[Music] [Music] Up until the third international sanitary conference that took place in Vienna in 1874, international public health was completely unorganized. Each port in the Mediterranean had its own set of rules, which were unique to it, specific, and no harmonization of these rules existed. In fact, health on boats, on ships, was overseen by the Constantinople "Conseil supérieur de santé" (Superior Health Council) established in 1838, funded by the Ottomans and which directors were in fact European doctors. And then the other structure of sanitary control or surveillance of navigation in the Mediterranean was what was called "les médecins sanitaires d'Orient" (the sanitary doctors of the Orient), that is to say some sort of health intelligence agents who advised the consuls, at least the French consuls, and who were stationed at Constantinople, Smyrna (Izmir), Alexandria, Cairo, Beirut and Damascus as a kind of advanced defense line. So that was what could be called, by diverting the formula a little, imperialism by invitation. The government, the power, the sultan, if you will, invited the Europeans to take care of health on his behalf. This is the first age of international public health, the classic regime if you will, in the early 19th century. And then there is a second period, which is the quarantines. And this quarantine period is entirely occupied by a conflict, or by disputes, between France which is prohibitionist and Great Britain or the United Kingdom, which is in favor of laissez-faire, except in Malta and Gibraltar where the quarantines are severe. The situation changes completely, objectively, with the opening of the Suez Canal in 1869. At that moment, the time needed to reach Marseille, Hamburg or London from Alexandria sharply decreases. What does this mean? It means that, whereas before the opening of the canal and before steam navigation, the length of the sea crossing was more than the incubation period of diseases, so symptoms could appear and even death occur while still at sea and so the quarantine took place on board the ship, from the moment the channel opens and steam navigation gradually replaces sailing, at that moment, crossing times become shorter than the incubation period of diseases like cholera or plague, and from that moment on the symptoms may very well appear at the end of the crossing, on arrival, and therefore death may also occur on arrival. But if the symptoms appear on arrival, that means that the person is contagious when she gets off the boat and walks around in the country of arrival. French doctrine, prohibition, is defeated, the doctrine is defeated first by the conference of Dresden in 1893 where the English system triumphs. What is the English system? It's when the surveillance of boats and ships at the source, at the point of departure, at the departure port, is abandoned - that was the French system – in favor of the surveillance of ships on arrival and medical examination of passengers also on arrival. So it's simply the British ports regulations adopted in 1872 by London. So obviously this triumph of laissez-faire supported by the British allows the great slogan of the classical system - the maximum protection against infections combined with the minimum of restrictions on trade and travel – to triumph too, at least on paper. So there are in total, between 1851 and 1951, the date on which the International Health Regulations are adopted, there are about twenty sanitary conferences. And amongst those twenty sanitary conferences, the turning point is the Paris conference of 1903. What happens in Paris in 1903? First, the conference builds upon a scientific breakthrough that is Pasteurian theory, the theory of germs. Thanks to Pasteurian theory, the Paris conference substitutes to an identical quarantine for the three quarantine diseases - cholera, plague and yellow fever - a detention period specific to the mode of transmission of each of these diseases. So there are no more uniform quarantine measures, the notion of the specificity of diseases replaces the notion of incubation or incubation time of the disease. So the history of quarantines, in passing, perfectly demonstrates that science has a very big influence on policies and regulations in the field of international public health. And now we are entering the third period of international public health: the monitoring of ships, and aircrafts from the 1933 conference of the Hague onwards, and medical examination of passengers. So, the Treaty of Paris is also at the origin of something quite important, the creation of the "Office International d'Hygiène Publique" (International Office of Public Hygiene) in 1907. In fact it will be operational in 1911. Until 1957, the "Office International d'Hygiène Publique" is in charge of monitoring the health consequences or the sanitary context of all maritime traffic in the whole world. So this is an extremely important Institution. It is the institution that regulates and monitors the notification by ports of cases of disease. Obviously this is not the first time sanitary conferences are concerned with the exchange of information and notifications between governments. That was already the case in Vienna in 1874 and in Washington in 1888. But if you will the "Office International d'Hygiène Publique" is really an extremely important creation that for a long time will compete with the health section of the League of Nations created in 1919-1923, and even at the beginning with the World Health Organization after 1948. Well, for the same period, I'm going fast because we have to go fast but in 1902 is created the International Sanitary Bureau which brings together eleven American republics and this International Sanitary Bureau is turned into a WHO Regional Office in 1949 and is renamed or re-titled Pan American Health Organization (PAHO) in 1958. Now, to finish, the following should be noted: international public health in the 19th century and the 20th century is the stage on which unfold two dramas. The chole”hara tragedy on the one hand, which accompanied from start to finish this adjustment of regulations and such, of surveillance of the navigation and other things, and then the Muslim pilgrimage. In 1865 breaks out the first maritime epidemic of cholera. In other words, it means that from the Indies to Marseille or London or Hamburg, cholera travels only along one route, that of Mecca. So, in addition, in 1865 there are also great advances made in steam navigation which obviously aggravate the risk of infection for the reason I mentioned earlier. Therefore, if you will, Muslim pilgrimage, steam navigation, what is now spreading in Europe is that Europe is at the mercy of the Muslim pilgrimage. With the maritime cholera of 1865, as we said, the Muslim pilgrimage has entered the history of international public health. It will stay there for half a century, in association with the plague but the plague only plays a secondary role in fact, the important thing is cholera. And so for Europeans, if you will, the fight, international public health, what is it? It becomes the absolute necessity to identify the places that need to be reinforced against the invasion of cholera and that can therefore be considered strategic positions. The term is used by Adrien Proust, health advisor of the French government so outbreaks are now considered strategic positions. And so Geopolitics now intervenes in this struggle against cholera. And that's why from the beginning, French and British have set up not only the "Conseil supérieur de santé" in Constantinople, which will set an example for others in Alexandria etc., but also two specialized diplomatic missions in the Red Sea in Jeddah. In 1838 a British consul is appointed in Jeddah. He is followed very quickly by a French consul who is also appointed and in 1892 the British consul is reinforced by a vice-consul who is both a doctor and a Muslim, and who therefore can go to Mecca while the British and French consuls, not being Muslims, cannot go to Mecca. So the surveillance of the Red Sea was the key point of this History of international public health at least for the region of the Mediterranean. Moreover, we can see that it combines both a surveillance of the health but also a surveillance of issues of international security, in particular the Muslim pilgrimage – I come back to it - and the Muslim brotherhoods as well, which worried Europeans a lot at that time. So from 1894 until 1930 the pilgrimage is the subject of a special regime in the health conferences, we see it here on this slide. And with changes that occur in 1912, 1926, 1938, 1944 and 1946, on which I do not dwell, the Treaty of Paris will lead directly to the adoption of the International Health Regulations in Geneva in 1951. This regulation will be revised in 1969. It will be renamed at that time "International Health Regulations" and the purpose of these regulations is still of course to ensure maximum security against the spread of infectious diseases, while respecting a minimum of interference with international trade. In 1995, a series of epidemics have many governments around the world very worried, namely cholera in Peru, the plague in India and Ebola in Zaire and the World Health Assembly, in May 1995, requests a revision of the International Health Regulations based on what was learned from these different epidemics. In 2001, one fact that we will come back to about SARS is that the General Assembly of the World Health Organization authorizes Geneva to collect information from non-governmental sources.
