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16. Rejecting Quarantine: A Frozen-in-Time Reaction to Disease

Published onMar 28, 2020
16. Rejecting Quarantine: A Frozen-in-Time Reaction to Disease
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On October 1, 2014, America awoke to an unwelcome surprise: A patient had been diagnosed with Ebola virus disease (EVD) in Texas. Surprise quickly turned to fear as people wondered what their risk was, and this risk turned to the question of quarantine. Who should be quarantined? Should everyone from Africa be quarantined? Everyone from EVD-affected countries? What constituted a case of EVD worth quarantining? Should everyone be quarantined, kept either in or out depending on your perspective? Should all medical workers be quarantined? And although all medical information stated that EVD is not contagious until symptoms manifest and quarantine is an overreaction, at no point did anyone stop to ask the simpler question: Should quarantine be a part of our disease response at all? The answer to this is no: Quarantine in the modern era is predominantly an outdated, unjustifiable violation of an individual’s rights to justice, autonomy, privacy, and liberty. It is, I contend, no longer a viable response to infectious disease.

To begin, it is helpful to distinguish between isolation and quarantine. The two are quite separate in concept and should remain so in discussion: Quarantine is a coercive social-distancing model that removes those who have been exposed to disease and might become sick, but who have not tested positive for disease or manifested clinical symptoms of disease, from the community.1 Isolation removes those who are confirmed sick from the population for treatment and recovery.2 But is it really accurate to call isolation coercive social distancing when you’re sick? As Annas notes, “as a general rule, sick people seek treatment.”3 Because of this voluntary seeking of medical assistance, anyone who is then admitted to an isolation ward is there because they have an interest in getting better.4

Likewise, most people do not want to infect those around them, especially family members, and will voluntarily seek out health care and follow reasonable public health advice to avoid spreading disease. The key here, of course, is what constitutes “reasonable public health,” and whether or not the people determining the definitions agree with the people who are expected to live out these definitions.

Quarantine is an epidemic story5—but as the media frenzy in the United States showed, an epidemic is not necessary in order to have the epidemic story of quarantine. As such, and before discussing the history, use, and limits of quarantine, it will be helpful to have several stories.

Thomas Eric Duncan

On September 26, 2014, Thomas Eric Duncan went to a Dallas-area hospital with abdominal pain, dizziness, nausea, and headaches. When he was evaluated, his temperature was noted at 100ºF; he was otherwise medically unremarkable. Although the hospital had implemented policy, over a month earlier, asking that all patients complete a travel history, the medical record indicates that the triage nurse did not obtain this information from Duncan, and thus missed the fact that he had recently arrived in America from Liberia. Duncan was diagnosed with “sinusitis and abdominal pain” and discharged. He continued to sicken and returned to the hospital on September 30, when he was properly diagnosed with EVD. He died October 8, 2014—the only person to have died of EVD in America to date.6

Duncan’s fiancée Louise Troh, their son, and two nephews were forcibly quarantined in an apartment that contained soiled blankets and towels so likely to be contaminated with EVD that Texas could not find a company with appropriate permits to transport the biohazardous waste.7 Despite caring for Duncan the entire time he was ill, and remaining in the contaminated apartment for several days before being moved, Troh, her son, and her nephews did not became sick.

Craig Spencer

Spencer returned to America on October 17, 2014, after working with Doctors Without Borders in Guinea. He entered the country through JFK International Airport in New York City and showed no symptoms of EVD. Spencer did not undergo voluntary quarantine while home in New York City, but he did monitor his vital signs and symptoms twice a day. He began to feel sick and run a fever on Thursday, October 23, and reported to a hospital, where he was diagnosed with EVD.8 Even though Spencer spent significant time with two friends and lived with his fiancée, all of whom were involuntarily quarantined at home, no one was infected by him.9

Kaci Hickox

On October 24, 2014, Kaci Hickox returned to American after a month working with EVD patients in Sierra Leone. She arrived at Newark International Airport, in New Jersey, on the same day that the governors of New York and New Jersey began mandatory quarantine of all medical workers returning from Western African nations.10 Although she showed no signs of illness and there was no medical concern that she was ill, Hickox was quarantined in a tent with no heat, television, shower, or portable toilet.11 She was originally told that she would be kept in this involuntary quarantine for 21 days. Instead, Hickox fought, was released, and traveled to Maine, where she continued self-surveillance and voluntary quarantine while fighting the quarantine efforts in courts.12

These stories give us some background to the lack of scientific fact behind the quarantine impulse, as well as highlight the outsized influence politicians and elections had on public health policy implementation.

A Brief History of Quarantine

In order to discuss the present use of quarantine, it is helpful to look to the past and our history with the term and action. In all likelihood, most people will be familiar with the public health narrative that places quarantine as an artifact of 1348 Venice, an action of Doge Andrea Dandolo and the Venetian Great Council13 to stem the effects of the plague on the city of Venice. While it is likely that some form of removing from society those who have been exposed to illness existed before this, most historical accounts focus instead on separating those who are already ill: that is, what we contemporarily refer to as isolation. Leviticus 13 goes into great detail about both when to isolate a patient and, if the infected person survives, when they can be released back into the community. Lazarettos, hospitals for lepers—often beyond city limits—existed in Europe in the late seventh century, and served as both a place to contain lepers and a place for treatment. And in a time where illness was often seen as divine punishment for transgressions, it was not uncommon for those who were sick to be driven out of society.14

What was different about Venice was that the effort to prevent plague moved beyond isolation of the sick to isolation of those who posed a threat of illness to society: sailors. Those aboard merchant ships could have been exposed to plague before getting on the ship and not yet be manifesting the symptoms. In order to protect the city, the Doge and Great Council ordered all ships held offshore for a period of time15 before entering the city proper. Other cities saw the virtue of Venice’s actions and followed suit over the next century;16 by 1374, the holding period was set at a biblically inspired forty days.17 Inspired by port cities, inland cities set up cordon sanitaires, a controlled border around a town that expressively forbade travel to or from plague-stricken areas without special dispensation from city elders.18

Two related things should stand out to any reader when discussing the history of quarantine. First, quarantine was established at a time where the cutting-edge theory of contagion was miasma. According to this theory, disease originated in the environment and was caused by decaying organic matter that released a poisonous air or rotting vapor, causing infection in weak or susceptible people.19 Prevention was a matter of removing decaying matter (early sanitation efforts) and cure frequently entailed removal to some countryside for its purifying airs. And while those sanitation efforts did provide some public health benefit, this was not from understanding the etiology of disease, but lucky happenstance—which ties in to the second thing that should be obvious to any reader: Quarantine is a 650-plus-year-old policy of disease prevention. Why are we relying on a medical practice from the fourteenth century today? We wouldn’t use most of 1300s-era medicine, so why this? In the 1300s, knowledge of disease was rudimentary, with limited understanding of why quarantine was effective at all. Broadly applied, we are more knowledgeable now and should act it.

Given that the principle of quarantine is ages old, and the justifications that made it so effective in 1348 are now outdated, we need to reevaluate our therapeutic use of quarantine, taking in to account both theoretical assumptions and actual behavior of people exposed to highly infectious, deadly diseases. If quarantine is to continue being used in contemporary disease management, it should be because there is a valid and contemporary explanation for it, not one whose justification is grounded in beliefs of miasma spreading disease.

The Ethics of Quarantine

Coercive public health interventions are typically justified under the notion that there are times when personal rights such as liberty or autonomy are subsumed to the needs of the community.20 Childress et al., for example, propose that although there will be conflicts between the moral considerations foundational to their defined goals of modern public health (producing benefits, preventing harms, maximizing utility) and other moral commitments, there is a set of justificatory conditions that will aid in determining whether public health measures may infringe on values such as liberty, equality, justice, and so forth.21 These five are briefly defined as follows:

  • Effectiveness: shows that infringing one or more general considerations will probably protect public health (the stated goal of the quarantine must be reachable).

  • Proportionality: shows that probable public health benefits outweigh the infringed general moral considerations (violations of personal rights must be weighed against positive features such as infection control).

  • Necessity: there are no other options that can be taken to achieve the public health goal in question (there must be a reason coercion is necessary over any other option).

  • Least infringement: it minimizes any infringement upon general moral considerations (if you have to step on a moral consideration like privacy, do so with as little intrusion as possible).

  • Public justification: explaining and justifying the rights infringement.22

Now, that stated, it almost immediately becomes clear that the 2013–2016 EVD pandemic fails to meet any of the five necessary justificatory conditions for violating individual rights in favor of the public’s health.

  • Effectiveness. The effectiveness of quarantine was grossly overstated, as seen by the number of people who were confirmed to be infected during their quarantine (in non-pandemic areas, none) versus the number of people quarantined.23 Even Duncan’s fiancée and family, who nursed him while sick and then were quarantined for days in as unsafe a condition as you might be able to dream up, were you inclined to dream scenarios for infecting someone with EVD, did not become infected with EVD.

  • Proportionality. Quarantine is an out-of-proportion response given that EVD is not contagious until symptomatic; symptoms also appear gradually, so there is time for an infected person to seek medical care before the symptoms become incapacitating—or capable of spreading to other people.

  • Necessity. There are less restrictive and violating alternatives available, such as symptom monitoring and community health check-in (“surveillance”). Nigeria experienced and successfully contained an outbreak of 20 EVD cases in 2014; among the public health initiatives credited with solving the outbreak were proactive contact tracing and monitoring of exposed individuals. Forced quarantine was not among them.24

  • Least infringing. See above; given the abundance of more effective and less invasive measures, it is not possible for quarantine to be the least infringing public health measure.

  • Public justification. You can give the public justification for almost anything—but that doesn’t mean it is an ethical or moral (let alone good) justification. “Public justification” was fed by Ebolanioa25 and unscientific, inaccurate fears stoked by many people—often politicians26—for political gain in the 2014 American mid-term elections.27 Because American media dominates international media, said fears spread without justification. Public justification must rely on truthfully representing the effectiveness, proportionality, necessity, and proof that the action being called for is the least restrictive or infringing alternative available. The media is responsible for holding those they are reporting on to those standards.28 (See Russell in chapter 11.)

Another popular way of evaluating the ethical justification of quarantine is to examine whether it is the least liberty-violating, or least restrictive means,29 available. However, the reality is that there is no reason liberty should be assumed to be the most important right to preserve.30 There are situations in which utility, equality, justice, and so forth, might actually be the right we want least violated. Because of this, I reject the phrase “least liberty-violating” or any phraseology that implies we should only care about one value to the exclusion of others; instead, I prefer the phrase “least restrictive option.”

This is not terribly pithy and certainly doesn’t have the memorable catchiness of “least liberty-violating,” but it also does not betray an alliance to any theoretical methodology, and acknowledges that what values are at stake will and likely should change based on the case in front of you. We should not assume that what the least restrictive option is for EVD will be universal, but instead commit to being sensitive to the different properties of infectious diseases.

A False Dilemma

The ethics of quarantine is premised on the apparent dilemma that arises between our obligations to public health and individual rights and liberties. But I contend that this is, in almost all cases, a false dilemma. If one holds to the premise that any coercive social-distancing measure implemented must be proportional to the disease threat, quarantine is prima facie impermissible in the case of EVD and other known diseases, because it actively undermines public health efforts.

In order to understand how this can be, it may help to first review the 2002/2003 SARS (Severe Acute Respiratory Syndrome) epidemic, the first modern pandemic to genuinely scare public health and other officials.

In hindsight, the first reported case of SARS occurred in Guangdong Provence, China, in November 2002. Cases spread in China, but the international community was not made aware of any issue until February of 2003. Soon after, the World Health Organization issued a pandemic alert; infections were eventually recorded worldwide.31

Limited local transmission of SARS was recorded in fewer places, including Toronto, a city that implemented quarantine during the outbreak. While all of Canada had 440 probable SARS cases, resulting in 40 deaths,32 approximately 23,000 people in Toronto were quarantined, most confined to their own homes.33 China quarantined nearly 30,000 people, although nearly sixty percent of those people were detained at centralized quarantine facilities and they had nearly 2,500 probable SARS cases to Toronto’s 250.34 Of course, the problem in both Toronto and China? Compliance. Stories abound of residents of Amoy Gardens in Hong Kong having fled ahead of officials who came to relocate the entire complex to a quarantine facility,35 and only 57 percent of those quarantined in Toronto were, according to health authorities, compliant.36 Although police and public health officials were working together, people were able to evade both if they were so inclined. And in the case of SARS, many were inclined.

While prior to the SARS outbreak, the general belief was that people would be happy to comply with sensible disease requests, like complying with quarantine, the lack of compliance and fleeing from quarantine that happened during SARS should have been an indication of what would come with the 2013–2016 EVD outbreak: People fleeing cordon sanitaire and unsanctioned night burials (see Henwood, chapter 2, this volume), evading official quarantine,37 and the reinforced stigmatization of the ill (see Phelan, chapter 9; and Kruvand, chapter 12, this volume).

Two pandemic outbreaks now show us people resist quarantine measures—and that they are ineffective because of this. The stated goal of quarantine is more effectively achieved via education,38 monitoring exposed people for signs of the disease,39 and instituting isolation and treatment should an exposed person start showing signs of infection.

We can thus reach the conclusion that quarantine is of limited use for two reasons: 1) people are noncompliant when faced with quarantine; and 2) it is of limited utility given the equal effectiveness of less restrictive alternatives.40

(Ebola) Babies on a Plane: Future Quarantine Scenarios

However, just because the criteria for coerced social distancing via quarantine has not occurred since the dual advent of effective vaccination and antibiotics does not mean that a situation may not occur, at some future time, wherein the Doge of Venice’s solution would again be appropriate. While it can be tempting to spin some chaotic tale of a mutant death ferret-flu laboratory escape, in reality, we can utilize a much simpler theoretical case study: a plane full of orphaned newborn infants that were exposed to Ebola virus.41

In this scenario, there is a plane full of orphaned newborn infants sitting on an airport tarmac. It is not discovered that they have been exposed to Ebola virus until the plane is airborne; at that time, flight attendants minimize interaction with the infants and the pilots stay inside the cockpit with no direct contact with the passenger cabin. Upon landing, the plane is directed to a distant corner of the airport and the pilots and flight attendants are escorted quickly off the plane and given instructions: They are to monitor themselves for a series of symptoms that indicate EVD, and will be contacted twice a day for 21 days for a status update. This leaves health responders with a quandary: What do they do with these newborn infants, who have no legal guardians to care for them and monitor them for symptoms? Should these babies be released to the lined-up foster or group homes that agreed to take the babies before their infection status was known?

I would argue that, as newborn infants are unable to communicate, a less restrictive alternative to quarantine such as surveillance via daily check-ins would not be possible, and quarantine becomes the most effective and least restrictive public health intervention. Furthermore, disease progression is often an unknown in infants, and while the ongoing EVD outbreak might eventually contribute relevant knowledge for infants and EVD, currently that data is not a part of the literature. An inability to communicate symptomatology and unknown symptom progression of a highly infectious disease seems to result in the argument that quarantine would be the least restrictive alternative for these infants42 that both provides for their care and also protects the larger community from possible exposure to contagion.

A focus on the science of disease infection, along with the realities of a specific situation on hand, also allows us flexibility in other situations. Currently, Australia quarantines animals that can bring rabies into the country for a 30-day period; animals, much like newborn babies, cannot express symptomatology or express distress in a clear-to-understand manner, and Australia has a vested interest in keeping their island-country rabies-free. A building can be quarantined when exposed to anthrax; buildings cannot communicate illness (yet) and there is no way to know whether or not spores of anthrax remain in the building until a careful and thorough cleaning is done. Fruits, vegetables, and other fauna are subject to border control and quarantine around the world; again, the fact that neither puppies nor potatoes can communicate means that the proportionate response is quarantine.

Conclusion

Mass quarantine is a relic of the past that seems to have largely outlived its usefulness.43 It is old-fashioned, outdated, and primarily driven by panic and political security theater, actively undermining public health efforts to contain and quell infectious disease spread. In times of infectious disease crises, almost all cases indicate that the least restrictive option available is a watch-and-wait, contact-monitoring surveillance approach, not quarantine. Along with monitoring those exposed to disease for disease-specific symptomology, a mass44 public education45 campaign based within the community and on scientific fact, not political elections or ratings, should be implemented.

Childress et al. discuss imposing versus expressing community, which is worthwhile to briefly examine. To impose community is to use the implicit threat of force to gain a desired outcome; for example, coerced social-distancing measures such as quarantine when there are other options available. To express community utilizes solidarity, protects interest, and, importantly, gains trust.46 An excellent example of this is the multilevel educational and science-communication outreach efforts in the West African nations of Guinea, Sierra Leone, and Liberia.47 What stopped EVD was a global improvement of health access48 and knowledge, not quarantine efforts.

The idea that “in a public health emergency there must be a trade-off between effective public health measures and civil rights”49 tends to be an unquestioned narrative. We are so habituated to the historical narrative of quarantine as a good, no one has stopped to evaluate whether or not it’s actually true that quarantine is a good. But as Annas notes, “human rights and health are not inherently conflicting goals that must be traded off against each other.”50 In the case of quarantine, the idea that it is the least restrictive option available to control disease outbreak is patently false. The 2013–2016 EVD outbreak shows that, in fact, surveillance is a more effective option to monitor possible infection while also retaining more liberties than quarantine.

A radical reconceptualization of the ethics of quarantine is necessary, and that reaction needs to be disease-sensitive. Different infectious agents have different symptoms and progression, and treating all diseases as alike, capable of being corralled by a single response, is a futile failure of medicine, policy, and rational thought.

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