ARE QUARANTINES BACK?
14 Apr 2003
Source: Los Angeles Times, April 14, 2003
Are quarantines back?
The practice has been used around the world for centuries. SARS is putting it back in the public consciousness and raising questions about its effectiveness.
By Melissa Healy, Times Staff Writer
For five passengers aboard an American Airlines flight from Tokyo earlier this month, it was a dilemma worthy of reality television: Go with Santa Clara County health authorities and risk being held in quarantine for hours -- maybe days -- for no good reason. Or go home, make the next connection or get to that business meeting, and risk spreading a potentially deadly new disease to family, fellow passengers and business associates.
Emergency vehicles had the aircraft surrounded, and across the nation, Americans watching on live TV got a new look at an old weapon in the fight to protect the public's health: the quarantine.
Dating back to the days of bubonic plague, the quarantine is a notion that had fallen on hard times in the turn-of-the-millennium United States: a government detaining and holding apparently healthy American citizens, potentially against their will, because they might be carriers of a contagious disease.
But in an age of mysterious diseases like Severe Acute Respiratory Syndrome, or SARS, and of bioterrorism threats like smallpox, the quarantine is staging a comeback.
Aboard American Airlines Flight 128, the five passengers who suffered flu-like symptoms on April 1 stepped aboard waiting ambulances and went willingly to a nearby hospital to be screened for the SARS virus. Another two chose the "every man for himself" route: They refused to go with authorities and went on their way, with a promise to call if they became ill. In the end, none of the five actually had SARS, and all survived.
By April 4, President Bush signed an unusual executive order that would add SARS to a list of diseases for which federal health officials may quarantine U.S. citizens against their will. It was the first such action since 1983, when the dreaded Ebola virus was added to a pantheon of epidemics that includes tuberculosis, leprosy, smallpox and cholera.
The president's action came after Santa Clara County health officials complained they lacked the authority to order the detaining or confinement of possible SARS patients. Though the president's executive order doesn't give county health officers that right, it does allow the U.S. Centers for Disease Control and Prevention, backed by federal law enforcement personnel, to do it instead.
Experts warn that the president's action might set up a legal tussle over who -- state officials or the federal government -- should be in charge in a public health emergency. And that, they say, is only one of many problems that could paralyze the system at a time when decisive action might be needed to stop a disease from spreading like wildfire.
Mainly, the quarantine seems to be a colorful anachronism in an age and a country devoted to protecting the rights of the individual.
The word "quarantine" comes from the Latin word "quaresma," or "40." That's a reference to the number of days that merchants and sailors arriving in Venice during the 14th century were forced to stay in the "House of St. Lazarus" when arriving from places thought to harbor bubonic plague. By the end of 40 days of sequestration, Venetian health officials reasoned, the travelers would be free of plague -- or dead.
In the United States, the history of quarantines is long and fitful. Throughout the 19th and early 20th centuries, outbreaks of tuberculosis, smallpox, scarlet fever, leprosy, cholera and bubonic plague prompted periodic quarantines throughout the nation. When these quarantines were challenged, courts invariably defended the state's authority to act: Quarantine, the Supreme Court ruled in 1909, does not thwart constitutional rights, since individuals have no right to harm others.
But though quarantines were frequently effective in protecting the public from the spread of illness, they can be a blunt instrument, and have often been abused or misapplied. Fears of cholera and yellow fever led authorities in New York and San Francisco to quarantine scores of immigrants -- often from unaffected countries -- throughout the late 1800s and early 1900s.
In 1900, the death of a Chinese laborer suspected of having bubonic plague in San Francisco prompted authorities to quarantine that city's entire Chinatown district. Trapped behind crude barriers and barbed wire, and experiencing food shortages, San Francisco's Asian population successfully challenged the measure as an act sparked by racial bias rather than concern for public health. Public fear of polio, more recently, prompted quarantine measures that continue to reverberate in today's debates. During a 1916 outbreak in New York, authorities made house-to-house searches and, in some cases, forcibly removed children from their homes if they were thought to have polio. At the height of the polio scares of the 1940s and '50s, children at risk of developing polio also were separated from their families, sometimes in the absence of symptoms, and placed in quarantine facilities. Schools and public swimming pools were closed in an effort to stop the spread.
Today, federal officials have broad rights, through the Centers for Disease Control, to examine and quarantine foreign citizens coming into the United States if they may be carriers of communicable diseases. And state and local officials across the country have broad powers to detain Americans -- to isolate them, in public health parlance -- if they are clearly ill with a contagious disease and they resist treatment. Patients who appear in hospital emergency rooms with tuberculosis, for instance, can be arrested if they try to leave against medical advice.
But that leaves plenty of holes for germs to slip through and become epidemics in this country. Officials can stop well people if they are foreign, and Americans if they are sick. Try to detain healthy American citizens, however, and that raises thorny legal and social problems. How do officials avoid charges that quarantines are based on racial or ethnic "profiling"? Do they have to compensate a hospital if they declare some part of it a "quarantine zone" and regular patients flee to avoid disease? How long can they bar someone without symptoms from going to work, and who's to blame if a worker loses pay or gets fired as a result? Can they separate a child from parents or family and treat the child without their consent?
Most states, including California, have laws on the books that are "antiquated, inconsistent and very often ineffective," says Lawrence O. Gostin, a law professor at Georgetown University in Washington. Many state and federal laws are virtually unenforceable because they lack the kinds of civil liberties protections that modern-day courts have come to expect: If someone believes he's been quarantined unfairly, for example, can he appeal to a judge?
Gostin has drafted a model law that aims to give public health officials tools, and regular citizens protections, in a health emergency. But while versions of his bills have been adopted by 22 state legislatures, they have run into a buzz saw of opposition in others. When Assemblyman Keith Richman (R-Granada Hills) introduced a version of Gostin's law in the California Legislature last year, it faced unusually broad opposition, not only from civil-liberties advocates but also conservative family-rights groups and wary hospital administrators. Richman's Emergency Health Preparedness Act was scuttled without debate.
This year, aided by SARS and what he sees as a growing public willingness to prepare for public health disasters, Richman believes his bill will win more serious consideration.
"Those people who think you can have all your civil liberties and all your public health are overly simplistic," says Gostin. "There are times when we'll need to override individual will for the good of the community. But in the modern United States, we are so focused on the salience of autonomy that we forgot the tradition of the common good."
Richard Daggett, 62, of Downey has seen two sides of that America and has little doubt of where he comes down. When Daggett was 13 years old, his parents willingly surrendered him to an isolation ward established at what was then Los Angeles County General Hospital, after he awakened with a stiff neck. It was 1953, the country was gripped with fear of polio, and people trusted doctors and government officials when they gave advice, says Daggett. It would take several days to confirm, but young Daggett did have the disease, and he spent six months in an iron lung.
As Daggett watched the drama in San Jose of American Airlines Flight 128 unfold on TV, he shook his head in wonderment. "I would have been one of those [passengers] who went" when authorities asked, he says. "If I had something contagious, obviously I wouldn't want to give it to my loved ones. But many people have other things on their mind.... It's part of this more individualist mind-set."
It's not that way everywhere, however, and several nations' response to SARS have provided stark illustrations of differing national attitudes about limiting individuals' rights in the interest of the public's health. When health officials in Singapore discovered a dozen nurses were infected with the virus, they ordered almost 1,000 people who had had contact with SARS victims to stay quarantined in their homes for 10 days, threatening stiff fines for those who failed to comply. Closer to home, Canada appears to be navigating a difficult course in its bid to curb the SARS contagion. In Ontario, where the outbreak of SARS has been most severe, officials have called on large groups of people exposed to the virus to stay home voluntarily, even when they feel well. While most have complied voluntarily, a few refused to stay home. Last week, Ontario health officials responded by ordering compulsory quarantine for nine people.
Dr. Trish Perl, director of epidemiology and infection control at Johns Hopkins University Hospital in Baltimore, fears that that a mandatory quarantine in the United States -- if ever needed -- would be "a nightmare" because so little is known about how, or whether, it would work. Perl is counting on Americans, when asked to stay home or report to quarantine stations, to rise to the occasion without the strong-arm tactics.
"That's probably me being a Pollyanna," Perl says with a laugh. "But I have tremendous faith."