The 2019 novel coronavirus (2019-nCoV) is a force to be reckoned with, despite its unclear origins (see here and here). From Wuhan, China, the virus has spread to all of the Chinese provinces, and, by 31 January, eighteen other countries. By 30 January, the World Health Organization (WHO) had declared the situation a public health emergency of international concern (PHEIC).
The Centers for Disease Control and Prevention (CDC) reported on 31 January that four states—Arizona, California, Illinois, and Washington—have a total of six known cases of persons infected with corona virus. In addition, 36 states have patients under investigation for the infection. Citing the approximately 10,000 confirmed cases of the virus in China, and evidence of person-to-person spread of the infection, the White House announced on 31 January the suspension of entry into the U.S. of persons posing a risk of transmitting the virus. One point of that announcement concerned quarantine:
Sec. 4. Orderly Medical Screening and Quarantine. The Secretary of Homeland Security shall take all necessary and appropriate steps to regulate the travel of persons and aircraft to the United States to facilitate the orderly medical screening and, where appropriate, quarantine of persons who enter the United States and who may have been exposed to the virus. Such steps may include directing air carriers to restrict and regulate the boarding of such passengers on flights to the United States.
The U.S. is not the only nation planning or implementing quarantine. China has already moved to at least partially quarantine persons in Wuhan. According to the BBC, the UK, South Korea, Singapore, and New Zealand will quarantine evacuees from Wuhan for two weeks. Australia will similarly quarantine their evacuees on Christmas Island.
In light of the evolving situation with 2019-nCoV, it is a good time to review some definitions and recommendations from the public health arena:
Isolation separates sick people with a contagious disease from people who are not sick.
Quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick.
The essence of quarantine is the restriction of movement of individuals, imposed by an authority, for some length of time. “Quarantine” has been attributed to the Venetians, who, in their effort to stem the spread of the Black Death, required ships “to lay at anchor for forty days” prior to landing. In the U.S., the National Quarantine Act was passed in 1878 in an attempt to avert the spread of Yellow Fever. A national quarantine system was enacted by Congress in 1893. Fast-forward to 1983, when Executive Order 12452 was issued by President Reagan:
Section 1. Based upon the recommendation of the National Advisory Health Council and the Assistant Secretary for Health of the Department of Health and Human Services, and for the purposes of specifying certain communicable diseases for regulations providing for the apprehension, detention, or conditional release of individuals to prevent the introduction, transmission, or spread of communicable diseases, the following named communicable diseases are hereby specified pursuant to Section 264(b) of Title 42 of the United States Code: Cholera or suspected Cholera, Diphtheria, infectious Tuberculosis, Plague, suspected Smallpox, Yellow Fever, and suspected Viral Hemorrhagic Fevers (Lassa, Marburg, Ebola, Congo-Crimean, and others not yet isolated or named).
Does quarantine constitute “an unwarranted diminution of personal liberty”? Ross Upshur, M.D., M.A., M.Sc, who is also a Hastings Center Fellow, deals with this question and more in a 2003 article in the AMA Journal of Ethics. He cites two goals achieved by quarantine: stopping the chain of transmission of infection, and allowing “individuals under surveillance to be identified and directed toward appropriate care if they become symptomatic.” Additionally, Upshur describes four principles that must be met for quarantine (or other autonomy-limiting steps) to be considered:
- The general principle of preventing harm: particularly, this would include prevention of person-to-person spread of the infection
- The “proportionality, or least-restrictive-means principle”: quarantine should be voluntary “before mandatory orders or surveillance devices, home cameras, bracelets, or incarceration are contemplated”
- Reciprocity: if persons are quarantined, they should be provided with “adequate food and shelter and psychological support . . . They should suffer no penalty on account of discharging their obligations to society.”
- Transparency: “(P)ublic health authorities have an obligation to communicate clearly the justification for their actions and allow for a process of appeal. (See full article here.)
If all of these criteria can be met—no small order—Upshur writes that quarantine is justified.