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Quarantine has been around since the 14th century when officials in
Venice, Italy, forced arriving ships to sit anchor for 40 days before landing
to protect locals from plague. Last spring, seven centuries later, the global
outbreak of severe acute respiratory syndrome (SARS) forced public health
officials around the world to implement or consider quarantine (the term was
derived from the Latin word quaresma, meaning 40),
a time-honored but controversial prevention tool.
Thousands were placed under quarantine in China, Hong Kong, and Canada.
President George W. Bush issued an executive order on April 10 adding SARS
to the list of communicable diseases for which public health officials could
use quarantine, although the measure was not invoked for the 33 people in
the United States who were diagnosed as having SARS.
Old issues revisited
With quarantine once again in the public eye, age-old questions regarding
its usefulness and effect on civil liberties are being reexamined.
"When you look at the effectiveness of quarantine, there is a hierarchy
of cases," explained Lawrence O. Gostin, JD, a professor of law at Georgetown
University in Washington, DC, and director of the Center for Law and the Public
"If you have a single individual or small group, known to be infected,
and you isolate them, then most people believe that this is proper," he said.
More controversial is mass quarantine of large numbers of individuals who
may or may not be infected.
Individuals who are healthy or think they are unaffected by a particular
disease resist being forced to stay at home or in some isolated environment.
This was seen during the SARS outbreak: When Hong Kong officials went to an
apartment to place its residents under quarantine for SARS, they found many
residents had fled, leaving more than half the units unoccupied.
Some governments respond to that reluctance to being quarantined with
severe penalties against those resisting. In China, where more than 10 000
individuals were quarantined, the measure came with threat of execution for
"Intentional spreading of pathogens in sudden epidemics, endangering
public security, causing serious injuries or death, or serious loss to private
or public properties will attract a sentence of imprisonment for a minimum
of 10 years, or life imprisonment or death sentence," said the Chinese state-controlled
news agency Xinhua.
US government officials, noting 85 suspected SARS cases in the United
States, downplayed any legal threats against those ignoring the theoretical
quarantine. But the law does allow for the "apprehension and detention of
persons with specific diseases" (68 Federal Register 17558
A long history
In the United States, protection from infectious diseases was left to
local public health authorities until 1878, when a wave of yellow fever epidemics
led to the passage of the first Federal Quarantine Act. Still, infectious
disease control remained primarily with state public health officials. It
was not until 1892, with the arrival of cholera from abroad, that the law
was reinterpreted to allow the federal government more authority in imposing
In 1944, with codification of the Public Health Service Act, the federal
government's authority over quarantine was fully established, although states
also are allowed to implement quarantine. However, the last federal use of
quarantine in the United States was during the Spanish Flu outbreak of 1918-1919.
Today, quarantine is run by the Division of Global Migration and Quarantine—a
part of the Centers for Disease Control and Prevention's (CDC's) National
Center for Infectious Diseases. Quarantine stations are located in Atlanta,
New York, Miami, Chicago, Los Angeles, San Francisco, Seattle, and Honolulu,
with each responsible for all ports in their assigned regions.
A checkered history
Prior to US federal control over quarantine, the isolation tool had
a checkered history. One episode, involving an Irish immigrant cook named
Mary Mallon, highlights the importance of quarantine. In 1907 New York, "Typhoid
Mary" was found to have infected 22 individuals, one of whom died. While she
denied having typhoid, Mallon was taken to North Brother Island to live in
isolation. By 1910, a health official decided Mallon could go free provided
she did not cook for people.
But Mallon resumed cooking, and in 1915 another outbreak of typhoid
occurred in New York among 25 individuals, with two fatalities. The source
of the outbreak was a cook named "Mrs Brown"—in actuality, Mallon, using
an alias. Mallon was again sent to the island, where she lived for another
23 years in relative confinement.
While Mallon was identified as a typhoid carrier who posed a health
threat to others, quarantine has been used too often against specific minorities
under the guise of protecting public health. The quarantine of Jewish immigrants
during a cholera epidemic in New York in 1892 had more to do with prejudice,
class, and politics than containing the outbreak. Similarly, the discovery
of plague in San Francisco in 1910 led local officials to arbitrarily set
quarantine boundaries around Chinese residences and businesses.
Such discrimination makes public health officials hesitant to use quarantine
again. It also makes certain populations leery about motives for the use of
quarantine, as evidenced by the uproar in the 1980s that met suggestions that
individuals with AIDS be subjected to quarantine.
"Nothing brings out the worst and best in a society as an infectious
disease—there are stereotypes and cultural bias, and it's a way society
can separate ‘them' from ‘us,'" Gostin said. "We saw this with
AIDS and the call for isolation, and with SARS and cultural stereotypes about
Asian communities being unclean and uncaring about transmitting infection."
Protecting civil rights
But today, with new diseases such as Ebola hemorrhagic fever, the fear
of another Spanish flu-scale influenza pandemic, and the threat of bioterrorists
using infectious agents such as smallpox or plague, federal and state government
officials are preparing to include quarantine in their public health arsenal
(JAMA. 2001;286:2711-2717). What appears to be different about current discussions
of the use of quarantine is an awareness of the need to protect civil rights.
When President Bush signed the executive order adding SARS to the quarantine
list of the Public Health Service Act, it joined only a handful of specific
communicable diseases—cholera, diphtheria, infectious tuberculosis,
plague, smallpox, yellow fever, and viral hemorrhagic fevers. And even if
a quarantine is issued with regard to these diseases, the federal law provides
for civil rights and due process.
States have their own quarantine laws, but that may be changing. Thirty-six
state governments have adopted "The Model State Emergency Health Powers Act"
(JAMA. 2002;288:622-628). The act puts into law five basic public health
functions: preparedness, surveillance, management of property (such as pharmaceuticals
and hospitals), communications, and protection of persons (including quarantine).
Gostin, along with colleagues from the Center for Law and the Public's
Health, coauthored the act at the request of the CDC. He said the document
provides protection from onerous government intrusion into a person's life.
It's important to ensure that the public authorities have all the power
they need to stem the tide of an epidemic, including quarantine, but safeguards
are needed to protect individuals against abuse of power, Gostin noted. "There
has to be due process, review by the courts, and strong standards."
For the first time, the model act gives legal rights to those under
quarantine issued by a state—they have to be assured safe environments,
food, and clothing while under isolation.
"Government always wants to appear it is strong and decisive, and nothing
is as strong as depriving citizens of their liberty—we saw this in China,
Hong Kong, Vietnam, and a little in Canada," Gostin said.
"But now the (US) government has to show that the risk from disease
is real and not a subterfuge for discrimination," he said.
Mitka M. SARS Thrusts Quarantine Into the Limelight. JAMA. 2003;290(13):1696–1698. doi:10.1001/jama.290.13.1696
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