U.S. Laws Grant Broad Authority to Quarantine and Isolate People, But Fears of Being "Roped Off" are Outdated, Experts Report

Isolation measures panel (L-R): Senior Associate Monica Schoch-Spana of the Center for Biosecurity of the University of Pittsburgh Medical Center; Eric Noji, a senior associate with the Johns Hopkins Bloomberg School of Public Health, who also serves as a senior medical and public health advisor to the White House Office of Homeland Security; Research Assistant Laura K. Donohue of Stanford University; and James G. Hodge Jr., an associate professor and executive director of the Center for Law and the Public's Health at the Johns Hopkins Bloomberg School of Public Health and Georgetown University.

In the United States today, "We can quarantine you on planes, trains, boats, in the hospital, at your workplace, in school settings—if necessary, we will find you and the government can quarantine or isolate any of these populations within any of these specific settings," according to James G. Hodge Jr., an associate professor and executive director of the Center for Law and the Public's Health at the Johns Hopkins Bloomberg School of Public Health and Georgetown University.

But, modern U.S. laws require that quarantine, isolation and other "social distancing" responses to naturally occurring disease outbreaks or to bioterrorism can only be used as a last resort, after all other, less restrictive options have been exhausted, Hodge said. Further, he emphasized that today's laws require those in quarantine or isolation to receive the best available medical care and access to communication with friends and family. Today, he emphasized, "quarantine is not about roping you off in a community or separating you or taking you to the football stadium or to the local hotel."

Hodge was one of four experts who took part in a 10 September 2008 panel discussion organized by the AAAS Center for Science, Technology and Security Policy and the Henry L. Stimson Global Health Security Program. Joining him on the panel were Research Assistant Laura K. Donohue of Stanford University; Eric Noji, a senior associate with the Johns Hopkins Bloomberg School of Public Health, who also serves as a senior medical and public health advisor to the White House Office of Homeland Security; and Senior Associate Monica Schoch-Spana of the Center for Biosecurity of the University of Pittsburgh Medical Center. An audio file of the panelists' complete remarks is available online.

U.S. laws have been broadened to provide federal and state governments, agencies and the military broad authority to quarantine people exposed to infectious agents, and to isolate individuals who are known to be infected, Hodge explained. In contrast in the United Kingdom, amid rising concerns about viral pathogens: "They actually state that they will not use quarantine in the event of a pandemic flu," Donohue said, although the country's government can execute quarantine procedures at ports related to five specific diseases. In the 19th century, the British monarch had authority to issue quarantine orders, but U.K. laws gradually changed to require the Parliament's blessing on all such efforts, and no quarantine procedures were used in England during the Spanish flu outbreak of 1918, according to Donohue.

Laws regarding quarantine and isolation have followed an opposite path in the United States, she added. Congress initially left such questions to the states, and although the first U.S. federal quarantine act was established in 1878, it stipulated that federal rules could not conflict with state laws. By 1944, Donohue said, the Public Health Service Act, and later, the Stafford Disaster Relief and Emergency Assistance Act began to shift authority for quarantine and isolation procedures to the federal level. "We went from having local authority, and specifically port authority, and that gradually became state authority, and now we are at the point of discussing what the role of military will be in all this," she explained.

Research Assistant Laura K. Donohue of Stanford University. As U.S. laws have been broadened to provide federal and state governments, agencies and the military broad authority to quarantine and isolate people, rules have followed an opposite trajectory in the United Kingdom, which did not execute quarantine procedures during the Spanish influenza outbreak of 1918.

It is unclear in some cases, though, when military authority might preempt federal or state supervision of such efforts, Donohue said. The U.S. situation was further complicated 23 May 2005, after the World Health Organization was granted the authority to investigate public health emergencies across national boundaries, Noji said. He commended efforts over the past six years to establish a cooperative global network for sharing information in the event of a pandemic, noting that an outbreak of deadly Ebola virus could travel from the Congo to New York in 16 hours, given modern transportation. Quarantine and isolation practices inevitably require balancing public health questions with concerns about constitutional rights and civil liberties, he noted.

Does quarantine work to stop disease outbreaks? Not entirely, Noji said, but such procedures clearly can slow the spread of disease. An outbreak in Thailand, for example, might take an extra month to reach the United States, if quarantine procedures are put into place. "The bottom line is, quarantine is not going to work, but in combination with other measures, perhaps prophylactic antibiotics ... antiviral agents, we can do a much better job at containing an epidemic," he said. Social distancing methods "won't be totally successful," he added, "but they buy us time."

Since the terrorist attacks of 11 September 2001, 25 American states have gained the ability to declare a "public health emergency," which also can be declared at an array of federal, agency and military levels, Hodge said. Once an emergency is declared, he noted: "The legal environment changes—it changes instantly, and I can assure you, it changes drastically."

In 1918, when the Spanish flu swept across Baltimore, Maryland, it hit the military installations of Camp Meade and Fort McHenry, then moved into the civilian workforce that helped to maintain those facilities, and finally affected the workers' families, said Schoch-Spana, who has studied social reactions to the outbreak. As the crisis deepened, she said, the Baltimore public's reaction shifted from denial, to devastation, to profound familial hardship, to anger over inconsistent quarantine rules. Public health officials initially tried to downplay the crisis, partly because they feared that inciting fear could reduce the public's resilience to infection. Members of the public, meanwhile, expressed anger because places of worship were ruled as being off-limits, whereas saloon hours were only restricted, Schoch-Spana said. Curtailed business hours also created economic hardships.

"The public can actually become resistant to certain epidemic controls," she concluded, "and we see from their point of view, reasonably resistant if they see controls as too burdensome, inconsistent, or contrary to commonsense and deeply held beliefs."

Ginger Pinholster

16 September 2008