Quarantine: An idea whose time may have come again

Quietly, the trail of disease stretched from the New York City suburb of Mamaroneck, N.Y., to Manhattan and Long Island's Oyster Bay, leaving suffering in its wake. Twenty-two people had been infected and one person had died from a terrible illness, marked by high fever, swollen lymph nodes and rose-colored spots on the chest and abdomen. It took time, but William H. Park, MD, and S. Josephine Baker, MD, zeroed in on where the illness was coming from -- an Irish-born cook employed by the wealthy families of those who had become ill.

The sickness, of course, was typhoid and the cook was Mary Mallon, who claimed in 1907 never to have had it. Nonetheless, she was found to be a carrier, excreting large numbers of typhoid bacilli. To keep her from infecting anyone else, she was isolated in a hospital for three years before being released with a warning that she must never again be employed in a kitchen.

She didn't listen.

When health department physicians next caught up with her, they hustled her into an ambulance and placed her in isolation for life on North Brother Island in New York's East River. She died there 23 years later of pneumonia.

Typhoid Mary's case spanned the early years of the 20th century and her physicians, even in 1907, wondered whether the health department had the right to deprive her of her liberty.

Today's physicians could find themselves puzzling through scenarios not so far removed, and public health experts urge them to think through such issues as personal liberty versus public health before they surface. Although typhoid has been supplanted by smallpox, severe acute respiratory syndrome and pandemic flu on today's physician watch lists, isolation and quarantine remain methods to be relied upon to keep infectious diseases in check.

"Good old-fashioned isolation and quarantine have a special role to play in any pandemic," Centers for Disease Control and Prevention Director Julie Gerberding, MD, MPH, said recently.

But the imposition of such strident disease-containment methods raises a number of ethical questions for a era in which civil rights and individual liberties are taken even more seriously than they were in Typhoid Mary's time.

The most obvious question is: "What right do we have to isolate or quarantine people?" asked Robert Baker, PhD, professor of philosophy and director of the Center for Bioethics and Clinical Leadership at Union College in Schenectady, N.Y. Dr. Baker helped organize a conference on Ethics and Epidemics held last March with Albany Medical College.

Another question, many add, is whether a containment order would be mandatory or voluntary.

Canada turned to quarantine and isolation and the techniques seemed to work in turning back last year's SARS outbreak. "At one point they had 30,000 people under quarantine, but the quarantine was primarily voluntary," said Dr. Baker. "People who had been in contact with a SARS patient were told, 'Look, if you go out you could contaminate other people. So would you voluntarily take your temperature and limit contact with other people?' And people, amazingly, did it!

"The Canadians tried to keep everybody informed without scaring or panicking anybody. And they asked for the public's cooperation. And that worked," he said.

However, a report produced last fall by the University of Louisville School of Medicine in Kentucky indicates that law enforcement played an important role in enforcing quarantine orders in Canada and questioned whether a largely voluntary approach would work in the United States with its "cultural notions of individuality, due process and skepticism of government."

Making distinctions

While sorting through the issues, it is important to distinguish between isolation and quarantine. Often lumped together the two options, although related, remain different approaches.

"With isolation you've already got the infection," explained James J. James, MD, MPH, director of the AMA's Center for Disaster Preparedness and Emergency Response. "Isolation is a fairly accepted medical practice that goes on every day. It is built into hospital procedures and infectious diseases procedures."

Quarantine is called for when an individual may have been exposed to an infectious disease but doesn't necessarily have an infection. "On the quarantine side you are almost always looking at a security or legal function in a given state, depending on who has the authority to impose a quarantine," said Dr. James.

Any declaration of a quarantine remains a job of the public health system, as it was in Mary Mallon's day. But the image of the public health official has undergone a transformation from the authoritarian cop of a century ago to a communicator. "You get a kinder, gentler approach to public health that is much more in keeping with a democratic society," said Dr. Baker.

However, public health's strong enforcement powers must remain on the books just in case the kinder, gentler approach doesn't work. "But they are the last resort, not the first resort," he noted.

"In fact, the best evidence we have indicates that if you arbitrarily impose a nonvoluntary quarantine you scare people off and they immediately flee and spread the disease," said Dr. Baker. That is the worst possible outcome.

Canada's single-payer health plan may have provided that nation an opportunity that doesn't exist in the United States, said Dr. Baker. But while SARS raged in Canada, New York state took strategic action -- quickly instituting a policy of emergency Medicaid coverage to make sure that affordable care would be available.

"What you want to do when you are trying to control an epidemic is make sure that everybody gets to see a doctor so they can be analyzed for isolation and quarantine and so they can get free treatment," he said. The New York policy was another example of a kinder, gentler way to assure that everyone gets care, he added.

Although the imposition of a quarantine is most definitely a function of the public health system, physicians play a vital role in reporting unusual cases to enable disease outbreaks to be detected quickly.

However, doctors do not always comply with mandatory reporting laws, said Matthew Wynia, MD, director of the AMA's Institute for Ethics. "We, by and large, do a pretty bad job of reporting them to the public health authorities."

Part of the problem may be that physicians don't know whom to report to or what to report. "They may feel it is a waste of time to fill out the paperwork and then it disappears into a black hole," said Dr. Wynia. Or physicians may think it's not a part of their jobs.

"Physicians need to understand that the public health community relies on us to detect new cases of disease and doing so is part of our ancient ethical obligation," he said. "A core portion of the original 1847 AMA Code of Ethics dealt with the community of public health."

Lessons from psychiatry

Beyond proper detection and reporting of disease, physicians' duties get a bit more murky. Given the increased attention paid to individual liberties in modern times, the question of holding patients against their will can trigger strong debate.

There is a good deal of uncertainty among physicians about what their powers are to isolate an infectious person in the emergency department, especially if that person wants to leave before the public health officials arrive, said Dr. Wynia. This concern also extends to physicians working in their offices, he noted.

"I think that physicians do have the right, and in fact the obligation, to hold someone like that because of our obligation to the rest of the community," Dr. Wynia said. There are analogous situations in psychiatry. "If someone says to you as their psychiatrist, 'I'm going to go kill my wife now,' you can say, 'No, you're not. You're going to stay here, in a locked room if necessary.' "

Thus, in psychiatry the question has been settled. But it has not been well worked out for the infectious disease field, Dr. Wynia said.

"We should consider patients with dangerous infectious illness to be similar to psychiatric patients who pose risk and we should be able to hold them with appropriate oversight and review to make sure we are not doing it inappropriately," he said.

Several others took issue with the idea that a physician has a duty to restrain a patient to protect the public's health. "The first obligation of a physician is to their patient, always," said George J. Annas, MPH, chair of the Health and Law Dept. at Boston University's School of Public Health. "Nowhere does a physician have an obligation to restrain people."

Dr. James agreed: "That's not a physician's job. But that doesn't preclude a physician's notifying public health. That's where the obligation is. He's not out there being the Lone Ranger."

Ideally physicians should use their skills to keep an infectious patient in a private room while the public health department is contacted, said Jay Jacobson, MD, professor of internal medicine and chief of the division of medical ethics at the University of Utah School of Medicine and the LDS Hospital.

Having the phone number of the public health department at the ready is a good idea, he added. "That's a great way to be prepared, in the same way that it's good to know where the fire extinguisher is."