|Fisherman. Painting by Victor Grech|
Malta in the British Empire
In the nineteenth century Malta had a population of around 91,000 people and was governed by the British Empire. Despite its small size and absence of natural resources, the island was an important Mediterranean crossroads, with a vital natural harbor and a crucial military base. Malta had a good reputation for preventing epidemics, having a lazaretto with quarantine facilities to house people and store goods until deemed safe for entry into the country. These facilities date back to the days of the Knights of St. John (1530 to 1798). The British reinforced the island’s repute by creating a post of Superintendent of Quarantine, its first office holder being William Eton. Bureaucratic friction precipitated Eton’s departure in 1802, the post remained vacant for nine years, and the eventual replacement also left after a few months. During this entire decade, the lazaretto was inadequately supervised by an ad hoc board of health, comprised of individuals who had other responsibilities.1
The Black Plague, Malta, 1813
The outbreak commenced in Constantinople in 1812 and spread to the Egyptian port of Alexandria in March. A ship from Alexandria docked in Malta in March and two sailors died from the plague while in quarantine. Goods from the ship may also have been smuggled in without proper quarantine protocol. The board of health wanted to destroy the ship and its cargo while the sailors were in quarantine but Civil Commissioner Lt. Gen. Hildebrand Oakes insisted that the owners of the vessel should be allowed to remove their property and return the vessel to Alexandria.1
In mid-April an eight-year-old girl died of the plague; her mother died the following day; and her father also fell ill. The surviving family members were quarantined in the lazaretto along with close contacts, but these measures were inadequate and another thirty perished between May 12 and 22. By the end of the month, 109 people had died.1
The board posted flyers with general health advice but Oakes refused their recommendations for a lockdown. Over the next months, all towns became infected. Distancing measures were introduced gradually, too slowly, and too late. Public buildings (except for the churches) were closed on May 5, and direct and indirect contact between people was discouraged, especially at the marketplaces. Two days later, communication between ships and the shore was prohibited. Churches were closed on May 9. On the 17th, the death penalty was imposed for anyone concealing the existence of the plague.1
On June 19, barriers were set up around the capital city Valletta and its suburb, and also for the port towns across the harbor. The harbor area was further subdivided into districts with restricted movement under threat of the death penalty. Shops selling food were only allowed to open four hours daily. Under strict enforcement by local police and soldiers, the epidemic began to subside by late 1813 and was over by the following January. The ultimate death toll was around 4,500 (5% of the population).1
Furthermore, Malta experienced significant economic losses due to its tarnished reputation. Competing ports used Malta’s poor standing to increase quarantine time for ships from Malta, with the result that merchants tried to avoid it. Local severe measures in order to prevent a recurrence included longer quarantine times, and this too affected commerce.1
COVID-19, Malta, 2020
The first case of COVID-19 was documented in Malta on March 7, 2020. The government has issued a daily COVID Bulletin and this provides a useful record of events and measures. The first bulletin on March 12 documented nine cases and mandated childcare, school, and university closures along with all mass activities. Incoming travelers from certain countries were to self-quarantine at home along with other household residents for two weeks, against a fine of €1,000 (later increased), which was extended to all counties on the following day. Flights to certain countries were also banned (this list expanded later). As stated in the bulletin:
This epidemic is still in its early stages and the health authorities are continuing to take gradual measures. Decisions are being taken on the basis of . . . what is happening abroad as well as on epidemic studies . . . The aim is that of having the health services always keeping up with the concomitant demand.
Other stepwise actions taken in March included: expanding services at free health clinics; government-funded measures to aid businesses; paid quarantine leave; increase in COVID testing, hospital capacity, and ventilators; and closing of all non-essential services.
Public health crises should be managed by continuous consultation with the appropriate specialists, and their advice heeded. Early and decisive actions taken in Malta have prevented much illness and death. This is in stark contrast to the actions and outcomes during the 1813 plague epidemic. The lessons from history and the science of epidemiology and public health have much to teach all nations around the world.
- Tully S. The History of Plague: As it Has Lately Appeared in the Islands of Malta, Gozo, Corfu, Cephalonia, Etc. Detailing Important Facts, Illustrative of the Specific Contagion of that Disease, with Particulars of the Means Adopted for Its Eradication. London: Longman, Hurst, Rees, Orme, and Brown; 1821.
- Grech V. Unknown unknowns – COVID-19 and potential global mortality [published online ahead of print, 2020 Mar 31]. Early Hum Dev. 2020;144:105026. doi:10.1016/j.earlhumdev.2020.105026
- Grech V. COVID-19 admissions calculators: general population and paediatric cohort. Early Hum Dev. – in press.
While I habitually paint bright landscapes and seascapes, I find myself painting a bit more somberly. While this fisherman has not stayed at home, he fishes alone, beneath a dark and brooding sky. As we rally for the upcoming fight, I find that my colleagues in the Health Department have rallied magnificently. Supplies have been procured (no expenses spared), staff have been trained and prepared, and contingencies have been planned. Several areas have been prepared so as to provide additional bed space, including corridors and Medical School.
VICTOR GRECH, MD, PhD, graduated from the University of Malta Medical School in 1988. He specialized in pediatrics and took up pediatric cardiology at The Hospital for Sick Children at Great Ormond Street (London), from where he completed a Ph.D on “Congenital Heart Disease in Malta” in 1998. He is a consultant pediatrician to the Maltese Department of Health, and has published in pediatric cardiology, general pediatrics, and the humanities. He completed a second Ph.D. with the English Literature Department of the University of Malta: “Infertility in Science Fiction.” He lives in Pembroke, Malta.