There has been a lot of chatter around here lately about the Avian Flu and potential federal action to isolate or quarantine victims and potential victims. Some seem to think that this is just a naked play for power by the Bush administration. I for one, while not comfortable with ANY President using Federal Troops for ANY purpose inside the United States (or outside for that matter), think that it MAY be a sad necessity in the event of a terrible, pandemic event. It also led me to so a little research on the history of quarantine in America and it led me to a very interesting
article "An Analysis to Determine Whether Quarantine is an Effective Response to a Bioterrorist Attack in the United States"
It is a very informative article. The author comes out fairly neutral as to the effectiveness of a quarantine. He also explores the civil liberties implications of a quarantine. He uncovered many things that surprised me. First, he explains that terminology is very important.
Although defined by the Oxford English Dictionary (1989) as a "period of isolation imposed on a person, animal, or thing that might otherwise spread a contagious disease", the term is broadly used today to describe any number of containment measures from travel restrictions, restrictions on public gatherings, or isolation of sick individuals (Barbera, et al., 2001). The CDC makes the following distinction: isolation is the separation of already ill persons with a contagious disease, usually applied at an individual level. Quarantine is the restriction of movement of healthy persons presumed to be exposed. This could be applied at an individual or community level and may be voluntary or mandatory (Simone, 2002). Both of these actions have numerous legal and social implications and Barbera, et al. (2001) stresses the need for medical and public health emergency managers to use the correct terminology.
He goes on to explain the evolution of state and federal law with regards to quarantine. Note the last time that the federal government enforced a quarantine -
Many of the difficulties with quarantine can be directly traced back to its history. Beginning with colonial times and continuing over the next two centuries, state governments were given very broad authority to protect public health, usually referred to as a state's "police power" (Annas, 2002).
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Massachusetts established quarantine powers in a comprehensive public health statute in 1797 (Barbera et al., 2001). The U.S. Supreme Court, in the 1824 case of Gibbons v. Ogden, opined that "inspection laws, quarantine laws, (and) health laws of every description" were essential regulatory powers of the state (Parmet, 1989). In 1905, the court in Jacobsen v. Massachusetts upheld the power of the state to require vaccination, and the Maine Supreme Court ruled in 1874, "when the smallpox or any other contagious disease exists . . .the law demands the utmost vigilance to prevent its spread . . .salus populi suprema lex, the safety of the people is the supreme law" (Parmet, 1989). However, at about the same time the states were beginning to exercise their authority, the Federal government also passed laws (1796) authorizing the president to assist in state imposed quarantines. In 1878, responding to a number of yellow fever epidemics, Congress passed the Federal Quarantine Act which directed the Surgeon General of the Marine Hospital Service (the forerunner of the U.S. Public Health Service) to draft rules and regulations governing the quarantine of vessels from foreign ports and directed consular officers overseas to keep the Surgeon General informed on the sanitary conditions of the ports in their countries. Nonetheless a vigorous debate ensued between the states, who believed public health was a state matter, and the Federal government which believed it had ultimate jurisdiction as the imposition of quarantine often impacted interstate commerce. Congress, responding to an imported cholera epidemic in 1892, expanded the interpretation of the 1878 law giving the Federal government greater authority in imposing quarantine. Finally, in 1944, the Public Health Service Act gave the Federal government ultimate jurisdiction when there was a conflict between state and federal activities, although the states still retained the right to impose quarantine within its borders. For all the legal activity, however, Federal imposition of quarantine has been rare. The last Federal use of quarantine was during the Spanish Flu outbreak of 1918-19 (Mitka, 2003; Barbera et al., 2001; Cummings, 1921).
For you flu doubters out there, how many people died during that flu outbreak?
The record for naturally occurring epidemics is equally long; two of the most notorious examples are the Black Death of the 13th century and the "Spanish flu" epidemic of 1918-19 that killed nearly 40 million worldwide (Lutz, et al., 2003).
He goes on to review incidents when states have enacted quarantines in response to disease outbreaks. Here is an interesting incident and response from the public -
In 1893 an outbreak of smallpox struck the city of Muncie, Indiana. Because of disagreement within the medical community that the disease was truly smallpox, there was a marked lack of community support for the quarantine measures, such as the elimination of public gatherings within the city (to include school and church services), the restriction of individuals wishing to enter the city on business, and mandatory vaccination. Police were stationed outside the homes of those afflicted. Violence broke out and several public health officials were shot. Fear spread well beyond the city as well; an adjacent county ruled anyone entering the county from Muncie would be forcibly quarantined for 10 days whether they could demonstrate they had been immunized or not (Eidson, 1990). This past history explains the reluctance of public health officials to propose quarantine and inevitable questions that arise when it is implemented...
The author states that in a country where there are basically 50 different state responses to the issue of quarantine, Johns Hopkins and Georgetown have developed a model law, but problems remain....
In response to the myriad of public health laws across the country, Georgetown and Johns Hopkins University developed a model state emergency health powers act (Gostin, et al., 2002) which combines the missions of preparedness, surveillance, management of property, protection, and communication into a draft law the states may use as a template when revising their own public health statues. In the model act, upon the declaration by the governor of a public health emergency (either naturally occurring or induced), the state may implement "special powers" which include confiscation of property, forced examination, vaccination, isolation or quarantine of individuals, and the waiver of licensing requirements in order to direct health care
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professionals to examine or treat patients (Gostin, et al., 2002). Although the model act has served as a template for the revision of public health legislation in 34 states, there is marked concern about the model's impact upon civil liberties if the model were adopted as law outright. Annas (2002), in his article opposing the model law, states "provisions that treat citizens as the enemy, with the use of police for enforcement, are much more likely to cost lives than to save them." Although the model act has been revised (Annas, 2002), concerns regarding civil liberties still exist.
The concerns the model act raise reflect a marked shift in how the public perceives illness and the public interest. Where few once questioned the power of the state, the decline of communicable diseases, the rise of the medical profession, and the development of an individualistic, rights-based jurisprudence have created a vision where the individual is given considerable latitude in making their own choices in how their disease will be treated, even when it is contagious (Parmet, 1989). This is true even in situations where the state continues to have a strong public health interest, such as tuberculosis (TB) and AIDS. The courts, while rarely challenging the state's authority to enact and enforce public health laws, generally have insisted the state exercise every recourse to protect an individual's civil liberty. A West Virginia court found in 1980 that the state violated an individual's right to due process when it involuntarily confined a man with TB but did not advise him of his right to counsel, even though this provision was not expressly written into the state statute. A 2002 decision found the state of California in violation of its quarantine law when it placed a Laotian woman with multi-drug resistant TB in jail for failing to appear for a medical examination. The court struck down the action because the quarantine order was only written in English even though the woman did not speak English and because the state incarcerated the woman in jail. This was in direct opposition to California law which mandated the state could only involuntarily quarantine persons in hospitals or other medical treatment facilities (Lacey, 2003). The problem remains that while Federal law takes precedence over state law when the two are in conflict, in most situations the myriad of 50 state public health laws remains the only law available. There are no contemporary U.S. Supreme Court cases interpreting state quarantine authority; nor has the question been resolved as to the Federal role should a state's enforcement of its public health laws impact another state or the rest of the country. For example, no hospitals have consented to be quarantine facilities in Washington State (Lacey, 2003)
There is a long middle section about how Taiwan handled the SARS outbreak in 2003. Interesting reading, but too long to excerpt. However, here are the conclusions that the CDC drew from it -
One cannot say with certainty that what was successful in Taiwan could be exported to other societies like the United States. In a briefing posted on the CDC website (CDC, 25 June 2002), Dr. Patricia Simone of the National Center for Infectious Diseases proposes principles for a "modern quarantine". These are:
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- short term, voluntary home curfew
- suspension or restrictions on group assembly
- cancellation of public events
- closure of mass transit systems
- closing of public places
- restriction of travel
- "snow days" or shelter-in-place
- "Cordon sanitaire" , i.e. sanitary barrier erected around an area
She advocates quarantine to be used in conjunction with other interventions such as enhanced surveillance, rapid accessibility to treatment for everyone who becomes ill, and preventive actions such as vaccination or preventive antibiotics. A key component of her approach is that quarantined individuals must be among the first to receive all interventions and it should only last as long as necessary to ensure quarantined persons do not become ill. Gostin and his colleagues (2003) propose four criteria to assess the legal and ethical justification for quarantine. Imposition of quarantine should be justified by the risk the disease poses to society; providing the opportunity for medical testing to rule out if an individual is infected or has been simply exposed to the disease (where available, in the case of SARS no such test exists); a safe and habitable environment for those upon whom quarantine has been imposed; assumption by the government of some of the individual financial burden quarantine imposes; and, the opportunity for those who believe they have been unfairly quarantined the right of due process to appeal such a measure in a reasonable period of time.
I find all of the above bulleted measures reasonable in the event of a 1918 style flu outbreak.
While the focus of the paper is a biowarfare event, the flu is very similar in concept and effect to smallpox. In response to a smallpox outbreak, (and, by logical extension, a major flu outbreak IMO) the author notes the following (italics in original):
This concept of quarantine may also be effective in that it enables public health officials to "do something" in order to modulate what would likely receive widespread and nearly constant media focus, particularly as pictures of the victims became public. The key parameters for any quarantine are that it should be of relatively short duration, it must be supported by the public as necessary to contain the epidemic, and information regarding the status of the epidemic should be accurate and made available to the public as soon as possible.
All in all, this is a facinating glimpse into current thinking on quarantine among military medical planners and I think it should be read before starting to discuss a military reaction to the flu.
Also, there is another good paper I found here on Winnipeg's response to the 1918 flu.