Vaccination certificate in the Ottoman Empire against a pandemic during the period of Sultan Abdul Hamid-ll in 1908 (1326 AH)
Infectious diseases and pandemics leading to mass deaths are a reminder of how intimately connected we are. Even with those who we have no social relationships, the simple act of being present in relatively close proximity is enough to have an imperceptible but potentially devastating physical impact on one another. Governments tackling this problem with public health measures is not a historically unique feature of our modern time. In terms of Islamic history, this goes back to the early days of Muslim polity, starting with the Caliph ‘Umar ibn al-Khattāb RA who was faced with an outbreak in the Shām region that eventually became known as the Plague of ‘Amwas. It’s interesting to note that an important element in his response was based on a directive of the Prophet Muhammad ﷺ in a Hadith related in the Collection of Imam al-Bukhārī stating that, “If you hear of an outbreak of plague in a land, do not enter it; but if the plague breaks out in a place while you are in it, do not leave that place.” The concern with formulating a response rooted in “Has anyone heard the Messenger of Allah ﷺ say anything about this?” is unfortunately foreign to many Muslims today who decry scholars and imams imploring their communities to get vaccinated and citing religious reasons for doing so.
An important factor in the response to our current COVID pandemic is the roll out of a number of vaccines. Contrary to a common misconception, the primary goal of these vaccines is not the prevention of infections per se. Rather, it’s the prevention of severe disease and mass hospitalizations. In this regard, despite the number of breakthrough infections and reports of high viral loads seen with the delta variant, currently available vaccines have been overwhelmingly successful in achieving their goal. In doing so, COVID vaccines have likely saved millions from developing long-term neurological and psychiatric problems that are diagnosed in over 30% of patients diagnosed with COVID. They’ve also succeeded in reducing the potential pressure on hospital admissions that would’ve had a flow on effect causing additional deaths in patients that continue to need hospitals for any other serious health crisis requiring hospitalization, including heart attacks, traumatic accidents, strokes, and the like. Indeed, with the majority of hospitalizations being among the unvaccinated, the new wave of infections has been dubbed the pandemic of the unvaccinated as those individuals according to the latest data were found to be 5 times more likely to become infected and 29 times more likely to be hospitalized.
Despite their demonstrable success and vital role as a public health response, COVID vaccines continue to garner the ire of a small but loud segment of the population. One must be careful not to essentialize this group of people who are not willing to receive the COVID vaccine because the reasons they provide are diverse. However, they do have a number of features in common, including the distrust of expertise, rejection of authority, and the privileging of individual liberty over public duty. Such groups are not historically unprecedented. What makes our time unique is the ease by which misinformation and disinformation can spread in online echo chambers combined with the democratization of platforms. A biologist with no training in medicine or public health can cast doubt through his podcast on the conclusions numerous experts in the fields where he has no training in have arrived it. The layperson who also has no training in medicine or public health will listen to this biologist and his or her agreement or disagreement with the biologist’s conclusion will ultimately be on based on ideological commitments and trust, not on a genuine understanding of the scientific process or available research. Combined with the concurrent pandemic of the Dunning-Kruger effect, governments today are faced with the dilemma of rolling out public health strategies to prevent a catastrophe of the scale last seen with the 1918 flu pandemic, while at the same time limiting their mandates to maximize their efficacy without infringing on people’s freedoms. It’s the perennial problem of determining where personal liberty to act in a certain way begins to infringe on others’ personal freedom not to be harmed by one’s actions.
Instead of directly forcing everyone to get vaccinated against COVID, a number of governments are taking the indirect approach of vaccine passports to remove limitations on mass group gatherings and movements, as well as allow workers in health care sectors to continue in their jobs. The principle underpinning this move is a simple one: this virus depends on people congregating together to spread, and those under the care of health care workers are the most vulnerable to severe complications if they become infected. The idea of vaccine passports is not new. First generation immigrants are all too familiar with proof of vaccination requirements that form an integral part of the immigration process. Most of us had a vaccination record that was updated periodically during our primary education. In health care, proof of vaccination against additional diseases is part of the job application. Historically, vaccine passports date back to 1897 when a vaccine against the bubonic plague was developed by Waldemar Haffkine and a verification of vaccination became a requirement in British India, which was resisted by the people given the colonialist context.
Below are excerpts from a 2020 article Mandating immunity in the Ottoman Empire: A history of public health education and compulsory vaccination by Emine Ö. Evered and Kyle T. Evered. The authors provide a historical account of how the Ottoman Empire was engaging in public health efforts to control smallpox outbreaks, including education initiatives directed at rural regions who were skeptical of therapies they were not familiar with, and vaccination mandates that came with proof of vaccination certificates and fines for noncompliance. Granted, a great deal of their plans never materialized given the immense resources required and the fact that the Empire was in its final days. However, among the many lessons to be learned from this historical record three are worth noting:
- The concern for public health and controlling infections outbreaks using the scientific method and latest medical knowledge is in the interest of the Muslim community
- Public health efforts to ensure the overall wellbeing of the community and safeguard the health of the vulnerable are within the scope of government duties to the public, which may include the rolling out of education programs and mandates
- Islamic law is recognizes the authority of relevant expertise to guide the implementation of policies that serve the demonstrable good of the community
The 1827 foundation of the Ottoman Mekteb-i Tıbbiye-i Adliye-i Şahane (Imperial School of Medicine; hereafter MTAŞ) under Sultan Mahmud II (1785–1839) was a major development in modern medical education and public health. In 1839 (when Mahmud II died of tuberculosis), when his imperial reforms enhanced accessibility for minority faculty and students, the school increased its attention to smallpox. In 1840, Sultan Abdülmecid I (1823–1861; who also died of tuberculosis) issued a ferman (an Ottoman royal mandate, as distinct from laws derived through the Ottoman Council of Ministers) declaring provision of all vaccinations at no cost. In 1845, Şeyh-ül İslam (the leading religious authority) Mekkizade Mustafa Asım Efendi (1762–1846) issued a fetva (a binding religious ruling) that declared, because smallpox had devasting effects on children—and Muslim physicians attested to vaccination’s soundness, that Islam endorsed the practice. By extension, the sultan’s order to vaccinate the public was both legitimate and obligatory.
Despite being in the grip of persistent domestic and geopolitical turmoil—and its failure to effect the 1885 and 1894 laws’ provisions, the empire responded to continuing outbreaks by enacting further public health regulations into the twentieth century’s initial decades. The first emerged in 1903 and the second in 1915. As with the 1894 law, each further specified and expanded on preceding ones. In both, new provisions noticeably extended the empire’s influence to encompass a wider demographic; employed workers, migrant and nomadic populations, and more local community residents. If implemented, the laws would each conspicuously augment the scope and depth of information collected by the empire regarding its citizens.
The 1903 regulation moved beyond prior laws’ focus on children, military servicemen, state employees, and students to include all workers employed by factories, businesses (e.g., stores or hotels), and other concerns, whether men or women, or paid daily or monthly. Its first article stipulated all workers to be vaccinated for smallpox, unless they could prove prior vaccination or infection. Expanding to include migrants, the second required vaccination of all domestic and international migrants. This provision was especially important then as the empire experienced increasing waves of internal and international migration within and from beyond its borders due to socio-economic, political, and conflict-induced displacements. The third enhanced the first, holding accountable owners, administrators, and managers of industrial and commercial sites (e.g., businesses and hotels)—and educational directors and principals—for entries of unvaccinated people into their factories, businesses, and schools. If guilty of such dereliction, the accused would be fined accordingly.
After a severe 1845 epidemic, authorities mobilized to educate the public and make the cowpox vaccine available. Early efforts focused on the empire’s youngest citizens. Published in 1846 by order of Sultan Abdülmecid I, the 48-page treatise Menafiü’l-Etfal (“Benefits to Children”) provided clear evidence of this agenda’s rationale. There is no stated author for the publication—despite erroneous attributions to an I. Pasha in several historical sources (“pasha” was an official title; not a surname), but it was likely penned by a MTAŞ physician. Printed in Ottoman Turkish and in languages of three leading ethno-linguistic and religious minorities (i.e., the Armenian, Greek, and Jewish communities), its purpose was to make information accessible and legible. Beyond its multiple languages of publication, it revealed a political shift among leaders of the empire to position themselves evermore proactively to assure public health. A major area of emphasis became prevention.
Following Menafiü’l-Etfal‘s introduction, the text inferred imperial goals for universal inoculation. As noted in the treatise, a critical obstacle preventing attainment of this ambition was the fact that rural areas lacked expert doctors and were often afflicted by ill-informed would-be apothecaries. Such charlatans allegedly visited remote communities, bled the villagers, applied leaches, and so forth, but typically left their victims enfeebled by the ordeal; citizens were thus wary of new and nontraditional therapies.
In subsequent articles, the empire’s grasp notably extended to encompass all communities, their religious and civic leaders, and residents. The thirteenth article required each imam or muhtar for the capital, other cities, towns, villages, and districts to complete and send a birth notification for each newborn within one month of delivery. The next specified that each notice received by the Ministry of Interior’s general administrative office for birth records would be recorded, then sending imperial birth certificates back to community leaders to redistribute to infants’ families. This birth (and health) document thus served as one of citizenship (an ilmuhaber), as well. The law indicated that all services would be conducted at no cost. Along with these duties, local leaders were required to certify each citizen’s vaccination status whenever they sought state employment. The imam or muhtarwould provide an affidavit that they verified the person’s vaccination record and include the vaccination’s date and registration number for corroboration. To ensure compliance, the subsequent article specified fines for any imam or muhtar who neglected their duties.
Amid the empire’s entry into World War I (1914–1918) and ongoing internal conflicts with minority communities, in 1915, it issued another smallpox-related regulation; it prohibited any citizen to willfully or otherwise evade inoculation. The law’s first article declared that “every person in the Ottoman Empire must be vaccinated three times by the age of nineteen”. The next specified vaccination within a newborn’s first six months and again at ages seven and nineteen. It also superseded 1903’s migration provisions; it stipulated vaccination of each immigrant at their first point of entry rather than at their eventual location of residency. Regarding internal migration, the law mandated pastoral nomadic tribe members’ vaccination when subjected to sedentarization at their eventual sites of settlement. Reflecting fears that arose decades earlier regarding variolation making recipients vulnerable to other diseases that beset the empire (e.g., syphilis, cholera, tuberculosis, and others), the law required subsequent vaccinations to be conducted only in a “scientific manner” utilizing “vaccine tubes” for administration, adding that “vaccination from person-to-person is absolutely prohibited”. While the 1915 law and its anticipated approaches for implementation clearly had gaps that left out segments of the population, it was an effort towards accounting for most “every person in the Ottoman Empire”
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