For over six months now, the outbreak of the new coronavirus disease, Covid-19, has had a devastating socio-economic impact worldwide. During the last days of 2019, rumours of ‘a mysterious disease’ prevailed in Wuhan in China, its nature causing scepticism and confusion. By early January 2020, the grim reality was that the cause of the disease was a novel virus of the Coronavirus family, to be named SARS-COV-2. It was soon observed that the disease, named Covid-19, was more violent and infectious than two other strains that caused SARS (2003) and MERS (2013). Its main symptoms are fever and dry cough, but it can also be asymptomatic. Up to now, the elusive nature of Covid-19 evades perfect understanding. Transmitted by droplets spread in the air by infected persons who cough and sneeze, it affects the lower respiratory tracks and lungs.  Since there is no existing drugs or vaccine for this novel infection, and the threat of large-scale transmission by people moving across the country during festivities was imminent, China decided to confine a large province involving millions of people. However, the virus escaped and cases were reported outside China, in Thailand, Taiwan, South Korea, Iran and Italy. When it continued to spread further, in Europe, the US and other countries, WHO declared Covid-19 as a pandemic on 11th March, and issued guidelines as how to deal with it and provided testing kits to needy countries.

In the wake of this ‘unprecedented’ emergency, international airports established stringent screening and other control measures before totally suspending commercial flights. Since co-ordination was lacking, travellers, unable to fly back home, were stranded in foreign countries, and repatriation became difficult. Ocean liners too were unable to disembark travellers, as port terminals closed. By mid-March, several European countries proceeded to suspend all except essential activities. India imposed the largest lockdown ever, while some Latin American countries delayed to do so until the number of cases surged. However, by early June, European countries, emerging from the lockdown after having reduced infection, began to open their borders. China, the first epicentre, which had already lifted its lockdown, is now bracing up to confront yet another outbreak. Epicentres have shifted to the Americas.

In Mauritius, from 23rd January, passengers in bound from China were admitted to quarantine. On the 20th March, lockdown was established. Schools and businesses closed down, commercial flights were grounded, inland travel was controlled by police roadblocks and social life came to a halt. The rationale behind these strategies was that Mauritius is densely populated, highly urbanised and connected by airlines to many countries. These strategies not only helped to maintain low transmission, but also allowed medical authorities to acquire testing kits, medical ventilators, facemasks and protective gears for hospital personnel. Physical distancing, hand hygiene and coughing etiquette were enforced. Working from home, video conferencing and online schooling became usual norms. After some confusion during the early days of confinement, the Mauritian public cooperated and observed the recommendations established by government. Efforts were made to reach out to the poor and to persons with handicaps, providing them with food. Medical services carried out the annual influenza vaccine exercise successfully, and dealt with a dozen of dengue cases.

‘Quaranta giorni’

Mauritians followed on television the daily explanation of government officials updating the course of the disease and reiterating sanitary instructions. They also watched with disbelief the unfolding of the pandemic across continents, viewing scenes that reminded them of Hollywood science-fiction movies such as ‘Contagion’. In the media, terms such as ‘quarantine’, ‘curfew’ or ‘lockdown,’ which had practically disappeared from the lexicon of the common man, have been profusely and often interchangeably used. The quarantine strategy, to which modern health systems have had recourse, goes back to the Middle Ages, when the bubonic plague devastated the Mediterranean world. Commercial ships coming from infected ports were put in compulsory isolation for forty days (‘quaranta giorni’, in Italian) to prevent infection. This duration probably referred to some Biblical event and not to the incubation period of any infection, as this is the case today. Quarantine practice first recorded at the port of Ragusa (Sicily) in 1377, was adopted by Venice, Marseilles and other ports. Today, the term mostly applies to the location of isolation facilities. Quarantine rarely hit the headlines in modern times, except in one or two exceptional events. On the return of Apollo 11 in 1969 from the moon, aeronauts were placed in quarantine, as it was feared they could be carrying disease from outer space! While ‘curfew,’ (couvre-feu in French) is an old term from the feudal times, when the ringing of a bell signalled the putting out of fires and lights at night. That term, used during world wars and all forms of riots and resurrections, has also been recouped.

After nearly one month of lockdown in Mauritius, the Quarantine Act 2020 was passed on 16th May, on the eve of a partial re-opening of administrative public services. It was argued that medical authorities needed a sound legal framework to address the prevailing pandemic, as well as future outbreaks of infectious diseases.  The new Quarantine Act promulgated 14-day compulsory isolation of all Mauritian citizens and foreign nationals entering Mauritius. Heavy penalties for those who contravened were stipulated.  Vacated holiday resorts on the coast, were rented for the isolation of travellers. Passengers found positive were admitted to a selected hospital for treatment. Rodrigues was spared by Covid-19, its airport too being closed.  The surveillance system activated by the Communicable Disease Control Unit traced and tested contacts. ‘Trace, Test and Treat’ became the mantra. The lockdown, at first extending to 30th May, was finally lifted on 15th June. No case had been registered for 46 days, and on-going testing had reached more than 140,000 persons, at that point in time.

In this global health crisis, controversies over quarantine and lockdown measures, have divided public opinion, governments and states. Resistance to quarantine measures is as old as the strategy itself. Not all medieval ports agreed to impose restrictions to maritime activities. In the 19th century, when repeated cholera pandemics occurred, medieval quarantine measures were again adopted in Europe and the colonies. However, quarantine did not stop cholera pandemics from breaking out inland. As trade was often disrupted by pandemics, European countries convened the first ‘international’ sanitary conference in Paris in 1852 to codify quarantine laws, exchange information on diseases, and prescribe a common preventive action. Other conferences, held throughout the century, recommended quarantine for commercial ships arriving from the Orient. However, governments with a ‘Laissez faire’ policy did not comply with quarantine measures that interfered with their commercial activities. In the early 20th century, when the League of Nations dealt with global health, again some imperial powers did not always accept that the League to interfere in health matters their colonies.

Long experience in quarantine legislation

Mauritius has a long experience in quarantine legislation, early measures dating back to the French revolutionary period. More laws were passed during the Indian immigration period to control infected ships. Quarantine stations guarded by soldiers were set up at Flat Island, Cannoniers Point and Ile aux Benitiers. Moreover, infected ships, flying a yellow flag, were isolated in a remote corner in the harbour of Port Louis, until quarantine was over and crew and passengers were allowed to go on shore. Again shipping companies protested against such measures causing delays and loss of profits. The Quarantine Act of 1954, prior to the present one, was passed after the DDT spraying campaign of 1949-1951 had destroyed malaria-carrying vectors. It was meant to control airplanes and ships coming from countries where malaria was endemic. Endemic malaria was eliminated in 1968, but imported cases caused another outbreak in 1975, which was eliminated in 1998.Other infectious diseases entered the island: HIV, Chikungunya, H1N1-2009 and Dengue. To deal with emerging infectious diseases as well as old ones that were re-emerging, the Communicable Disease Control Unit was established around year 2000.   

These days, lifting the lockdown and opening borders are the main topic of debate in most countries which have succeeded in stemming the outbreak. After saving lives, it is time to save livelihoods, argue many decision makers, the economy of most countries being in dire straits. According to WHO, the first wave of Covid-19 is still around, complacency is a threat, and a vaccine is several months away. Moreover, in the backdrop the pandemic, the world witnessed huge movements of people in the USA and other countries, hitting the streets, undeterred by sanitary measures, claiming racial justice. Covid-19 also laid bare worldwide the difficult situation of migrant workers, homeless and displaced people, refugee-camp dwellers and people in war-torn areas.

The Mauritian community has entered a ‘new’ world since the easing of confinement on 15th June. If nearly all the public spaces are open, sanitary measures are to be strictly maintained. The opening of schools is yet another challenge. At this opportune time, the 2020-2021 Budget, has proposed new medical institutions to upgrade the health system, such as a new central health laboratory, the present one having been built during colonial times 62 years ago, and a National Centre for Disease Control and Prevention to deal with infectious disease.

How will history see this global lockdown? For several decades, scientific institutions have sounded the alarm about the emergence of new pathogens. Did governments take sufficient precautions? People often prepare in case there are cyclones, earthquakes, or terrorist attacks. Were they prepared to fight an infectious disease?  How can the population be better educated to respond to infections of all kinds?

Definitely, the Covid-19 era will require a great deal of introspection by decision makers. Let us hope tragic lessons will bring out the best out of people all over the world to build better health systems.