The term cordon sanitaire dates to 1821, when the
Duke de Richelieu deployed French troops to the border between
France and
Spain, to prevent
yellow fever from spreading into France.[3][4]
Definition
A cordon sanitaire is generally created around an area experiencing an
epidemic or an outbreak of infectious disease, or along the border between two nations. Once the cordon is established, people from the affected area are no longer allowed to leave or enter it. In the most extreme form, the cordon is not lifted until the infection is extinguished.[5] Traditionally, the line around a cordon sanitaire was quite physical; a fence or wall was built, armed troops patrolled, and inside, inhabitants were left to battle the affliction without help. In some cases, a "reverse cordon sanitaire" (also known as
protective sequestration) may be imposed on healthy communities that are attempting to keep an infection from being introduced. Public health specialists have included cordon sanitaire along with
quarantine and
medical isolation as "nonpharmaceutical interventions" designed to prevent the transmission of microbial
pathogens through
social distancing.[6]
The cordon sanitaire is not used now in its most extreme historical form, mainly due to our improved understanding of
disease transmission, treatment and prevention. Today its function is primarily to facilitate the identification of infectious disease and to prevent its transmission. In its more traditional role, the cordon also remains a useful intervention under conditions in which: 1) the infection is highly
virulent (contagious and likely to cause illness); 2) the
case fatality rate is very high; 3) treatment is nonexistent or difficult; and 4) there is no
vaccine, or other means of immunizing large numbers of people (such as needles or syringes) are lacking.[7] During the
COVID-19 pandemiccordons sanitaires were imposed on geographic regions around the world in an attempt to contain the infection.[8]
16th century
In 1523, during a
plague outbreak in
Birgu, the town was cordoned off by guards to prevent the disease from spreading to the rest of
Malta.[9]
17th century
In 1655, cordon sanitaire was imposed on the town of
Żabbar in
Malta after a
plague outbreak was detected. The disease spread to other settlements and similar restrictive measures were imposed, and the outbreak was successfully contained after causing 20 deaths.[10]
In May 1666, the English village of
Eyam famously imposed a cordon sanitaire on itself after an outbreak of the
bubonic plague in the community. During the next 14 months almost eighty percent of the inhabitants died.[11] A perimeter of stones was laid out surrounding the village and no one passed the boundary in either direction until November 1667, when the pestilence had run its course. Neighbouring communities provided food for Eyam, leaving supplies in designated locations along the boundary cordon and receiving payment in coins "disinfected" by running water or vinegar.[12]: 72
In 1770 the Empress
Maria Theresa set up a cordon sanitaire between
Austria and the
Ottoman Empire to prevent people and goods infected with plague from crossing the border. Cotton and wool were held in storehouses for weeks, with peasants paid to sleep on the bales and monitored to see if they showed signs of disease. Travelers were quarantined for 21 days under ordinary circumstances and up to 48 days when there was confirmation of plague being active in Ottoman territory. The cordon was maintained until 1871, and there were no major outbreaks of plague in Austrian territory after the cordon sanitaire was established, whereas the Ottoman Empire continued to suffer frequent epidemics of plague until the mid-19th century.[14]
The 1821 yellow fever epidemic ravaged
Barcelona and a cordon sanitaire was set up around the entire city of 150,000 people. Between 18,000 and 20,000 died in four months.[14]
During the
1830 cholera outbreak in Russia,
Moscow was surrounded by a military cordon, most roads leading to the city were dug up to hinder travel, and all but four entrances to the city were sealed.[14]
During the 1856 yellow fever epidemic a cordon sanitaire was implemented in several cities in the state of
Georgia with moderate success.[18]
In 1869,
Adrien Proust (father of novelist
Marcel Proust) proposed the use of an international cordon sanitaire to control the spread of cholera, which had
emerged from India and was threatening Europe and Africa. Proust proposed that all ships bound for Europe from India and Southeast Asia be quarantined at
Suez, however his ideas were not generally embraced.[19][20]
In 1882, in response to a virulent outbreak of yellow fever in
Brownsville, Texas, and in northern Mexico, a cordon sanitaire was established 180 miles north of the city, terminating at the
Rio Grande to the west and the
Gulf of Mexico to the east. People traveling north had to remain quarantined at the cordon for 10 days before they were certified disease-free and could proceed.[14]
In 1888, during a yellow fever epidemic, the city of
Jacksonville, Florida, was surrounded by an armed cordon sanitaire by order of Governor
Edward A. Perry.[21]
In 1899,
an outbreak of the plague in
Honolulu was managed by a cordon sanitaire around the
Chinatown district. In an attempt to control the infection, a barbed wire perimeter was created and people's belongings and homes were burned.[22]
The 1918 flu spread so rapidly that, in general, there was no time to implement cordons sanitaires. However, to prevent an introduction of the infection, residents of
Gunnison, Colorado isolated themselves from the surrounding area for two months at the end of 1918. All highways were barricaded near the county lines. Train conductors warned all passengers that if they stepped outside of the train in Gunnison, they would be arrested and quarantined for five days. As a result of this
protective sequestration, no one died of influenza in Gunnison during the epidemic.[25]
In late 1918,
Spain attempted unsuccessfully to prevent the spread of the 1918 flu by imposing border controls, roadblocks, restricted rail travel, and a maritime cordon sanitaire prohibiting ships with sick passengers from landing, but by then the epidemic was already in progress.[28][page needed]
During the
1972 Yugoslav smallpox outbreak, over 10,000 people were sequestered in cordons sanitaires of villages and neighborhoods using roadblocks, and there was a general prohibition of public assembly, a closure of all borders and a prohibition of all non-essential travel.[29]: 17
In 1995, a cordon sanitaire was used to control an outbreak of
Ebola virus disease in
Kikwit,
Zaire.[30][31][7] President
Mobutu Sese Seko surrounded the town with troops and suspended all flights into the community. Inside Kikwit, the
World Health Organization and Zaire medical teams erected further cordons sanitaires, isolating burial and treatment zones from the general population.[32][page needed]
21st century
During the
2003 SARS outbreak in Canada, "community quarantine" was used to successfully reduce transmission of the disease.[33]
During the 2003 SARS outbreak in
mainland China,
Hong Kong,
Taiwan, and
Singapore, large-scale quarantine was imposed on travelers arriving from other SARS areas, work and school contacts of suspected cases, and, in a few instances, entire apartment complexes where high attack rates of SARS were occurring.[34] In China, entire villages in rural areas were quarantined and no travel was allowed in or out of the villages. One village in
Hebei province was quarantined from 12 April 2003 until 13 May. Tens of thousands of individuals fled from areas when they learned of an impending cordon sanitaire, thereby possibly spreading the epidemic.[35]
In August 2014, a cordon sanitaire was established around some of the most affected areas of the
Western African Ebola virus epidemic.[36][5] On 19 August 2014, the Liberian government quarantined the entirety of the district of
West Point of the capital,
Monrovia, and issued a statewide curfew.[37][38] The cordon sanitaire of the West Point area was lifted on 30 August. The information minister,
Lewis Brown, said that this step was taken to ease efforts to screen, test, and treat residents.[39]
Guidance on when and how human rights can be restricted to prevent the spread of infectious disease is found in the Siracusa Principles, a non-binding document developed by the
Siracusa International Institute for Criminal Justice and Human Rights and adopted by the
United Nations Economic and Social Council in 1984.[46] The Siracusa Principles state that restrictions on human rights under the
International Covenant on Civil and Political Rights must meet standards of legality,
evidence-based necessity, proportionality, and gradualism, noting that public health can be used as grounds for limiting certain rights if the state needs to take measures "aimed at preventing disease or injury or providing care for the sick and injured." Limitations on rights (such as a cordon sanitaire) must be "strictly necessary," meaning that they must:
respond to a pressing public or social need (health)
proportionately pursue a legitimate aim (prevent the spread of infectious disease)
be provided for and carried out in accordance with the law
be neither arbitrary nor discriminatory
only limit rights that are within the jurisdiction of the state seeking to impose the limitation.[47]
In addition, when a cordon sanitaire is imposed, public health ethics specify that:
all restrictive actions must be well-supported by data and
scientific evidence
all information must be made available to the public
all actions must be explained clearly to those whose rights are restricted and to the public
all actions must be subject to regular review and reconsideration.
Finally, the state is ethically obligated to guarantee that:
infected people will not be threatened or abused
basic needs such as food, water, medical care, and preventive care will be provided
communication with loved ones and with caretakers will be permitted
constraints on freedom will be applied equally, regardless of social considerations
those who are affected will be compensated fairly for economic and material losses, including salary.[48]
In popular culture
A cordon sanitaire was used as a plot device by
Albert Camus in his 1947 novel The Plague.
In the 1995 film Outbreak, an Ebola-like virus brought from Africa causes an epidemic in a small town in
California, resulting in the
United States Army forming a cordon sanitaire around the town.
The 2002 film 28 Days Later depicts a cordon sanitaire imposed on
Great Britain as a viral infection devastates the population.
In the 2014 Belgian TV series Cordon, a cordon sanitaire is set up to contain an outbreak of
avian influenza in
Antwerp.
In the 2016 television limited series Containment a cordon sanitaire is set up to contain an infectious virus in
Atlanta, Georgia.
In the 2019 novel The Dreamers by
Karen Thompson Walker, the fictional California town of Santa Lora is placed under cordon sanitaire due to a sleeping sickness that infects its residents.
^
abTaylor, James (1882). The Age We Live In: A History of the Nineteenth Century. Oxford University. p. 222.
^
abNichols, Irby C. (1972). The European Pentarchy and the Congress of Verona, 1822. Dordrecht: Springer Netherlands. pp. 29–30.
ISBN978-94-010-2725-0.
^Arnebeck, Bob (30 January 2008).
"A Short History of Yellow Fever in the US". Destroying Angel: Benjamin Rush, Yellow Fever and the Birth of Modern Medicine. Retrieved 31 January 2021.
^Rothstein, Mark A.; Alcalde, M. Gabriela; Elster, Nanette R.; Majumder, Mary Anderlik; Palmer, Larry I.; Stone, T. Howard; Hoffman, Richard E. (November 2003).
Quarantine and Isolation: Lessons learned from SARS(PDF) (Report). Institute for Bioethics, Health Policy and Law; University of Louisville School of Medicine. Retrieved 31 January 2021.
^M. Pabst Battin, Leslie P. Francis, Jay A. Jacobson, The Patient as Victim and Vector: Ethics and Infectious Disease, Oxford University Press, 2009.
ISBN019533583X
The term cordon sanitaire dates to 1821, when the
Duke de Richelieu deployed French troops to the border between
France and
Spain, to prevent
yellow fever from spreading into France.[3][4]
Definition
A cordon sanitaire is generally created around an area experiencing an
epidemic or an outbreak of infectious disease, or along the border between two nations. Once the cordon is established, people from the affected area are no longer allowed to leave or enter it. In the most extreme form, the cordon is not lifted until the infection is extinguished.[5] Traditionally, the line around a cordon sanitaire was quite physical; a fence or wall was built, armed troops patrolled, and inside, inhabitants were left to battle the affliction without help. In some cases, a "reverse cordon sanitaire" (also known as
protective sequestration) may be imposed on healthy communities that are attempting to keep an infection from being introduced. Public health specialists have included cordon sanitaire along with
quarantine and
medical isolation as "nonpharmaceutical interventions" designed to prevent the transmission of microbial
pathogens through
social distancing.[6]
The cordon sanitaire is not used now in its most extreme historical form, mainly due to our improved understanding of
disease transmission, treatment and prevention. Today its function is primarily to facilitate the identification of infectious disease and to prevent its transmission. In its more traditional role, the cordon also remains a useful intervention under conditions in which: 1) the infection is highly
virulent (contagious and likely to cause illness); 2) the
case fatality rate is very high; 3) treatment is nonexistent or difficult; and 4) there is no
vaccine, or other means of immunizing large numbers of people (such as needles or syringes) are lacking.[7] During the
COVID-19 pandemiccordons sanitaires were imposed on geographic regions around the world in an attempt to contain the infection.[8]
16th century
In 1523, during a
plague outbreak in
Birgu, the town was cordoned off by guards to prevent the disease from spreading to the rest of
Malta.[9]
17th century
In 1655, cordon sanitaire was imposed on the town of
Żabbar in
Malta after a
plague outbreak was detected. The disease spread to other settlements and similar restrictive measures were imposed, and the outbreak was successfully contained after causing 20 deaths.[10]
In May 1666, the English village of
Eyam famously imposed a cordon sanitaire on itself after an outbreak of the
bubonic plague in the community. During the next 14 months almost eighty percent of the inhabitants died.[11] A perimeter of stones was laid out surrounding the village and no one passed the boundary in either direction until November 1667, when the pestilence had run its course. Neighbouring communities provided food for Eyam, leaving supplies in designated locations along the boundary cordon and receiving payment in coins "disinfected" by running water or vinegar.[12]: 72
In 1770 the Empress
Maria Theresa set up a cordon sanitaire between
Austria and the
Ottoman Empire to prevent people and goods infected with plague from crossing the border. Cotton and wool were held in storehouses for weeks, with peasants paid to sleep on the bales and monitored to see if they showed signs of disease. Travelers were quarantined for 21 days under ordinary circumstances and up to 48 days when there was confirmation of plague being active in Ottoman territory. The cordon was maintained until 1871, and there were no major outbreaks of plague in Austrian territory after the cordon sanitaire was established, whereas the Ottoman Empire continued to suffer frequent epidemics of plague until the mid-19th century.[14]
The 1821 yellow fever epidemic ravaged
Barcelona and a cordon sanitaire was set up around the entire city of 150,000 people. Between 18,000 and 20,000 died in four months.[14]
During the
1830 cholera outbreak in Russia,
Moscow was surrounded by a military cordon, most roads leading to the city were dug up to hinder travel, and all but four entrances to the city were sealed.[14]
During the 1856 yellow fever epidemic a cordon sanitaire was implemented in several cities in the state of
Georgia with moderate success.[18]
In 1869,
Adrien Proust (father of novelist
Marcel Proust) proposed the use of an international cordon sanitaire to control the spread of cholera, which had
emerged from India and was threatening Europe and Africa. Proust proposed that all ships bound for Europe from India and Southeast Asia be quarantined at
Suez, however his ideas were not generally embraced.[19][20]
In 1882, in response to a virulent outbreak of yellow fever in
Brownsville, Texas, and in northern Mexico, a cordon sanitaire was established 180 miles north of the city, terminating at the
Rio Grande to the west and the
Gulf of Mexico to the east. People traveling north had to remain quarantined at the cordon for 10 days before they were certified disease-free and could proceed.[14]
In 1888, during a yellow fever epidemic, the city of
Jacksonville, Florida, was surrounded by an armed cordon sanitaire by order of Governor
Edward A. Perry.[21]
In 1899,
an outbreak of the plague in
Honolulu was managed by a cordon sanitaire around the
Chinatown district. In an attempt to control the infection, a barbed wire perimeter was created and people's belongings and homes were burned.[22]
The 1918 flu spread so rapidly that, in general, there was no time to implement cordons sanitaires. However, to prevent an introduction of the infection, residents of
Gunnison, Colorado isolated themselves from the surrounding area for two months at the end of 1918. All highways were barricaded near the county lines. Train conductors warned all passengers that if they stepped outside of the train in Gunnison, they would be arrested and quarantined for five days. As a result of this
protective sequestration, no one died of influenza in Gunnison during the epidemic.[25]
In late 1918,
Spain attempted unsuccessfully to prevent the spread of the 1918 flu by imposing border controls, roadblocks, restricted rail travel, and a maritime cordon sanitaire prohibiting ships with sick passengers from landing, but by then the epidemic was already in progress.[28][page needed]
During the
1972 Yugoslav smallpox outbreak, over 10,000 people were sequestered in cordons sanitaires of villages and neighborhoods using roadblocks, and there was a general prohibition of public assembly, a closure of all borders and a prohibition of all non-essential travel.[29]: 17
In 1995, a cordon sanitaire was used to control an outbreak of
Ebola virus disease in
Kikwit,
Zaire.[30][31][7] President
Mobutu Sese Seko surrounded the town with troops and suspended all flights into the community. Inside Kikwit, the
World Health Organization and Zaire medical teams erected further cordons sanitaires, isolating burial and treatment zones from the general population.[32][page needed]
21st century
During the
2003 SARS outbreak in Canada, "community quarantine" was used to successfully reduce transmission of the disease.[33]
During the 2003 SARS outbreak in
mainland China,
Hong Kong,
Taiwan, and
Singapore, large-scale quarantine was imposed on travelers arriving from other SARS areas, work and school contacts of suspected cases, and, in a few instances, entire apartment complexes where high attack rates of SARS were occurring.[34] In China, entire villages in rural areas were quarantined and no travel was allowed in or out of the villages. One village in
Hebei province was quarantined from 12 April 2003 until 13 May. Tens of thousands of individuals fled from areas when they learned of an impending cordon sanitaire, thereby possibly spreading the epidemic.[35]
In August 2014, a cordon sanitaire was established around some of the most affected areas of the
Western African Ebola virus epidemic.[36][5] On 19 August 2014, the Liberian government quarantined the entirety of the district of
West Point of the capital,
Monrovia, and issued a statewide curfew.[37][38] The cordon sanitaire of the West Point area was lifted on 30 August. The information minister,
Lewis Brown, said that this step was taken to ease efforts to screen, test, and treat residents.[39]
Guidance on when and how human rights can be restricted to prevent the spread of infectious disease is found in the Siracusa Principles, a non-binding document developed by the
Siracusa International Institute for Criminal Justice and Human Rights and adopted by the
United Nations Economic and Social Council in 1984.[46] The Siracusa Principles state that restrictions on human rights under the
International Covenant on Civil and Political Rights must meet standards of legality,
evidence-based necessity, proportionality, and gradualism, noting that public health can be used as grounds for limiting certain rights if the state needs to take measures "aimed at preventing disease or injury or providing care for the sick and injured." Limitations on rights (such as a cordon sanitaire) must be "strictly necessary," meaning that they must:
respond to a pressing public or social need (health)
proportionately pursue a legitimate aim (prevent the spread of infectious disease)
be provided for and carried out in accordance with the law
be neither arbitrary nor discriminatory
only limit rights that are within the jurisdiction of the state seeking to impose the limitation.[47]
In addition, when a cordon sanitaire is imposed, public health ethics specify that:
all restrictive actions must be well-supported by data and
scientific evidence
all information must be made available to the public
all actions must be explained clearly to those whose rights are restricted and to the public
all actions must be subject to regular review and reconsideration.
Finally, the state is ethically obligated to guarantee that:
infected people will not be threatened or abused
basic needs such as food, water, medical care, and preventive care will be provided
communication with loved ones and with caretakers will be permitted
constraints on freedom will be applied equally, regardless of social considerations
those who are affected will be compensated fairly for economic and material losses, including salary.[48]
In popular culture
A cordon sanitaire was used as a plot device by
Albert Camus in his 1947 novel The Plague.
In the 1995 film Outbreak, an Ebola-like virus brought from Africa causes an epidemic in a small town in
California, resulting in the
United States Army forming a cordon sanitaire around the town.
The 2002 film 28 Days Later depicts a cordon sanitaire imposed on
Great Britain as a viral infection devastates the population.
In the 2014 Belgian TV series Cordon, a cordon sanitaire is set up to contain an outbreak of
avian influenza in
Antwerp.
In the 2016 television limited series Containment a cordon sanitaire is set up to contain an infectious virus in
Atlanta, Georgia.
In the 2019 novel The Dreamers by
Karen Thompson Walker, the fictional California town of Santa Lora is placed under cordon sanitaire due to a sleeping sickness that infects its residents.
^
abTaylor, James (1882). The Age We Live In: A History of the Nineteenth Century. Oxford University. p. 222.
^
abNichols, Irby C. (1972). The European Pentarchy and the Congress of Verona, 1822. Dordrecht: Springer Netherlands. pp. 29–30.
ISBN978-94-010-2725-0.
^Arnebeck, Bob (30 January 2008).
"A Short History of Yellow Fever in the US". Destroying Angel: Benjamin Rush, Yellow Fever and the Birth of Modern Medicine. Retrieved 31 January 2021.
^Rothstein, Mark A.; Alcalde, M. Gabriela; Elster, Nanette R.; Majumder, Mary Anderlik; Palmer, Larry I.; Stone, T. Howard; Hoffman, Richard E. (November 2003).
Quarantine and Isolation: Lessons learned from SARS(PDF) (Report). Institute for Bioethics, Health Policy and Law; University of Louisville School of Medicine. Retrieved 31 January 2021.
^M. Pabst Battin, Leslie P. Francis, Jay A. Jacobson, The Patient as Victim and Vector: Ethics and Infectious Disease, Oxford University Press, 2009.
ISBN019533583X