The outbreak and subsequent spread of Covid-19 is not the first time that Malta has had to deal with a significantly contagious disease in the country.

Indeed, there have been several occasions of such medical situations, with the outbreak of Spanish flu between 1918 and 1920 and the outbreak of the Plague in 1813 and in 1675 being chief amongst those in Maltese history.

In times of such difficulty, the burden of responsibility falls firstly on the country’s leadership.  As we have seen in the present day, the government and health authorities must decide on a course of action and on measures which would mitigate the spread of any contagion.

Malta was for many centuries a bustling trade centre through the Grand Harbour, with connections to various destinations across the Mediterranean. While these connections brought prosperity to the island through trade, they also brought risks of disease.

The traditional means of dealing with any potential outbreak was not necessarily all too different from the measures we have seen implemented today.  Indeed, quarantine was the mainstay of Malta’s disease prevention measures.

The use of quarantine in order to avoid the spread of disease can be traced back almost 500 years to the time of the Knights of St. John.  A temporary ‘Lazaretto’ was built on a small island known as Isolotto, which later became known as Manoel Island, in 1592 after an outbreak of plague on the island which was initially imported on a Tuscan galley which had captured the cargo and around 150 crew members of a couple of Ottoman ships.

After the outbreak became more severe in March, Grand Master Hugues Loubenx de Verdalle requested assistance from the Viceroy of Sicily, who sent Pietro Parisi from Trapani, a doctor who had experience with contagious diseases. Upon the latter's arrival on 15 May that year, he took control of dealing with the outbreak along with the Health Commissioners and the Maltese doctor Gregorio Mamo. 

900 suspected and confirmed cases were sent to Lazaretto, and they were kept separate from each other. The rest of the population was told to self-isolate in their own houses, with only one person per family being allowed to go out daily for errands. These measures were enforced with harsh penalties including flogging and death.

Washing places near the sea were set up in Valletta, Birgu and Senglea allowing suspected cases to wash in an attempt to purify themselves and their clothes. Walls of houses with confirmed or suspected cases of the disease were washed with seawater and whitewashed with lime, and similar measures were undertaken in burial grounds.

In spite of all these measures, the plague spread in three waves and left 3,000 – some 11% of Malta’s population – dead.

Plague broke out again in Malta in 1623, although this outbreak was much smaller than the 1592–1593 epidemic. The outbreak began in the household of the Port Chief Sanitary Officer, and it is possible that it was caused by handling refuse from the earlier epidemic. Strict measures were taken and the 1623 outbreak was contained with only 40 deaths. Two further outbreaks would occur in Hospitaller-ruled Malta, a limited outbreak in 1655 which killed 20 people and a massive epidemic in 1675–1676.

By the time of the latter, a Lazaretto had been permanently built on Manoel Island, having been commissioned by Grandmaster Giovanni Paolo Lascaris.  The first case of the plague then was registered on Christmas Eve of 1675 in the house of a merchant named Matteo Bonnici.

By the end of January 1676, several members of Bonnici’s household had died and by February cases were reported in Valletta, Senglea, Birgu and in the village of Attard.

This is where the authorities had failed to act.  Research by Monique Grech, a nurse and historian, unearthed that although steps for isolating the patients had been taken, the Knights’ four doctors had disagreed that the disease that was spreading was the plague, instead attributing it to a malignant fever brought about by “some sort of celestial influence”.  It was only after they sent letters out to experts across Europe asking for their opinion that they became aware of their error.  By then, it was too late.

Foreign assistance was eventually requested in April and arrived the following month, almost six months after the first case was discovered.  Strict quarantine measures were imposed and a powerful concoction of some 14 drugs and chemicals was used as a disinfectant.  By September, the island was given a clean bill of health – but not before the plague had taken over 11,000 lives.

It had spread to such an extent that only Gozo, Mdina, and the village of Safi were spared.  It is said that Safi derived its name, which translates to ‘pure’, from not having been hit by the plague – although historians still disagree on whether this is true or not.

The Knights however, it seemed, had learnt their lesson from the mistakes of the past.  No further mass outbreaks were registered during their rule of the island, which ended after the French ousted them in 1798.

The British, who in turn ousted the French two years later, also appreciated the need to focus on public health and on quarantine in the Harbour area in particular.  They therefore created a new position: The Superintendent of Quarantine, with the first person appointed being one William Eton.

New research by Andrew Zwilling, an assistant professor at the United States Naval War College, states that Eton was a fairly competent man in his field, but had aspirations of taking his superior’s post. When that didn’t pan out, he left Malta in 1802.

“Eton never returned to Malta. This in and of itself is not noteworthy but for one crucial factor: he never lost his job. Inexplicably, Eton retained his position as an absentee superintendent of the quarantine, despite attempts by Malta’s civil administration to have him removed. It was not until nine years following his departure when Eton was finally replaced by William Pym in late 1811. Unfortunately, Pym only spent a few months on Malta before asking for a leave of absence due to poor health”, Zwilling wrote.

“As a result, for more than a decade the most important position when it came to the health of Malta remained vacant. This was a critical gap in leadership and a major failure by those responsible for assigning the position.”

A Board of Health was set up but, while well-meaning, it was not a board with full-time positions meaning that it not get the full and undivided attention that it needed. Procedures at Lazaretto became lax and supervision was not carried out with any great vigour either.  However, with no Superintendent of Quarantine, there was nobody to put their foot down.

In March 1813, there was an outbreak of plague in Alexandria. It is largely agreed that the plague made its way to Malta as a result of that, either through sailors – two had died in quarantine in Malta – or through good smuggled out of Manoel Island in ignorance of the stipulated quarantine protocol.

Either way, by the end of May over 100 people in Malta had already died. 

Malta, at the time, was not a Crown Colony yet and was hence headed by a Commissioner – Sir Hildebrand Oakes.  He and the Board of Health tried to stem the tide.  They put the first family to be on the receiving end of the plague in quarantine, and posted public flyers in English and Italian giving advice on how best to protect people’s health.

However, Oakes and the Board did not see eye to eye on certain major policy decisions, which is where the lack of a full time Quarantine expert was felt.

“For instance, when the ship from Alexandria docked at the lazaretto, members of the Board of Health wanted to immediately destroy the ship and its cargo while the sailors waited the requisite number of days in quarantine. Oakes, interpreting Malta’s quarantine rules differently, insisted that the owners of the vessel must be allowed to remove their property and then return the vessel to Alexandria. Ultimately, the Board of Health lost the argument”, Zwilling writes.

“It was while these types of large policy decisions were being made that Malta’s chronic lack of a full-time superintendent of the quarantine became a serious liability. A superintendent’s experience and bureaucratic weight would have been a valuable resource for Malta. As it was, the Board of Health and civil commissioner continued to butt heads, fighting over how important it was to keep people isolated in their homes”, he continues.

Zwilling also, interestingly, writes of how there was no shortage of people who tried to take advantage of the situation.

“Even in London, British authorities received several unsolicited letters from gentlemen who believed they knew the solution to Malta’s problem. One man callously suggested forcing all British residents in Malta onto the small and sparse island of Comino and letting the Maltese fend for themselves until the plague died out. A chemist from Leith wanted to pump hydrogen into all the houses to push out the bad humors. Yet another man promised to find the solution or die trying, so long as he was paid three guineas a day”, he writes.

In the end it was the imposition of measures similar to, and even more drastic than, those in place today which helped curb the virus.

People were not allowed to move between towns or districts in a city without explicit written permission, some towns were isolated by military force, and offenses like hiding your own illness or concealing others’ illness became punishable by death.

Churches were closed, while public areas and businesses were also shut down.  Internationals hipping, with the exception of emergency supplies, became non-existent.  Malta was cut off from the rest of the world – but it was a necessary measure in order to curb the spread of the disease.

In the end, 4,500 people – some 5% of the population – died as a result of the outbreak.  Stricter quarantine measures were put in place with hefty fines for those who avoided quarantine, even if by accident. The outbreak and resultant initial mis-handling of the plague had an effect on the reputation of the island, which translated into short-term economic difficulties.

However, Zwilling points out, there are lessons to be learned from 1813 in today’s climate in dealing with Covid-19.

“First and foremost, Malta’s experience emphasizes the need for clear leadership. Without it, delay and confusion are inevitable. It also shows the importance of heeding technical and scientific expertise — COVID-19 will not be the last pandemic crisis. Second, it is important to remember the political ramifications of disease, be it the plague in 1813 or COVID-19 in 2020. In Malta, a potentially controversial executive authority took power while the people stayed isolated for fear of sickness”, he explains.

“Finally, separation, isolation, and social distancing worked in Malta to reduce the spread and impact of the disease, and it can work for the current crisis”, he points out.

“The economic cost of these measures in 1813 was high, but weighed against saving lives, it was a price worth paying”, Zwilling concludes.