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Global Public Health and the Ghosts of Pilgrimages Past

[A pilgrim wears a surgical mask. Mecca, Saudi Arabia, 2009. Photo from Flickr/Al Jazeera English.] [A pilgrim wears a surgical mask. Mecca, Saudi Arabia, 2009. Photo from Flickr/Al Jazeera English.]

As the control of disease became a pressing concern of colonial administrators in the late nineteenth century, the hajj was transformed by novel and intensified legal and institutional arrangements developed for the management of transitory Muslim populations. In 1880, the Ottoman Empire issued a decree that all pilgrims would be required to produce a passport upon arrival in the Hjjaz. In 1882, the Ottomans opened the Kamaran Island quarantine station. All pilgrimage vessels arriving from the Indian Ocean were subjected to a stop on this barren patch of earth just off the coast of Yemen. At roughly the same time, British officials in Bombay dispatched Muslim Vice-Consuls to Jeddah and Hudayda in order to monitor the increasing medicalization of the hajj. Due to repeated outbreaks of cholera among pilgrims during the preceding decades, the management of hajj had become an object of international scrutiny. Pilgrims were racialized and singled out as a dangerous, decidedly pre-modern class of travelers, requiring new documentary practices and constant medical surveillance. While the empires that erected these mobility controls have long since crumbled, the medicalization of the modern hajj continues to echo down to the present. And although both the science of epidemiology and the technologies of surveillance deployed to monitor pilgrims have undergone radical transformations since the late nineteenth century, the stubborn persistence of the underlying assumption that pilgrims are a uniquely dangerous category of travelers suggests that the Kingdom of Saudi Arabia has taken up the mantle of its colonial predecessors.

Just days before the start of the current hajj season, Saudi authorities and international disease control experts find themselves locked in another “urgent” struggle against an emerging public health threat. With some three million Muslims from around the world expected to arrive in Saudi Arabia for the annual pilgrimage to Mecca, scheduled to take place between 24-29 October, a new SARS-like coronavirus is thought to be circulating in the Arabian Peninsula. This year, a reinforced army of medical professionals will greet pilgrims. And like every other year, they will be forced to run a gauntlet of visas, vaccinations, and medical inspections. Yet few will think that they are experiencing a form of colonial governmentality. Most will likely view these intrusive measures as a necessary, even natural, part of the pilgrimage experience. After all, aren’t these measures meant to protect them?

But is the risk posed by the novel Arabian coronavirus serious or will it turn out to be another non-event like the H1N1 influenza scare of 2009? More importantly, is the recent fascination with the hajj’s epidemic potential warranted, or are the hajj-related panics of recent years a symptom of something else? Are these surges of medical surveillance actually just repackaged versions of old colonial discourses and institutions? And, if so, for whose benefit are they performed?    

Finding Meaning in Non-Events

First identified in the 1960s, coronaviruses usually produce the mild respiratory symptoms associated with the common cold in humans. However, this family of viruses also appears in a wide range of domesticated animals, birds, and bats. The potential for coronaviruses to jump species from animals to humans, causing severe illnesses to be transmitted from person to person, was painfully demonstrated during the 2003 outbreak of severe acute respiratory syndrome (SARS). SARS affected more than eight thousand people worldwide, proving fatal in roughly ten percent of infected patients. 

The exact origin of this latest incarnation of the coronavirus is still unknown. According to Ron Fouchier, the virologist who led the effort to sequence the genome of this new SARS-like illness, the new coronavirus likely came from bats. The new pathogen most closely resembles coronavirus infections among Southeast Asian bat populations. As Fouchier explained to Shots, NPR’s Health Blog, “Bats harbor many coronaviruses, so it's logical to assume that bats are the natural reservoir” for this new strand. However, Fouchier added that this does not necessarily mean that the victims of the Arabian novel coronavirus were infected by bats. “When viruses jump from animals to humans, there's usually a second animal that connects the natural carrier with humans. This species is called the amplifier because it increases the number of viral particles that can hop over into people.” Others have hypothesized that the secondary source of this new coronavirus may be the Gulf’s camel or sheep population. 

Despite its familial resemblance to SARS, great caution should be taken not to stretch this comparison too far. It should also be stressed that coronaviruses display a wide spectrum of infectiousness, severity, and mortality. At present, this new illness appears considerably less explosive than its more contagious cousin. 

Thus far, there have been only two confirmed cases of the novel Arabian corona virus. A previously healthy forty-nine-year-old Qatari man, who had traveled to the Red Sea port city of Jeddah, Saudi Arabia in August, was admitted to the hospital in Qatar on 8 September. The man presented with fever and pneumonia in both lungs. With his condition rapidly deteriorating, his family had him transferred by air ambulance to London. However, by that time he was already suffering from kidney failure. Once in London, the patient’s mystery illness was reported to the United Kingdom Health Protection Agency’s Imported Fever Service. No longer able to breathe on his own, the man still remains on life support in a London hospital. 

The trail of this mysterious respiratory illness could easily have gone cold there, but one of the patient’s doctors noticed a Saudi case report posted on ProMED Mail, the International Society for Infectious Diseases’ online reporting system. The report described the first case of the novel coronavirus, a sixty-year-old Saudi man who had been treated in Jeddah and had died from severe respiratory symptoms and kidney failure. As a result of this break, the Qatari patient’s London doctors conducted a general test for coronaviruses. When tests came back positive, they quickly compared the genetic sequence of the Qatari patient’s coronavirus with the deceased Saudi man’s revealing a practically identical match. It was at this point that the UK doctors alerted the World Health Organization of a second confirmed case of the Arabian novel coronavirus.

Once a link between two cases had been established, the Qatari victim’s travel history began to yield new clues about the virus. It was initially assumed that the Qatari man contracted the coronavirus while traveling to Jeddah in August. He had reported recovering from a mild illness during his travels. Had this nightmare scenario proven true, it would have placed the main transportation hub for Mecca-bound pilgrims as the pathogen’s ground zero. However, according to reports in the journal, Eurosurveillance, it now appears more likely that the Qatari man contracted the coronavirus after his return to Qatar. This hypothesis is partially supported by reports by the man’s family that he spent time on a farm in Qatar, where he is reported to keep camels and sheep.

Evidence suggesting that the illness was possibly contracted through contact with domesticated animals in Qatar, rather than in Jeddah, is sure to relieve officials in the Saudi ministries of Health and Hajj. Another promising sign for anxious Saudi officials is that of the Qatari patient’s sixty-four known contacts, including healthcare works, family, and friends, only thirteen reported mild respiratory symptoms after contact with the patient and all recovered completely within ten days. Other suspected cases in the United Kingdom and Hong Kong have also been ruled out. However, information regarding the deceased Saudi man’s possible contacts with animals and travel history has yet to be made public.

This is encouraging news, suggesting that infections from this new coronavirus may prove isolated. The absence of an outbreak among the victims’ contacts provides strong evidence that the new coronavirus came from animals and that the pathogen is not yet transmissible from human to human. 

Another positive sign is that the Saudi government has reached out for help from the international public health community. Teams of experts from the World Health Organization, the US Centers for Disease Control, and a Columbia University team headed by Ian Lipkin, the man Discovery Magazine dubbed “the world’s most celebrated disease hunter,” have all descended on the Kingdom. In light of the rapid pace of the recent findings and the apparent absence of human-to-human transmission, both the statements of the Saudi Ministry of Health and international health authorities have downplayed fears of a worst-case scenario and arriving pilgrims are now being assured that there is little to worry about. According to the CDC’s Morbidity and Mortality Weekly Report of 4 October, the WHO and CDC have issued no new travel alerts and have made no alterations to their recommendations to citizens traveling to Saudi Arabia in order to make the hajj. In short, the Arabian novel coronavirus is likely to be a non-event.

This is certainly the impression one gets from Elizabeth Dickinson’s recent article, “Haj at the heart of global health,” in the The National. It reads a bit like a cross between an advertisement for the Saudi monarchy’s benevolent stewardship of the pilgrimage and an admiring love note to Dr. Ziad Memish, Saudi Arabia’s Deputy Minister of Health. As Dickinson puts it: “Every year, the kingdom spends hundreds of millions of dollars to deploy a small army of medical professionals to the pilgrimage, in what is easily the world's largest—and arguably most successful—experiment in public health.” Upon their arrival in Jeddah, pilgrims often receive health pamphlets and masks to prevent the spread of airborne illness. In the run-up to this year’s hajj, more than a million brochures in five languages have already been distributed. Pilgrims will be met by some twenty-two thousand Saudi-employed health professionals staffing one hundred fifty locations. Pilgrimage group leaders are also mandated to report any alarming symptoms to security or medical staff. Citing Maurizio Barbeschi, an expert on mass-gathering medicine at the WHO, Dickinson concludes her article with this ringing endorsement: “Are the Saudis ready for this year? The answer is that they cannot be more prepared, because everything they’ve learnt in past years has been incorporated…They are the best possible given the knowledge they have.”

In recent years, we have become accustomed to hajj-related panics that turn out to be non-events. Vaccinations required in order to obtain pilgrimage visas have decreased the risk of hajj-related meningitis, polio, and yellow fever infections. In living memory, the hajj has mostly been free of catastrophic outbreaks of disease. In many respects, the risks associated with stampedes and trampling have been the most deadly threats to pilgrims in recent decades. Many have complained bitterly about Saudi stewardship of the Holy Places themselves, citing the “cultural vandalism” and wholesale bulldozing of Mecca’s architectural heritage, which has transformed the city into what Jerome Taylor recently dubbed a “Las Vegas” of gaudy skyscrapers, shopping malls, and luxury hotels. At the same time, however, Saudi management of public health aspects of the hajj has never enjoyed more respect.

To what should we attribute this vaulting confidence in the Saudi pilgrimage regime? The answer is at least partially a product of the Saudi mobilization to thwart the last big epidemic scare. In 2009, newspapers and cable news channels across the globe raised the specter of a catastrophic outbreak of the H1N1 Influenza or “Swine Flu” during the hajj. Photographs of Muslim men and women’s faces obscured by respiratory masks blended almost seamlessly with the orientalist post-9/11 symbols of a violent Islamic world, masked terrorists and burqa-clad women. Worried Arab ministers placed a ban on pilgrims over the age of sixty-five and under age twelve. Even the Grand Mufti of Egypt, Ali Gomaa, flirted with the idea of issuing a fatwa calling for the postponement of the hajj. Instead, the Saudi Ministry of Health mobilized a surge of more than seventeen thousand medical personnel. Thermal cameras were installed in both air and sea terminals in order to screen for sick pilgrims. Tens of thousands of pilgrims were targeted for further screening, vaccinations, preventative medication, and/or quarantine. In the end, the swine flu scare fizzled. There were only five confirmed deaths from H1N1 influenza during the 2009 hajj season.

To be sure, this year’s even larger surge to guard against the novel Arabian coronavirus builds on the template forged during 2009 panic. However, journalists chasing down each hajj season’s potential for disaster tend to overlook or only dimly grasp the political stakes of the hajj, the deeply-rooted significance of public health’s role in the Saudi pilgrimage regime, and its centrality for the monarchy’s self-image, legitimacy, and sovereignty.

Global Public Health and the Colonization of the Hajj

The hajj has not always been a symbol of Saudi sovereignty. In fact, for the first three decades of the kingdom’s existence, the administration of the hajj was a painful reminder of the extent to which the Hijaz was still a semi-colonial space. It should not be forgotten that global public health institutions like the WHO are the direct descendants of the international sanitary conferences of late nineteenth century. These colonial-era diplomatic and scientific conventions produced the first global networks for reporting and tracking the outbreak and spread of epidemic diseases.

During the 1865 hajj season, cholera struck the Hijaz, killing some fifteen thousand pilgrims. As the surviving pilgrims returned home from Mecca, they carried cholera in their wake, setting in motion further outbreaks across Egypt, the ports of the Mediterranean, Europe, and even as far away as New York City. The severity of the epidemic focused international attention on cholera prevention for the remainder of the century. In 1866, the third international sanitary conference was held in Istanbul in order to discuss how best to protect Europe from future outbreaks of “Asiatic cholera.” Conference attendees concluded that cholera was endemic in India. As for the mode of transmission, the delegates pointed to the squalid conditions of Hindu pilgrimage centers within India, as well as the hajj, which they argued was the second stage by which cholera was spread from the subcontinent to Europe. Between 1831 and 1912, cholera spread from India to the Hijaz on at least forty separate occasions.

With the dawn of the steamship era and the opening of the Suez Canal in 1869, the volume of oceangoing traffic between India and the Red Sea increased exponentially. As a result of the shift from sail to steam, pilgrims were freed from the rhythms of the monsoon cycle, leading to a dramatic decrease in both the cost and duration of passage. Thus, while previous generations of pilgrims had consisted mainly of nawabs, wealthy merchants, and members of the ulama, the relative affordability of the steamship-era made the journey possible for Muslims of modest means. These so-called “pauper pilgrims” were blamed as the primary conduit for the globalization of cholera. In an attempt to discourage the poor, colonial regimes marshaled Islamic legal arguments against making the hajj without the necessary physical and financial means (istitā‘a). They also imposed passport fees, financial means tests, and mandatory roundtrip tickets, and even attempted to manipulate steamship markets to raise ticket prices.  

Although the Ottoman Empire’s Board of Health was ostensibly responsible for the administration of the international quarantine system and the policing of the hajj, in reality, this organization was itself a mixed body of Ottoman and European representatives, an almost perfect symbol of the Capitulations. The situation on the ground in the Hijaz was no better. By the 1880s, European consular agents in Jeddah spent much of their time charging their Ottoman counterparts with fleecing pilgrims and gross medical incompetence. Likewise, Ottoman officials posted to the Hijaz came to regard European attempts to provide consular protection for their colonial subjects as merely a pretense for espionage and, thus, a corrosive threat to Ottoman sovereignty. However, as Ottoman officials well knew, the Ottoman state could no longer act as the sole protector of the hajj and the Holy Places. The conduct of the hajj had become an interdependent system, requiring coordination and cooperation between the Ottoman Empire, British India, Dutch Java, French Algeria, and the rest of the European colonial world. The hajj became ensnared in an inter-imperial web of conflicting regulations governing passports, quarantines, shipping firms, pilgrimage guides, and even the legal interpretation of Islamic ritual itself. The result was a weak and fractured regime of mobility controls, which produced decades of diplomatic gridlock and horrific levels of mortality.

With the Ottoman Empire’s collapse during World War One, the Ottoman quarantine system and the public health of the hajj became a ward of the colonial powers. This is the hajj that the new Kingdom of Saudi Arabia inherited when it conquered the Hijaz in 1925. Although the Saudis took over political and religious control of the pilgrimage in 1926, public health aspects of the hajj remained under the extraterritorial supervision of the Jeddah-based consulates of European colonial states. Following the drafting of a new international sanitary convention in 1926, a League of Nations office was established in Paris to coordinate public health controls over Mecca with Egyptian Quarantine Board. This system remained in effect until the World Health Organization’s creation in 1948. In 1951, the Saudis created the Ministry of Hajj. However, the kingdom was not deemed capable of taking over full control of its public health responsibilities from the WHO until 1957. While it is tempting to mark this event as the decolonization of the hajj, in reality, the Saudi hajj regime has reproduced the same colonial logic.

While it is undoubtedly true that much of Saudi Arabia’s power is derived from its oil wealth, the monarchy knows that the efficient and safe conduct of the hajj is perhaps its greatest legitimizing tool, offering it a measure of protection from a myriad of internal and foreign threats. Thus, while King Fahd’s adoption of the title Khadim al-Haramayn al-Sharifayn in 1986 was motivated by the ideological threat posed by Ayatollah Khomeini’s revolutionary Iran and, to a lesser degree, by Juhayman al-‘Utaybi’s attack on the Masjid al-Haram in 1979, an argument could easily be made that the most consistent threat to Saudi prestige comes not from attacks on the regime’s religious legitimacy but from microbes and pathogens borne by the hajj. Mismanagement of the hajj leading to a great pandemic like the cholera and plague outbreaks of the colonial era would prove equally devastating to the Saudi monarchy’s standing in the world. Moreover, repeated failures would also likely raise the prospect of outside interference from the international community.

Despite Saudi Arabia’s impressive track record, ghosts from the decades of cholera’s dark reign still linger and their lessons still apply. Pilgrims will invariably desire to make the hajj regardless of the risks. The governments responsible for managing the hajj are loath to inspire panic or be viewed as restricting access to the pilgrimage, regardless of the potential risks. Whether it was the Ottomans, the British Raj, or today the Saudis, governments tasked with maintaining the hajj derive legitimacy, religious authority, and international power from it, making it extremely difficult for them to admit when mistakes are made. Saudi Arabia’s position is made doubly difficult by the re-articulation of colonial narratives in the Western media marking the hajj as a dangerous, even uncivilized mode of travel. Thus, while the management of the hajj is generally framed as a “legitimate” object of disease and passport controls, there is a risk that the repeated production of ostensibly public health crises is yet another pretense for the ever-expanding political program of monitoring, documenting, and circumscribing the mobility of “suspect” Muslim populations.

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