WIELDING A BIG STICK, CAREFULLY, AGAINST SARS
20 Apr 2003
Source: New York Times, April 20, 2003
Wielding a Big Stick, Carefully, Against SARS
By DONALD G. McNEIL Jr.
"Public health generally doesn't go swinging the heavy hand of the law," Dr. Colin D'Cunha, the chief medical officer of Ontario, said recently, after asking an estimated 10,000 Canadians to put themselves in voluntary quarantine to stop the spread of severe acute respiratory syndrome, or SARS. "By nature, we're not police persons. We believe in being reasonable. But we'll take steps if we need to."
Despite his mild words, extraordinary powers are available to Dr. D'Cunha, as they are to public health officials around the world. The authority to declare quarantines to stop the spread of disease is no less sweeping today than it was for Dr. Cyrus Hudson, the New York City health commissioner during the cholera outbreak of 1892, who told a Congressional committee, "If we see fit, we may take possession of the City Hall forcibly and turn it into a contagious-disease hospital."
Over the last three months, as SARS has spread from southern China to at least 25 other countries and regions, sickening an estimated 3,457 people so far and killing 182 of them, health officials have imposed ever-stricter measures to stem it.
According to experts in the history and law of quarantine, the most draconian laws are seldom needed because frightened citizens usually cooperate. But such laws are on the books virtually everywhere, though they can backfire, driving infected people underground, as did early threats to lock up anyone with AIDS.
In the face of any epidemic, health officials can generally isolate the infected and anyone in contact with them, restrain the sick if they resist treatment and close down whole institutions, from hospitals to bathhouses.
"They have such an enormous latitude of powers that maybe we don't even want to think about it," said Dr. Howard Markel, a medical historian and the author of "Quarantine!" a history of New York epidemics.
In China, after a halting response to the first SARS outbreak last fall, the authorities have ordered that everyone exhibiting SARS symptoms, including foreigners, must be hospitalized. Students are to be examined daily, and whole trainloads of passengers have been ordered to report symptoms.
In Singapore, where even littering laws are strictly enforced, people suspected of having SARS have been confined to their homes with Web cams watching them and electronic bracelets waiting to alert the police if they slip out.
And in Taiwan, the authorities clamped down late but hard, ordering all travelers from China and all visitors to hospitals to have their temperatures taken. Anyone showing symptoms is to be quarantined, along with their relatives and contacts. The government has offered a $72 bounty for reporting a suspected case.
But even in long-established democracies like Canada and the United States, the winged caduceus that serves as an emblem of medicine can also be a nightstick
Last week, in an extraordinary step, the Province of Ontario took out newspaper ads asking anyone with even one SARS symptom to stay home, and avoid family and church over the Easter weekend. (The symptoms include fever, cough, aches, pains, shortness of breath or fatigue.)
Ontario had previously isolated 7,000 people at home, made phone calls and sent investigators to check on some and posted a police guard on one hospitalized patient who was uncooperative.
Thus far, health authorities in the United States have taken no such measures. Under the stricter definition of SARS used by the World Health Organization, the nation has only 36 cases, none of them fatal yet. Federal officials look into each one, and the Centers for Disease Control and Prevention recommend the isolation of anyone showing signs of SARS. No one has been held involuntarily and healthy contacts have not been asked to quarantine themselves.
But broad federal and state powers exist, and "most go back to the pre-antibiotics era, when rough and ready isolation was a common means of containing disease," said David P. Fidler, a specialist in infectious disease and international law at the University of Indiana Law School.
At one time, New York Harbor even had three quarantine islands: Ellis Island for the federal government, Hoffman for the state and North Brother for the city.
The Federal Quarantine Act was passed in 1878. Just two weeks ago, President Bush added SARS to the list of diseases that federal officials may use to stop an immigrant at a frontier or, under powers to regulate interstate commerce, a citizen at a state border. It joined cholera, diphtheria, tuberculosis, smallpox, yellow fever and Ebola and other hemorrhagic fevers.
But "having the authority to do it and doing it are two different issues," said Dr. Martin S. Cetron, chief of the C.D.C.'s global migration and quarantine division.
Even now, he said, anyone with infectious tuberculosis is routinely isolated.
Most cooperate voluntarily, but during the New York City outbreak of drug-resistant tuberculosis in the early 1990's, patients who refused medication "were, in effect, put in lockup on Roosevelt Island," Dr. Markel said.
Still, health officials are often reluctant to use their most sweeping powers, fearing they may serve to drive infected people away from treatment or into hiding. And shutting borders can cause economic disruption; pursuing individual carriers often makes more epidemiological sense. The Chinese government says that at the beginning of Easter weekend, about 64,000 people crossed the border between Hong Kong and Guangdong Province, on the Chinese mainland. Stopping them all to ward off a handful of carriers would not be efficient.
Bans may also be inappropriate, Professor Fidler said. A decade ago, the European Union, afraid of an East African cholera outbreak, restricted all fish from the area, punishing African fishermen even though scientists said that antibiotics could cure any case of cholera.
Dr. Markel says the world tends to overreact to epidemics, and their very novelty creates irrational fears. In 1892, Hamburg, a major port, lied about its cholera outbreak for fear of hurting commerce, just as China did this year. And while anthrax and SARS spread panic, flu fails to make millions of Americans nervous enough to get vaccinations, even though it kills 36,000 a year.
Still, Dr. Markel said, quarantines have slowly become much more humane.
The term comes from the Italian quaranta giorni — 40 days, the length of time ships with plague aboard had to sit at anchor in Venice's harbor in 1374 while the crew either died or recovered. Until the late 19th century, quarantines were run on that model — "separating out the sick," as Dr. Markel put it, "to cut your losses."
Tuberculosis sanitariums changed that thinking somewhat. The sick — those who could afford it — were separated, but given fresh air, food and exercise in the hope that some would recover. With the advent of antibiotics, Dr. Markel said, "people are put in a hospital and given medication."
"In the '94-95 Ebola virus scare in Zaire, they were careful to treat them well," he said.