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Last Updated

30 Apr 2003

Source: Wall Street Journal, April 30, 2003


With Few Cases in U.S., Patients Accept Isolation and Quarantine


Voluntary isolation and quarantine are working well to contain the small number of SARS cases in the U.S. But if the outbreak mushrooms as it has in Asia, officials worry that more sweeping measures could strain the system and erode public compliance.

With just 52 cases in the U.S. -- a small fraction of the more than 5,400 cases of SARS globally -- isolating the sick and quarantining the exposed have so far been mostly a matter of persuasion. But overseas in major centers of SARS infection, some frightened people have tried to escape isolation and quarantine. In rural China, residents rioted over concerns that sick people would be quarantined nearby.

Earlier this month, President Bush signed an executive order adding SARS to a list of diseases for which quarantine can be ordered, but as a practical matter most quarantine actions are taken by state and local officials. Many U.S. states have a patchwork of quarantine laws dating to the 19th century. Twenty-two states have passed all or part of a Model Emergency Health Powers Act to update state powers. But the proposed statute spawned acrimonious debate over its potential impact on civil liberties.

Health authorities haven't needed to impose the sweeping quarantine measures used in the early 20th century for outbreaks of plague, yellow fever or smallpox. Currently, in New York City, voluntary isolation has worked to contain all but one of the city's 20 suspected or probable SARS cases. One man who resisted was temporarily placed in involuntary isolation at a hospital after refusing to comply.

In San Francisco, health officials threatened a court order to persuade one reluctant SARS sufferer to be confined, said director of epidemiology Susan Fernyak. Isolation is enforced with random phone calls and nurse visits, she said.

"I'd be livid if I had to stay in my house for 10 days. That doesn't change the public health necessity," Dr. Fernyak said.

The city's health department also has had to fight rumors and hysteria.

"We've gotten calls from offices saying, 'Susie in the cubicle next to me just got back from Hong Kong. Can you call the boss, and tell her to go home?' " Dr. Fernyak said. She declined to take such action. Moreover, when Internet rumors falsely accused a local dim sum shop of having an infected employee, Dr. Fernyak drank tea and held a news conference with the proprietor.

In Santa Clara County, Calif., home to Silicon Valley, "Voluntary measures have worked pretty well," said Joy Alexiou, a health department spokeswoman. There, officials have counted three probable and four suspected SARS patients amid look-alike flu cases.

"If it became a mass quarantine, the question is whether any agency would have the resources to enforce it," Ms. Alexiou said, recalling that when the Amoy Gardens apartment complex in Hong Kong was quarantined, people tried to flee. "That's why quarantine is a last resort. It's a shock to the body politic."

History suggests sweeping quarantines stiffen public resistance. An outbreak of bubonic plague in 1900 in San Francisco triggered a race-based quarantine of thousands of Asians in Chinatown, provoking lawsuits and riots. The New Orleans yellow fever epidemic of 1905 saw initial resistance from parish priests and brothel madams, and a "shotgun quarantine" by farmers preferring self-isolation to federal control.

In recent years, the most frequent exercise of quarantine powers has revolved around tuberculosis patients who have been isolated in hospital, sanitoriums and jail facilities or at home, says Georgetown University law professor Lawrence Gostin, author of the model act. He worries about large-scale natural outbreaks or bioterrorism.

"The U.S. is highly unprepared for a mass quarantine," Prof. Gostin says. He cites the lack of hospital isolation rooms and absence of dedicated quarantine facilities. Quarantine of healthy and infected people together risks spreading the infection. "You're asking individuals to forgo liberty for the common good [but] you owe them safety and humane treatment."

Still, given the current small SARS outbreak, Diana Bonta, head of California's health department, said her state's 54 counties have all experienced good compliance. One isolated patient even called the public-health nurse monitoring him by phone, Dr. Bonta said. "He said he was going to be in the shower, but told her not to worry, because he was still home."

Amid plunging Chinatown business as a result of SARS fears, a few San Franciscans have taken to elective self-quarantines to reassure patrons. In Chinatown, behind the counter of the Sweet Mart confectionery, Winnie Lo said she returned from a purchasing trip to Hong Kong in March and, though perfectly well, went straight into home quarantine. "I stayed home for 10 days because I don't want my friends to be afraid," she said.