovnikby author quarantine ESCMID Online• Major Lecture ethical Library issues © by author • As a city open to travellers, Dubrovnik faced continuous exposure to epidemics of contagious diseases ESCMID Online Lecture Library • The leper house in Dubrovnik, mentioned in the city’s statute of 1272, was provided outside the walls for the sick

• The most important goal was to prevent the © by author spread of the plague in Dubrovnik without impedingESCMID the free Online trade Lecture Library vital for the city

(Belitza, Ferencic, Blazina Tomic)

High mortality • Ragusans recognized empiricaly the nature of plague in its pneumonic and bubonic forms, and were above all, aware of its extreme contagiousness

• All the physicians and surgeons present in Dubrovnik in 1348 died during the epidemic

• They seemed to know that medical doctrine was useless © by author

ESCMID Online Lecture Library

(Belitza, Ferencic, Blazina Tomic)

• On July 27 in the year 1377, the Great Council, with 47 members present, has decided by 34 votes that those who, come from plague-infested' areas', will not be admitted to Ragusa (Dubrovnik) or its surroundings unless they previously spend a month on the island of Mrkan or in Cavtat for the purpose of disinfection © by author ESCMID Online Lecture Library

Dr. Zlata Blažina Tomić, McGill University, Toronto,1981 and 2007 State Archives in Dubrovnik, (Sponza Palace)

The text of this decree can be seen in Liber viridis (c.49 fol. 78) under the title:

“Veniens de locis pestiferis non intret Ragusinum vel districtum” (“It is forbidden to newcomers from the infested regions© toby enter author Dubrovnik and its surroundings”) ESCMID Online Lecture Library (QUARANTINE: Marseille 1383, Venetia 1403, Pisa 1464, Genova 1467, Mallorca 1471) © by author ESCMID Online Lecture Library

Liber viridis, cap. 49, fol. 78, Regulation on the introduction of quarantine in Dubrovnik from the year 1377, (State Archives in Dubrovnik, Sponza Palace)

• Before entering the city the newcomers had to spend 30 days in a special place to see whether they would develop the symptoms of the disease

• The one who was found responsible for spreading the plague to the city was punished even with© the by author death sentence ESCMID Online Lecture Library • The quarantine was later prolonged to 40 days © by author ESCMID Online Lecture Library • The quarantine was first situated near Cavtat on the islands of Mrkan, Bobara and Supetar In 1430 the quarantine was moved to Danče- Later it was moved to the island of Lokrum across the old Dubrovnik harbour

Lokrum

ESCMID Online Lecture Library Danče In 1590 the quarantine was moved to the place near the east city gates where it remains today 18th- century picture of Dubrovnik harbour showing the quarantine of Dubrovnik

• ESCMIDComplex of various Online buildings called Lecture “lazareti” represents Library the quarantine of Dubrovnik • The truth about the establishment of the quarantine in Dubrovnik took a long time to be discovered because of omissions in the medico-historical literature in the 19th century

• Lechner, writing© in 1884,by author and Gelchich, in 1891 included the text "of the Ragusan quarantine ESCMIDordinance of Online 1377 in their Lecture publications Library which meant that its existence could no longer be overlooked

Dr. Zlata Blažina Tomić, McGill University, Toronto,1981 and 2007

• Special tribute should be paid to Grmek, who has been examining Ragusan quarantine regulations for years and whose latest essay on this subject dispelled previous misconceptions in medico-historical literature © by author

ESCMIDGrmek MD. The concept Online of infection Lecture in antiquity and theLibrary Middle Ages, the old social measures against contagious diseases and the foundation of the first quarantine in Dubrovnik (1377) [in French] Rad Jugoslavenske Akademije. 1980;384:9–55

studied public health regulations in old Dubrovnik and published:

HISTORICAL DEVELOPMENT OF THE LAWS AND REGULATIONS CONCERNING PUBLIC HEALTH IN DUBROVNIK (RAGUSA) FROM THE 13TH - 15TH CENTURY

The health officers- Cazamorti

• As early as 1390, after the Ragusan councils added other health regulations to the quarantine, the health office was established to ensure their application

• The health officers- Cazamorti, chosen exclusively among the aristocrats, could not decline this burdensome and dangerous© by author duty that they had to perform for a whole year if they survived that long ESCMID Online Lecture Library

Dr. Zlata Blažina Tomić, McGill University, Toronto,1981 and 2007 Personal Protective Equipment

Iconic costume: the most potent symbol of the Black Death Beak doctor mask

A beaked Venetian carnivalmask Medico della Peste (‘Plague doctor’) • The purpose of the costume was to prevent contracting the bubonic plague, though doctors were frequently infected anyway, and as such were subject to quarantine

• The beak masks were filled with various herbs to prevent breathing in "bad air", which was believed to be responsible for the spread of the disease. The doctors carried a long stick to help treat patients without actually touching© them by author

– The head-to-toe cloaked style of plague doctor costume was devised in 1619, though it was not worn by all ESCMIDdoctors who treated the plague. Online Most of the "doctors" Lecture Library were unskilled and lacked any formal medical training. The rate of survival for plague doctors was rather slim – A common treatment for plague victims was "bleeding"; draining the patients blood in order to rid them of the disease. Iconic costume: the most potent symbol of the Black Death

“Iconic costume of 21st century

• Introduction • Public health measures in old Dubrovnik ©• Dubrovnikby author quarantine ESCMID Online• Major Lecture ethical Library issues Major ethical issues

• HEALTH WORKERS ROLES & RESPONSIBILITY

• ECONOMIC IMPACT

HEALTH WORKERS ROLES AND RESPOSIBILITIES

• Duty to care for the sick

• Ethical obligation to provide safe care, and bear a high personal risk of infection • on the front line in a pandemic, and the most affected by the disease © by author • Institutions have a reciprocal duty to support and protect health care workers ESCMID• to help them Online cope with very Lecture stressful situations, Library and recognize their contributions

ECONOMIC IMPACT

• Today, infections emerge, reemerge, and spread around the world

• Consequences of infectious disease to commerce among nations could be fatal for the economy

• Governments must,© by therefore, author attempt to balance two competing goals: minimizing the international spread of disease while interfering as little as ESCMIDpossible in Onlineworld trade, Lecture transportation, Library and travel

EQUALITY TO HEALTH-CARE RESORCES

• Some epidemics recur year after year because the affected populations do not have access to the appropriate medical care (vaccines, drugs)

• There is a need to strengthen the global health system to cope with infectious diseases in the interests of all, including those in the richer and poorer nations © by author

ESCMID• This will require Online global solidarityLecture and Library cooperation in the interest of everyone's health

INDIVIDUAL RIGHT

• There are times when the interests of protecting public health override some individual rights, such as freedom of movement

• Challenge of balancing of individual rights versus public welfare

• At such times, society has a duty to inform people of the nature of the threat, be open in explaining the reasons for over-riding individual freedoms © by author

(Today, travelers through certain airports receive mandatory thermal ESCMIDscans, thoseOnline with fevers areLecture taken aside, examined Library and, at times, prevented from traveling.)

• Dubrovnik was definitely a historical and conceptual leader, not only in promulgating quarantine regulations starting with 1377., but also in establishing the permanent health office in 1390. © by author (Marseille 1383, Venetia 1403, Pisa 1464, Genova 1467, Mallorca ESCMID1471) Online Lecture Library

Dr. Zlata Blažina Tomić, McGill University, Toronto,1981 and 2007

The oldestESCMID protuepidemic Online measures Lecture of the LibraryRepublic of Dubrovnik - quarantine isolation, without doubt is the most important contribution of Croats to the medieval world health heritage