Between 1831 and 1914, cholera spread from India to Mecca and the Hijaz on at least forty separate occasions. Between 1817 and 1947, it is estimated that at least 38 million Indians died of cholera. During this period, colonial India experienced an ecological and demographic implosion. While climatic factors, such as altered El Niño Southern Oscillation (ENSO) patterns and the repeated failure of the monsoons certainly contributed to colonial India’s catastrophic mortality rates, the synergistic relationship between drought, famine, malaria, plague, and cholera were in fact man-made crises, born of the British Empire’s unjust agrarian, environmental, economic, and political systems. Working in tandem, vicious cycles of famine, dislocation, and disease set into motion a cascade of public health crises that would assume global proportions for the better part of the long nineteenth century. Though cholera had long been endemic in Bengal and the Ganges Delta, over the course of the nineteenth century it rapidly transgressed its previous boundaries. Unlike the outbreaks of pre-colonial times, however, new patterns of British trade and military movement, eventually intensified by steam and rail, created entirely new circuits of transmission, allowing to India’s disease pool to spill over into the Red Sea and the Persian Gulf, leaving the Ottoman state to defend itself (and the rest of Europe) against colonialism’s ecological fallout. This paper traces the development of Ottoman quarantine and public health controls in the Hijaz, Red Sea, and Persian Gulf between 1865 and World War I. Typically, the Ottoman Empire’s role in questions of quarantine and international sanitary regulation has been overshadowed by concerns of Europe. The nexus between the Hijaz, pilgrimage and quarantine has been well covered in the history of public health, but has focused primarily on Europe, Egypt, and British India. By contrast, this paper asks what the Ottoman response to the crisis of Indian Ocean cholera looked like. It explores why the Ottoman state took such an enthusiastic role in the erection of international quarantines. It outlines what the Ottoman state hoped to achieve through its participation in international quarantine regulations directed against the hajj. Was this merely a defensive policy or did cholera and the erection of the Red Sea quarantine system play a constructive role in the late Ottoman resurgence in the Arabian Peninsula? And conversely, what were the limitations of Ottoman sanitary discipline on its Red Sea frontiers?