The power to quarantine is as "American as apple pie."
by David Kravets
"I'm not willing to stand here and let my civil rights be violated when it's not science-based."
Those were the recent words of nurse Kaci Hickox, who successfully fought Maine's 21-day home quarantine order last week after she returned from treating Ebola patients in Sierra Leone.
Hickox first made headlines last month after she was detained in a plastic isolation tent near the Newark airport and later transferred to Maine. The 33-year-old Hickox then defied Maine's stay-at-home quarantine orders and went on a bike ride, prompting a showdown of sorts. Hickox's defiance highlighted the science, fear, hysteria, and politics surrounding a disease that has no cure but just arrived to the United States—with four known cases nationwide—from Ebola-ravaged West Africa.
“We have been researching this disease for 38 years, since its first appearance in Africa. And we know how the infection is transmitted from person to person. And we know that it’s not transmitted from someone who is asymptomatic, as I am and many other aid workers will be when they return," Hickox, who worked for Doctors Without Borders, told Meet the Press Sunday.
Hickox's plight demonstrates the powers that health officials—from the federal level to every state—have when it comes to preventing infectious diseases. And because time is of the essence to stop an outbreak, officials don't need a court's authority to involuntarily confine someone. As New York attorney and CNN analyst Paul Callan described those powers, they're "as American as apple pie" and date on the books back to the 1872 battle against yellow fever.
In Texas, where Ebola-infected patient Thomas Duncan from Liberia was the first and only US patient to die last month, it's a "criminal penalty" for anybody who "refuses to perform or allow the performance" of quarantine measures. People close to Duncan were quarantined in Dallas and kept under police guard. Those quarantined included his girlfriend, two men, and a teenager. They were not allowed to touch anybody, including one another. Duncan was cremated and his belongings were incinerated, but even those ashes were caught in a legal limbo, amid a battle over what US state they'd be buried in.
Duncan died October 8 at Texas Health Presbyterian Hospital, infecting treating nurse Nina Pham, who recovered from the disease. Nevertheless, a climate of fear gripped the nation. Would the United States become West Africa—Guinea, Sierra Leone, and Liberia—for example, where some 5,000 people died in the latest outbreak, another 13,000 were infected, and no reliable cure is available?
History on repeat?
The quarantine concept isn't new by any means. In the past, an affected area within the US could be as small as a Washington state residence with diphtheria, as shown above, or it could be on a much greater scale. Ships with disease-laden passengers entering America were being quarantined as early as 1758 at the site today where the Statue of Liberty rests. And as many as 420 people reportedly died while being quarantined at Ellis Island between 1909-1911.
So the Hickox quarantine is a tiny affair relative to long-term US quarantines. For example, there was a wholesale quarantining of the Chinatown district in San Francisco more than a century ago. In 1900, the city erected a barbed-wire fence [PDF] around Chinatown after a Chinese laborer, suspected of having Bubonic plague, died. Wendy Mariner, a Boston University School of Public Health professor, said the quarantine was "struck down by the courts because it essentially quarantined the healthy with the sick" and was "highly discriminatory."
According to the National Park Service:
While the cause of death was still undetermined, a cordon was placed around Chinatown, and no Chinese American was allowed to leave the area bounded by California, Kearny, Broadway, and Stockton streets. This restricted the freedom of movement of people, some of whom were American citizens. It caused them many hardships, for they had difficulty in obtaining goods and services from people outside Chinatown. There was a shortage of food, and prices increased sharply. Chinese American businessmen faced a loss of income, and workers a loss of wages. Finally, after three and a half months, it was found that there were no cases of bubonic plague within Chinatown. This lengthy quarantine of Chinatown was motivated more by racist images of Chinese as carriers of disease than by actual evidence of the presence of bubonic plague.
The list goes on. That same year in Maui, Hawaii, "the Chinatown section of Kahului was burnt down leading to the end of detectable plague on Maui until 1931." Between 1917-18, quarantine was widely used in the United States during the influenza pandemic, which killed as many as 50 million globally and up to 675,000 in the United States.
In the 1920s, Mariner said, "there was sometimes isolation for somebody with sexually transmitted infections before there were antibiotics to treat them. But again, it was targeted largely at poor sex workers and some immigrants." And more recently in the 1980s and 1990s, she added, "a lot of treatment programs for tuberculosis lost funding and there was an influx of both HIV and TB—immigrants, homeless people, many who were mentally ill, or many who were on drugs and didn’t have any place to go, so they ended up being isolated in the hospital." California voters defeated a ballot measure in 1986 and again in 1988 amid the AIDS onslaught that sought to list AIDS as a communicable disease. And opponents said it was a veiled attempt toward quarantining those with AIDS while proponents claimed the disease was spread by insects and even casual contact with a public toilet seat.
Even within the last 10(ish) years, the Western world has used massive quarantines to fight disease. In 2003, some 15,000 people in Toronto, Canada, voluntarily separated themselves amid fears of SARS, a respiratory illness. "It was frightening because of the unknown," nurse Susan Sorrenti told local media last year, reflecting on the 10 years since.
To quarantine or not to quarantine?
Maine Governor Paul LePage, who won reelection Tuesday, was a central force pushing for Hickox to be quarantined. Among other things, he feared the US would become another West Africa, so he fought nurse Hickox's defiance in court. However, the courts didn't agree. Because Hickox was showing no Ebola symptoms, she could not transmit the disease, the judge ruled last Friday.
LePage still doesn't buy it.
"My duty to protect the health of the individual, as well as the health and safety of 1.3 million Mainers, is my highest priority. Despite our best effort to work collaboratively with this individual, she has refused to cooperate with us," LePage said Friday in a statement. "As Governor, I have done everything I can to protect the health and safety of Mainers. The judge has eased restrictions with this ruling and I believe it is unfortunate. However, the State will abide by law."
Later in the day while campaigning, the governor continued. "We don't know what we don't know about Ebola," LePage said. "I don't trust her. And I don't trust that we know enough about this disease to be so callous."
Again, Maine District Court Judge Charles C. LaVerdiere said science was on the nurse's side. In overturning the nurse's quarantine order, he ruled [PDF] that Hickox "currently does not show any symptoms of Ebola and is therefore not infectious." Yet, he did put limitations on Hickox. He ordered her to succumb to "direct active monitoring" as defined by the Centers For Disease Control, which means "the public health authority conducts active monitoring through direct observation." Under the ruling, Hickox must also "coordinate her travel with public health authorities" and "immediately" notify them if symptoms like high fever, vomiting, or diarrhea appear.
The judge added that he is "fully aware of the misconceptions, misinformation, bad science, and bad information being spread from shore to shore in our country with respect to Ebola. The Court is fully aware that people are acting out of fear and that this fear is not entirely rational. However, whether the fear is rational or not, it is present and it is real."
The woman's boyfriend, Ted Wilbur, said Monday that he and the University of Maine, where he is a nursing student, have tentatively agreed for him to stay away from campus, perhaps until November 10, when the 21-day incubation period for Ebola runs out on Hickox.
James Hodge, a professor of public health law and ethics at Arizona State University, said quarantines, isolation, and active monitoring do, indeed, involve civil rights issues. But, he said, they're not just about those carrying a disease.
"Individual rights don't allow you to put at risk others with the Ebola," he said in a telephone interview. "It's a balance to protect public health with individual expectation of privacy and fundamental liberties."
The global response
The fear of the rampant spread of Ebola wasn't helped when a Harlem, New York, doctor from Doctors Without Borders returned from Guinea. The man performed self monitoring, went bowling, and took a cab the day before he was diagnosed October 23 with the virus. Two of Dr. Craig Spencer's roommates were quarantined. Spencer's condition, now stable, prompted the governors of New York and New Jersey to declare mandatory quarantine periods for those exposed to Ebola in West Africa, a decision blasted by President Barack Obama. The governors' actions further emphasize the hodgepodge of responses to the Ebola outbreak from public officials here and abroad.
"We don’t just react based on our fears. We react based on facts and judgment and making smart decisions," the president said October 28.
A Washington Post-ABC News poll found that 49 percent of respondents approved of Obama's handling of the Ebola situation. But 70 percent of respondents said they wanted a travel ban, and 61 percent said the government could do more to keep Ebola from spreading in the United States.
To be sure, the United States is requiring airline passengers returning from Africa's Ebola hotpots to Georgia, Maryland, New Jersey, New York, Pennsylvania, and Virginia to undergo 21-day monitoring similar to what the Maine judge ordered nurse Hickox to undergo.
Under the plan, which commenced October 27, travelers from Ebola-inflicted nations of Guinea, Liberia, and Sierra Leone must provide to authorities e-mail addresses, telephone numbers, a home address, and an address where they'll be for the next 21 days. They also must provide similar information for a relative or friend in the US.
"This information is essential for health departments as they track individuals who have arrived in this country," said Tom Frieden, the director of the US Centers for Disease Control and Prevention, when announcing the initiative. He said about 150 people a day from West Africa travel to the United States. About 70 percent of them land in those targeted states.
Recently, the US also began quarantining its soldiers returning from Ebola missions. Elsewhere things are even stricter. Countries like Australia and Canada are taking a more extreme approach, entirely barring travelers from West Africa.
Anthony Banbury, who heads the United Nations Ebola Emergency Response Mission, said those decisions could "dissuade foreign trained personnel from coming here to West Africa and joining us on the frontline to fight the fight" against Ebola.
And just two weeks before Frieden's announcement, Larry Klayman, a former Justice Department lawyer who founded Freedom Watch and Judicial Watch, sued the Obama administration. He accuses the administration of "facilitating terrorism" for refusing to block travel from the Ebola hotspots in Africa.
The administration, Klayman contends, "knowingly and willfully provided material support and aid to international terrorism and facilitated terrorism by allowing unrestricted entry of persons from countries experiencing outbreaks of the Ebola virus and adamantly opposing efforts, including calls from the US Congress, to restrict travel from outbreak countries."
This week the World Health Organization had similarly biting words. On Tuesday, the WHO said the Ebola outbreak could have been averted in the first place had "profit-driven" Western medicine not turned a blind eye to the disease, which was first discovered in 1976 in Zaire (now the Democratic Republic of Congo).
For now, there's no telling what the future holds for Ebola in the US. And how quarantine practices will be implemented, handled, and debated will be directly tied to that uncertain outcome. All we know is Ebola has certainly traveled to the West, prompting everyone from casual observers and politicians, civil rights advocates and vaccine makers to take notice.
"This ain't gonna be over until the global community can put the resources into the area that is medically underserved and provide the basic infrastructure to beat this inevitable thing of mother nature," Gene Mathews, the CDC's former chief legal advisor, told Ars in a telephone interview.
Until that kind of proactive action is taken, he said, quarantines will continue to happen. And in Matthews' eyes, it's an easy correlation—we should expect more quarantines and other restrictions if more cases of Ebola crop up.
"It's the law of common sense."