Beginning with its outbreak in June 1829 along the Syrian coast, and especially with its reappearance in 1829, cholera represented an enduring challenge in the Mediterranean space for humans and societies. This was a decisive period in the history of hygiene and public health. The nation states of the Old World were responsible for a significant increase in human and commercial circulations. Driven by industrialization, European powers embarked on a dynamic of imperial and colonial expansion that saw them unite with and confront one another, in the Mediterranean as elsewhere, in accordance with the Eastern Question, the Great Game, and the Scramble for Africa.
In the field, more specifically in ports and with local authorities, European representatives and nationals (sailors, soldiers, diplomats, doctors, clergymen) were mediums for long-standing influence efforts that crystallized around health-related proto-imperialisms in the 1820s, before becoming wholly formalized in the ensuing decades.
In order to repel the epidemic, the debate focused on identifying and establishing hermetic health borders, which were symbolized by networks of lazarettos on both land and sea. They represented the tangible form of the quarantine measures and cordon sanitaire imposed since the fourteenth century by sovereign states to contain plague epidemics. The 1840s saw the beginning of an evolution toward a more preventive health strategy, one more compatible with the imperialist interests and free-trade concepts of the major liberal European powers (United Kingdom, France). It was embodied, for instance, in the gradual inclusion of Algeria within a trans-Mediterranean health space, in which systematic quarantines gradually disappeared even before its conquest and pacification were complete.
This space was established as part of the dynamics from—and in conformity with the recommendations of—the First and Second International Sanitary Conferences (ISC) held in Paris in 1851 and 1859. As the only European power on both shores of the Mediterranean at the time, France wanted to set an early example in the origins of international public health. It certainly saw it as a way to extend its influence over a disputed space by way of a technical issue. It is therefore easy to understand the reluctance of the British and Austrians to adopt regulations that were largely inspired by the French.
The effort to externalize health borders nevertheless predated the Paris meeting. In the late 1830s, a number of European states helped establish sanitary councils in the Orient (Constantinople in 1839, Tangiers in 1840, Alexandria in 1843). Despite the long-standing proactive stance of Ottoman and Egyptian authorities, management by Western countries took hold in the Orient, with their nationals enjoying primacy in health-related decision-making. This entailed, in Peter Baldwin’s words, making “the Turks the gatekeepers of Europe’s public health.” The relocation of sanitary control to the Orient combined negotiation between states and arrangements in the field between quarantine and hygiene practitioners.
Externalization accelerated with the cholera epidemic of 1865, when the disease returned to the Mediterranean with pilgrims from the Hajj. Alison Bashford has argued that “in Europe, cholera and the Mecca pilgrimage constituted the “eastern question” as a “health question”. The 1865 pandemic prompted the ISC’s third meeting in Istanbul in 1866. The decisions made at this conference initiated a long period of intrusion by Western powers over flows of pilgrims, and the conference ratified the principle that barrier measures must be applied as close to the epidemic center as possible in order to stifle the diffusion of cholera. The objective was to isolate affected areas and first cases as early as possible. The health unification process was subsequently reinforced in 1882, when the British secured their position in Egypt, especially within the country’s health institutions. The Alexandria Sanitary Council played a pivotal role in the health measures implemented in the Red Sea to control pilgrims to Mecca.
Despite interference arising from competition between the imperialisms of European powers, the result of this strategy of quarantine externalization—inspired by Adrien Proust in particular—validated a uniformization of sanitary measures in the Euro-Mediterranean space. The major international sanitary conferences of Venice (1892), Dresden (1893), and Paris (1894) included the initial results of the Pasteurian revolution. In these arrangements, which made adjustments to the principle of quarantine rather than abandon it, the central consideration was to locate and implement sanitary precautions as close to epidemic clusters as possible.
In the late nineteenth century, European powers held the reins of the international sanitary system, which was part of a subtle dialectical relation between the construction of an international space for public health, and the affirmation of sovereignty and imperial ambitions by states. In the early twentieth century, the European order and the international order in sanitary matters were densely entangled within organizations intended to be universal. The internationalization process of public health increased in 1907 with the creation of the International Office of Public Hygiene in Paris. This paved the way for a hybrid and multipolar international health system, which initially materialized via the establishment of a Health Organization within the League of Nations (1921-1946). The World Health Organization (WHO) took over in 1946 after the creation of the UN.