As the Ebola Epidemic of 2014 continues, some officials are calling upon a centuries-old tactic to combat the disease: medical quarantine. In an effort that began on October 24th, New York and New Jersey state officials instituted a mandatory 21-day quarantine on all medical personnel returning from volunteer efforts to combat the disease in West Africa.

No Standard Protocols

While some states are embracing the idea and implementing quarantines of their own, other state and national officials are denouncing them. Medecins Sans Frontieres (MSF), the main humanitarian group coordinating volunteer efforts in Africa also denounced the quarantines:

There are other ways to adequately address both public anxiety and health imperatives, and the response to Ebola must not be guided primarily by panic in countries not overly affected by the epidemic,” said Sophie Delaunay, executive director of MSF-USA. “Any regulation not based on scientific medical grounds, which would isolate healthy aid workers, will very likely serve as a disincentive to others to combat the epidemic at its source, in West Africa.

International MSF staff members commit to burdensome four-to-six week assignments in the Ebola affected countries. The risk of being quarantined for 21 days upon completion of their work has already prompted some people to reduce their length of time in the field. Others will be less inclined to volunteer in the first place. This will present significant operational disruptions at the field level for MSF and other organizations, and lead to an overall shortage of desperately needed health workers, precisely when the Ebola outbreak is as out of control as ever.

In response to the overwhelming amount of criticism from the Obama administration and physician and humanitarian groups, Governors Cuomo and Christie announced that asymptomatic workers who had been in contact with Ebola patients would be able to spend their 21-day quarantine at home and would be compensated for lost income. Much of this stemmed from the forced quarantine of nurse Kaci Hickox, who upon arrival at Newark airport was rushed to a Newark hospital and placed within a tent set up within the hospital. The Obama administration criticized these quarantine measures, calling the plan “uncoordinated, very hurried, an immediate reaction to the New York City case (Craig Spencer, a NYC Emergency Physician who has been diagnosed with the disease) that doesn’t comport with science.” In response to the criticism, Ms. Hickox was allowed to return to Maine to serve the remainder of her 21-day quarantine, which she refuses to follow, claiming that she tested negative for the disease twice and is asymptomatic (the disease is only contagious when an individual is symptomatic).  She claims the quarantine measures are an infringement on her civil liberties, specifically the Due Process Clause of the 14th Amendment. On October 29th, Secretary of Defense Chuck Hagel announced a 21-day quarantine for all military personnel upon return from Ebola stricken countries in West Africa.

Historical Context

Medical quarantines have a long history, with the first known incidence occurring in AD 549 when the Byzantine emperor Justinian enacted a law to isolate individuals entering his lands from plague-infested regions. The term quarantine comes from the Italian term “quaranta” that literately means “forty,” which was the number of days ships had to remain at sea before passengers could disembark on shore during the Black Death plague epidemic during the 17th century. The first quarantine in America was in 1738 in New York City where a quarantine station was set up on a ship anchored off Bedloe Island to isolate contagious passengers with concerns for smallpox and yellow fever. In 1793 Philadelphia also enacted  a quarantine of sailors at Lazaretto hospital in a misguided attempt to stop the spread of the mosquito-borne disease through the city. The latest large-scale quarantine in the United States occurred doing the Influenza Pandemic of 1918 where patients and their contacts were quarantined and isolated and public gatherings were banned.

You can learn more about the history of quarantine from this 4 minute audio clip from NPR.

Public Disease Control vs. Individual Rights

The CDC also published this article on quarantine last year. While the authors praise the effectiveness of quarantines, they also caution that there are many legal and ethical considerations to be made when implementing such a sanction:

In the face of a dramatic health crisis, individual rights have often been trampled in the name of public good. The use of segregation or isolation to separate persons suspected of being infected has frequently violated the liberty of outwardly healthy persons, most often from lower classes, and ethnic and marginalized minority groups have been stigmatized and have faced discrimination. This feature, almost inherent in quarantine, traces a line of continuity from the time of plague to the 2009 influenza A(H1N1) pandemic.

The historical perspective helps with understanding the extent to which panic, connected with social stigma and prejudice, frustrated public health efforts to control the spread of disease. During outbreaks of plague and cholera, the fear of discrimination and mandatory quarantine and isolation led the weakest social groups and minorities to escape affected areas and, thus, contribute to spreading the disease farther and faster, as occurred regularly in towns affected by deadly disease outbreaks. But in the globalized world, fear, alarm, and panic, augmented by global media, can spread farther and faster and, thus, play a larger role than in the past. Furthermore, in this setting, entire populations or segments of populations, not just persons or minority groups, are at risk of being stigmatized. In the face of new challenges posed in the twenty-first century by the increasing risk for the emergence and rapid spread of infectious diseases, quarantine and other public health tools remain central to public health preparedness. But these measures, by their nature, require vigilant attention to avoid causing prejudice and intolerance. Public trust must be gained through regular, transparent, and comprehensive communications that balance the risks and benefits of public health interventions. Successful responses to public health emergencies must heed the valuable lessons of the past.

Additionally, instances in history of increased disease spread within quarantined communities and ethnic discrimination when considering groups to quarantine, make enacting quarantines a delicate task.

Legal Support for Quarantines

A difference exists between quarantine and isolation. Quarantine involves confining individuals who may have been exposed to the disease, and isolation involves separating an individual with known disease from the general public. States are allowed to place an individual under involuntary isolation if they have a dangerous and easily transmissible disease and are unable or unwilling to isolate themselves. The first legal statute authorizing quarantine in the United States was by the federal government in 1796 which authorized national governmental assets to be used to assist in state quarantines. As federalism debates continued, the consensus was such that now states hold primary power in exercising and implementing quarantines, though the federal government can institute similar measures if they can claim to be protecting interstate commerce – generally when risk of disease transmission crosses state lines. Once a decision for federal quarantine has been made, under 42 Code of Federal Regulations parts 70 and 71, the CDC manages its implementation in coordination with the Department of Defense, FEMA, and state and local authorities. A listing of state-by-state regulations on isolation and quarantine can be found here.

The courts have also generally upheld quarantines. In 1963 U.S. ex rel Siegel v. Shinnick, 219 F.Suupp. 779, an individual was quarantined for 14 days after returning from a “smallpox infected area” even though she was asymptomatic and denied any direct exposure to the disease. The court upheld the quarantine, stating:

[The] judgment required is that of a public health officer and not of a lawyer used to insist on positive evidence to support action; their task is to measure risk to the public and to seek for what can reassure and, not finding it, to proceed reasonably to make the public health secure. They deal in a terrible context and the consequences of mistaken indulgence can be irretrievably tragic. To supercede their judgment there must be a reliable showing of error.

Unfortunately, many physicians oppose the quarantines. Dr. David Pigott of University of Alabama at Birmingham School of Medicine stated, “It’s not something I think the [Centers for Disease Control and Prevention] would recommend right now and the [National Institutes of Health] also, would not recommend it”. Additionally, the Association for Professionals in Infection Control and Epidemiology (APIC), stated, “While we understand public concerns, APIC does not support mandatory quarantine of health care providers with no symptoms of Ebola who have treated patients with EVD.”

The actions of government officials to Ebola are important not just in the current situation but also in setting the framework on how we as a nation respond to public health emergencies in this increasingly connected world. As travel between distant nations becomes easier and rates of vaccination in the United States remain low, the probability of epidemics within our borders continues to rise. It is, therefore, important to consider the legal and ethical ramifications of isolation and quarantine before we set a precedent that we do not wish to keep.

Report written by Vidya Eswaran, MD