At Cairo, sanitary matters are nearly at a standstill; the executive administration cannot enforce their orders. On Saturday last, the bad feeling … nearly stirred up a rebellion, so that matters looked very serious. The Egyptian lower classes consider all precautions to be impious; “God is Great,” they cry, and all is predestined; hence they obstruct the very little sanitary work that has been carried into effect.
–Dr. J. Mackie, British Consular Physician at Alexandria, July 25, 1883
In the summer and fall of 1883, the newly-installed Anglo-Egyptian government faced its first public health crisis when cases of cholera were reported in the Nile Delta and rapidly spread throughout the country. The government’s response was based in part on long-standing European prejudices about the “Orient” as the origin of plague and pestilence and “Orientals” as people who did not understand health, science, or hygiene, and were unconcerned—even fatalistic—in the face of life-threatening illnesses. To the contrary, Egypt had, over the course of the 19th century, developed a basic national health system, which had earned praise from European observers prior to the British occupation in 1882. The prejudices expressed by British occupation authorities also elides the British government’s own stance in ongoing debates among European scientists about contagion and the appropriate methods for preventing the spread of diseases like cholera. The Anglo-Egyptian government’s response was based on imperial policies, racial prejudices, and scientific understandings that failed to adequately deal with the pandemic at the cost of 50,000 Egyptian lives.
In 1831, following a plague outbreak that took a heavy toll on the Egyptian army, Ottoman viceroy Mehmet Ali (1805-1848) contracted a French doctor, Antoine-Barthèlemey Clot, to oversee the creation of a health system to protect the military. Clot, a graduate of the University of Montpelier, argued that military and civilian health were intertwined. With the viceroy’s permission, Clot founded the Egyptian School of Medicine to train a cadre of Egyptian medical professionals that would serve both military and civilian health care needs. Given the strict gender segregation of Egyptian society, a parallel institution to train women in obstetrics and gynecology was established in 1837. Despite skepticism among European observers about the “Arab” capacity for higher learning, the medical school’s top graduates successfully sat for exams in Paris. They returned to assume faculty positions in Cairo; by the mid-1840s most faculty positions were held by Egyptians. In the 1840s, the first successful outreach into rural areas was achieved with a national vaccination campaign against smallpox, coupled with the establishment of hospitals and dispensaries in major cities throughout the Nile Valley. This began the process of transforming the Egyptian populace into consumers of state public health resources, especially of pharmaceuticals and outpatient care provided through the dispensaries. While investment in public health infrastructure stagnated after Mehmet Ali’s death in 1849, both schools of medicine continued to turn out trained professionals, and Egypt maintained one of the highest vaccination rates outside of Europe.
Egyptian autonomy was gradually lost through a series of fiscal crises in the 1870s, culminating in the British occupation of 1882. The late 19th century British imperial mindset was buoyed by the notion of science-as-progress; admitting that the colonies could compete with the metropole in scientific output ran counter to the mission civilisatrice. This attitude had a deleterious affect both on the medical schools and the public health system in Egypt. The School of Medicine was placed under British administration, and the female graduates were disenfranchised en masse in 1884. British officials who had previously been complementary about Egyptian health and medical institutions changed their positions soon after the occupation. Writing in 1877, Dr. James Grant, a member of the International Quarantine Board in Alexandria, stated optimistically that “The Public Health of Egypt was never better than it is now … The sanitary regulations have latterly been very strict and fairly carried out, so that no danger to the public health is now anticipated.” After the occupation, however, the Board routinely denounced the “unsatisfactory” and “filthy” condition of Egypt and called for outside assistance in correcting it. Many of the administrators in the Anglo-Egyptian government had previous experience in India, and were of the mindset that “oriental” societies were largely the same. If there was any chance these assumptions might be proven wrong in the Egyptian case, it evaporated with the handling of the 1883 cholera epidemic.
Contagion, Anticontagion, and Cholera
As Justin Stearns has explained, the traditional understanding of disease in the Islamic world was based in large part on Galenic (humoric) medicine, and debates about the existence of contagion created a substantial corpus of legal treatises on the matter. Orientalist scholars frequently asserted that Islam rejected the idea of contagion, and colonial administrators were quick to ascribe what they saw as “low” or “unsanitary” practices, especially among the poor, to a sense of invulnerability and fatalism springing from this belief. In particular, a (probably apocryphal) ʿAbbasid-era ḥadīth asserting that those who died of the plague would meet the same reward in the afterlife as a martyr was oft repeated in administrative circles. Such derision from European observers, however, elides the fact that in the mid-19th century the contagion vs. anti-contagion question was far from settled in European scientific circles, and remained a source of vigorous debate among scientists there. These opposing paradigms influenced the teaching of medical science in Europe, and the debate played out in the administration of the Egyptian School of Medicine once Clot stepped down from the directorship, as successive headmasters championed different schools of thought with each insisting that the school’s curriculum be rewritten to reflect their preferred medical paradigm.
The British government, motivated not only by the economic concerns of government spending on public health, but the far greater outcry that would result if trade out of Indian ports bound for the UK were to be quarantined, had adopted an anti-contagionist position more pleasing to British shareholders in Egyptian and Indian companies and shipping lines. Cholera was particularly concerning and troublesome, not least because of its short incubation period, spectacular symptomology, and very high mortality rate. A healthy-looking individual could, after experiencing high fever, cramping, and rapid expulsions of bodily fluids, be dead within a matter of hours. The mortality rate was over ninety percent; contracting the disease was a death sentence. When the disease appeared in Egypt in 1883, the Anglo-Egyptian government’s response was not only based on Egypt’s previous experiences with cholera, but also grounded in the imperial experience in India. As David Arnold observes: “[Cholera] made it possible, after the manner of Florence Nightingale, for Western observers to equate sanitation with civilization and find India woefully wanting in both.” These evaluative criteria would also be applied to Egypt with the same result. The British government also refused to recognize cholera as endemic to India, arguing that the disease had appeared in Europe, going so far as suppressing an 1867 report from the Government of India’s Sanitary Commissioner concluding that the disease was transmitted from person to person.
The 1883 epidemic
The first cases of cholera appeared in the Mediterranean port city of Damietta in late June 1883. When news of the disease’s appearance in Egypt was transmitted, European and Ottoman ports began to close both to Egyptian and British ships on the fear that the disease had been transmitted from India to Egypt through shipping lines. British officials first claimed that the outbreak was not cholera, but rather typhoid, dysentery, and “choleric fever”; when it became clear that the outbreak was, in fact, cholera, they insisted that the disease must have spontaneously originated in Egypt and that there was no validity to the theory that it had originated in India. However, while insisting that international quarantine efforts were futile, from the beginning of the outbreak, Anglo-Egyptian medical and consular authorities focused their efforts on attempts to control the disease’s spread within Egypt by restricting population movement through quarantines and sanitary cordons—measures that had been abandoned in India on the grounds that they were useless to prevent the spread of the disease.
The Conseil de Santé, the pre-occupation governmental organ charged with protecting public health, forwarded a number of recommendations to the Khedive intended to stop the spread of the disease. The Conseil was severely underfunded and unable to do more than issue recommendations and enact quarantines, whose actual maintenance was under military control. The government’s response was overseen by Sir Geyer “Guy” Hunter, the British Surgeon-General, who traveled to Egypt to “investigate” the origin of the outbreak, which, according to several sources, he had already determined would be found locally and not in India. The director of the Conseil, Salīm Pasha, attempted to withstand Hunter’s interference, but resigned in protest after Hunter’s report reiterated his pre-determined conclusion. Hunter and British Consul-General Sir Edward Malet then established an Extraordinary Sanitation Committee to deal with the epidemic; the now-irrelevant Conseil was disbanded the following February.
The stereotype of the fatalistic and ignorant “Oriental” pervaded administrative correspondence and English-language press coverage of the epidemic. Consular Surgeon Mackie despaired that, “The Egyptian lower classes consider all precautions to be impious; ‘God is great,’ they cry, and all is predestined; hence they obstruct the very little sanitary work that has been carried into effect.” The London Spectator reported an incident that was intended to convey the lack of order and discipline in Egypt in its sensational coverage of the outbreak:
While a man stricken with cholera was on his way yesterday in a cart to the hospital, the driver stopped opposite a café and gave the invalid a drink from a water bottle used by customers of the place. A few minutes afterward the sick man died opposite the largest café in Cairo. The only precaution taken in this case was to spring a little chloride of lime on the corpse. The cart then pursued its way.
One London editorial went so far as to suggest that the Egyptian lack of discipline and interest in controlling the disease were culturally ingrained because “the value for life is less vehement and potent in the Oriental, while the belief in a discernible destiny is stronger; … The Oriental is less terrified by the prospect of death and more profoundly impressed by the impossibility of escaping it when the time comes.”
At the same time, the press and administration alike complained about Egyptians attempting to circumvent quarantine measures. For the people trapped inside, these were not just a nuisance obstacle but a physical barrier between life and death. Residents fled through fields in the middle of the night in the hopes that soldiers would not see them, while others attempted—often successfully—to bribe guards to let them pass. The Times of India reported that “no one has any confidence in Egyptian administration … A military cordon of Egyptian soldiers has been placed around Damietta and Manṣūra, but anyone wishing to break it will only have to backsheesh [sic] the gallant soldier.” The daily press reports of the disease’s slow spread toward the capitol through the major towns of the Nile Delta caused panic; it is estimated that forty thousand people fled Cairo within the span of a week—in all likelihood this contributed to its spread into Upper Egypt. An illustration drawn during the epidemic shows panicked citizens of Būlāq (Cairo’s Nile port) boarding overcrowded boats in the hope of fleeing the disease (Figure 1). This contradiction inherent in the idea that “lazy and fatalistic” Egyptians would also resort to desperate measures to flee in panic from a disease with no effective treatment or cure was never addressed.
Figure 1. William James Palmer and Charles Auguste Loye. The Cholera in Egypt: Inhabitants of Boulak, Cairo, Crowding into Barges on the Nile (detail). 1883. Wood engraving, with watercolour and gum arabic, 31.7 x 47.6 cm. 5895i. Wellcome Library.
The Epidemic as Litmus Test
In the eyes of the British occupation, the cholera epidemic of 1883, and the population’s response to it was intrinsically linked to Egypt’s inability to rule itself, and therefore laid the groundwork to justify the colonial mission:
The Egyptians … are languid and lymphatic, wanting in energy and power of continued application … Their brain power is weakened from the same cause, though other causes, arising from the customs of Orientals, have their effect. … Until they are taught by sanitary medicine to improve their health and raise healthy children, their brain-power will remain deficient and self-government for the Egyptians … is, in my humble opinion, a thing of the far future…
Mackie officially stated his recommendation that lax Egyptian attitudes toward sanitation justified the British colonial presence in the country:
…the Egyptian has no appreciation nor experience of good sanitary arrangements, which he has never seen and never learnt. The sympathy of class for class is too little developed, if it exists at all; their value of life is too low to stimulate them to energetic action. Fatalism also has its effects … The Egyptian in this respect is the Egyptian of a hundred years ago. He deserves help more than blame; but it must be help administered with authority.
As we have seen, however, there was widespread understanding of basic health and hygiene in 19th century Egypt; what was lacking was an effective method of dealing with the 1883 epidemic. British officials were outwardly concerned with protecting English trade by insisting that the disease could not have originated in India. The disease’s rapid spread and the inability of the population to handle the epidemic by themselves justified the British administration of Egypt indefinitely.
A German team under Robert Koch was dispatched to Alexandria and tentatively identified the cholera bacillus. While Hunter initially rejected Koch’s findings, Koch’s final report in 1884 settled the contagion/anticontagion debate and highlighted the importance of clean water and sanitation. While public health was severely underfunded until the first decade of the 20th century, concrete measures were taken in the wake of the 1883 epidemic to prevent diseases like cholera and plague from spreading easily, particularly under the tenure of H.R. Green as Director of the new Public Health Department (1885-1891). Unlike both his predecessor and successor, Green firmly rejected the idea that problems of sanitation and hygiene stemmed from some inherent quality of the Egyptian people. Green argued strenuously that Egyptians would practice good hygiene, visit hospitals, and avail themselves of filtered water and sanitary toilets if they had access to them, and he faulted the Anglo-Egyptian government for not doing more to providing such services widely. Under his supervision, many of the country’s major cities were retrofitted with adequate sewage systems and the Anglo-Egyptian government dispatched clean water distribution to poor neighborhoods. These measures were largely successful; when cholera reappeared in 1895, the number of cases and fatalities were one third of what they had been in 1883.
Re-examining the 1883 pandemic gives us new clarity on the British determination to remain in Egypt for a longer period of time than initially proposed in 1882, as the epidemic itself was used as a justification that the country could not govern itself. The government’s one-size-fits-all approach to dealing with the epidemic in Egypt as would have been done in India was an abject failure. The 1883 cholera, as would be the case with the “Spanish” influenza pandemic of 1918, and now with the COVID-19 in 2020, social fault lines and divisions of social inequality were laid bare. In Egypt’s major cities, poorer neighborhoods suffered more than others because they had no access to clean water or emergency medical facilities; this was the case then as it is now. The 1883 epidemic also highlights the ways that scientific facts can be manipulated to support government policies in ways that run contrary to academic consensus. Then, as now, such measures also tend to cost lives for political purposes; with the passage of time such decisions by policy makers seem to have borne far too high a cost.
 J Mackie, “Cholera in Egypt,” The British Medical Journal 2, no. 1178 (July 28, 1883): 179.
 This story is recounted in LaVerne Kuhnke, Lives at Risk, Comparative Studies of Health Systems and Medical Care 24 (Berkeley and Los Angeles: University of California Press, 1990); and Chapter 1 of Khaled Fahmy, In Quest of Justice: Islamic Law and Forensic Medicine in Modern Egypt (Oakland: University of California Press, 2018).
 See Hibba Abugideiri, Gender and the Making of Modern Medicine in Colonial Egypt (New York: Routledge, 2016).
 David Arnold, Colonizing the Body: State Medicine and Epidemic Disease in Nineteenth-Century India (Berkleye and Los Angeles: University of California Press, 1993), 40–41.
 “Public Health in Egypt.” The British Medical Journal 1, no. 836 (January 6, 1877): 19.
 Justin K. Stearns, Infectious Ideas: Contagion in Premodern Islamic and Christian Thought in the Western Mediterranean (JHU Press, 2011); Justin K. Stearns, “Against ‘Flattening the [Curve of] Diversity of Approaches’ to Muslim Understandings of Contagion in a Time of Pandemic :: Part Two,” Islamic Law Blog (blog), April 29, 2020, https://islamiclaw.blog/2020/04/29/against-flattening-the-curve-of-diversity-of-approaches-to-muslim-understandings-of-contagion-in-a-time-of-pandemic-part-two/; Justin K. Stearns, “Against ‘Flattening the [Curve of] Diversity of Approaches’ to Muslim Understandings of Contagion in a Time of Pandemic :: Part One,” Islamic Law Blog (blog), April 28, 2020, https://islamiclaw.blog/2020/04/28/against-flattening-the-curve-of-diversity-of-approaches-to-muslim-understandings-of-contagion-in-a-time-of-pandemic-part-one/.
 Lawrence I. Conrad, “Medicine and Martyrdom: Some Discussion of Suffering and Divine Justice in Early Islamic Society,” in Religion, Health, and Suffering, ed. John R. Hinnells and Roy Porter (Kegan Paul International, 1999).
 Kuhnke, Lives at Risk, sec. introduction.
 Arnold, Colonizing the Body, 199.
 Sheldon J. Watts, “From Rapid Change to Stasis: Official Responses to Cholera in British-Ruled India and Egypt: 1860 to c. 1921,” Journal of World History 12, no. 2 (2001): 349.
 United Kingdom. Parliament, Circular Addressed to Her Majesty’s Representatives in European Countries on the Subject of the Recent Outbreak of Cholera in Egypt. Commercial. No. 27., C. 3729, 1883.
 United Kingdom. Parliament, “Supplement to the « Moniteur Égyptien » of July 9, 1883” in Correspondence Respecting the Cholera Epidemic in Egypt: 1883. Commercial. No. 34., C. 3783, 1883.
 Robert L Tignor, “Public Health Administration in Egypt under British Rule, 1882-1914” (PhD diss., New Haven, CT, Yale University, 1960), 63.
 James A. S. Grant-Bey, “The History of Hygiene in Modern Egypt, With Critical Remarks and Practical Suggestions,” in Transactions of the International Medical Congress. Ninth Session (Washington, DC, 1887), 440, https://play.google.com/books/reader?id=ivufAAAAMAAJ&printsec=frontcover&output=reader&hl=en&pg=GBS.PA436: “…he declared on the first evening of his arrival in Egypt, and in the presence of a mixed multitude of ministers of State, army officers, lawyers, doctors, etc., that the British Government had sent him to tell them that the cholera had taken its origin in Egypt, and had not been important, and he challenged any one to contradict him. … one could easily guess in what groove his investigations would run. It was but natural to suppose, therefore, that he would influence the newly-arrived English doctors to adopt his theory without any more investigation than he had carried out himself.”
 Grant-Bey, “The History of Hygiene,” 440. Grant spares no words in upholding Salīm’s position as morally correct, and states outright that Salīm’s successor was appointed on the sole basis that he loudly supported Hunter’s theory about the origin of the outbreak.
 Ibid; “The New Egyptian Sanitary Law,” The Lancet 123, no. 3161 (March 29, 1884): 572, https://doi.org/10.1016/S0140-6736(02)22529-5.
 J Mackie, “Cholera in Egypt,” 179.
 “Plague-Ridden Egypt: The Cholera Still Spreading-Sanitary Measures Sadly Neglected,” The New York Times, July 21, 1883.
 “Plague and Panic: How the Europeans and the Orientals Face Death. From the London Spectator,” The New York Times, July 23, 1883.
 “The Cholera Epidemic in Egypt. (From Our Own Correspondent),” The Times of India, July 11, 1883.
 “Cholera in Egypt from a French Point of View.” The Lancet 147, no. 3782 (February 22, 1896): 497–98. https://doi.org/10.1016/S0140-6736(01)93229-5.
 J Mackie, “Cholera in Egypt.” The British Medical Journal 2, no. 1185 (September 15, 1883): 541.
 Mackie to Granville, July 7, 1883, 23.
 “The Sanitation of Egypt.” The British Medical Journal 2, no. 1391 (August 27, 1887): 477.
 Christopher S. Rose, “Implications of the Spanish Influenza Pandemic (1918-1920) for the History of Early 20th Century Egypt,” Journal of World History 32, no. 2 (tentative) (2021); Christopher S. Rose, “The ‘Spanish Flu’ in Egypt,” Christopher S Rose (blog), April 10, 2020, https://christophersrose.com/2020/04/10/the-spanish-flu-in-egypt/.