The U.S. Centers for Disease Control and Prevention (CDC) recently announced plans for screening incoming passengers from Wuhan, China for the new coronavirus 2019-nCoV. Passengers showing symptoms or having fevers will be quarantined until they can be tested for the virus.
For centuries, quarantining has been part of the organized response to outbreaks of infectious diseases, but its use has always been controversial because it pits individual rights against the public interest.
In an NPR article, professor of global health law at Georgetown University, Lawrence Gostin, described quarantine as: "The most draconian measure, because it allows you to literally imprison somebody who you don't know for sure is a danger to the public."
Our globalized world is vulnerable to communicable diseases, and the recent outbreak of a new coronavirus in Wuhan, China has brought the issue of quarantine to the forefront. The authority for the U.S. to isolate or quarantine people comes from the Commerce Clause of the U.S. Constitution.
Also, Section 361 of the Public Health Service Act (42 U.S. Code §264) gives the U.S. Secretary of Health and Human Services authority to take measures to prevent the entry and spread of communicable diseases from foreign countries into the United States and between states.
The Centers for Disease Control and Prevention (CDC) is tasked with carrying out these functions, and it can both isolate and quarantine individuals. The CDC defines the difference between the two as:
- 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.
Federal isolation and quarantine are authorized for these communicable diseases:
- Infectious tuberculosis
- Yellow fever
- Viral hemorrhagic fevers such as Marburg, Ebola and Congo-Crimean
- Severe acute respiratory syndromes
- Flu that can cause a pandemic
However, Federal isolation and quarantine can be authorized by Executive Order by the President of the U.S. The President can also revise the items in the above list by Executive Order. This raises the uncomfortable possibility that the president could add say, acne, to this list, and could quarantine indefinitely anyone suffering from that condition.
During the 2014-2016 Ebola outbreak, President Trump tweeted that U.S. healthcare workers who had traveled abroad to help should not be allowed to return home.
The U.S. cannot allow EBOLA infected people back. People that go to far away places to help out are great-but must suffer the consequences!— Donald J. Trump (@realDonaldTrump) August 2, 2014
According to Title 42 Code of Federal Regulations, parts 70 and 71, the CDC is authorized to detain, medically examine, and release people who have arrived into the U.S., or who are traveling between states, who are suspected of carrying a communicable disease.
Both isolation and quarantine are considered "police power" functions, meaning that the state has the right to take action affecting individuals for the benefit of society. The U.S. Customs and Border Protection and U.S. Coast Guard officers are also authorized to enforce federal quarantine orders.
In most states, breaking a quarantine order is a criminal misdemeanor, while breaking a federal quarantine order is punishable by fines and imprisonment.
To better understand quarantine, it pays to look at it from an historical perspective. The word quarantine originated in 14th century Venice, a time when "The Black Death," or bubonic plague, killed 20 million people in Europe.
Bubonic plague - Venice 1347-1352
While not understanding the role of fleas and rats in spreading the disease, the Venetians did understand the benefit of quarantining incoming ships for 40 days before allowing them on shore. The 40-day waiting period was known as quarantinario from the Italian word for 40.
Yellow fever - Philadelphia 1793
At that time, Philadelphia was the capital of the U.S. From 1793 to 1794, 5,000 people died of yellow fever, and that was 10% of the city's population.
Yellow fever is spread by mosquitoes, and at the height of the epidemic, 100 people a day were dying of the disease. Federal officials fled to the countryside, and the city began quarantining people at the Lazaretto Hospital, which was opened in 1743 on the small island of Santa Maria di Nazareth.
Named for the leper from the Bible, Lazaretto Hospital is the oldest quarantine hospital in the U.S. The yellow fever epidemic was finally stopped by the onset of winter, when cold temperatures killed the mosquitoes.
Cholera - East Coast 1893
The influx of immigrants arriving from Europe brought cholera to U.S. shores, and the federal government imposed quarantine requirements. Congress passed legislation outlining the role of the federal government in quarantine, and federal facilities were built to house those quarantined.
The quarantine system was fully nationalized by 1921, and in 1944, the Public Health Service Act stated the federal government's quarantine authority for the first time.
It gave the U.S. Public Health Service (PHS) responsibility for preventing the introduction, transmission, and spread of communicable diseases from foreign countries into the United States.
Typhoid - New York City 1907
Irish-born cook Mary Mallon loved working for the upper crust families of turn-of-the-century New York. Then, an outbreak of typhoid fever hit the city. Typhoid fever is a form of salmonella, and it can cause severe diarrhea, fever, and death.
When the outbreak was traced to Mary Mallon, it was determined that while she was a carrier of the disease, she herself was immune, and it earned her the title of "Typhoid Mary". Authorities immediately sent Mallon to be quarantined on North Brother Island, where she remained for the next three years.
After agreeing to never work as a cook again, Mallon was released, but she soon went right back to working as a cook, and in 1915, authorities traced another outbreak of typhoid right back to her. Mary was returned to North Brother Island, where she remained for the next 23 years, which was the remainder of her life.
Venereal disease - U.S. 1917
When the U.S. military noticed that many young men couldn't be drafted into service during World War I due to diseases such as syphilis and gonorrhea, they began a search for a culprit, and they found one in the women who hung around military training facilities and recruitment centers.
The military requested, and got a federal order allowing the women to be rounded up and quarantined. According to Harvard University medical historian Allan Brandt an estimated 30,000 women were detained and continued to be detained long after they had tested negative for STDs.
Influenza - Worldwide 1918-1920
"The Spanish Flu" pandemic struck the world in three waves over the course of three years. An H1N1 influenza virus, it infected 500 million people around the world, including those on remote islands in the Pacific and native tribes in the Arctic.
The movement of troops during World War I facilitated the spread of the virus, and health authorities closed schools, churches and theaters, and suspended public gatherings.
Two additional influenza pandemics have occurred since then: the "Asian flu" pandemic of 1957–1958, which was a novel virus of the type H2N2, and the influenza A pandemic of 1968–1969, which was type H3N2.
Severe Acute Respiratory Syndrome - China, Hong Kong, Singapore, and Canada 2003
SARS originated in Guangdong Province, China in 2003, and quickly spread through air travel. It had a high rate of transmission, and a high mortality rate. People had no prior immunity to it, and there were no effective antiviral drugs or vaccines.
Public health authorities in Canada asked those who might have been exposed to voluntarily quarantine themselves. In China, police cordoned off buildings and instituted checkpoints on roads. Punishment for breaking quarantine included death, and entire communities were discriminated against and stigmatized.
Tuberculosis - Atlanta 2007
When a lawyer from Atlanta, Andrew Speaker, was suspected of having extensively multi-drug-resistant tuberculosis, which is a deadly version of the infectious disease, Speaker was asked to voluntarily isolate himself.
Instead, while awaiting the results of tests, Speaker flew to Europe for his wedding and honeymoon, jetting off to Paris, Athens, Mykonos, Rome, and Prague. Realizing that returning to the U.S. was likely to be a problem, Speaker instead flew to Montreal, Canada.
Renting a car, Speaker was waived through the Canada-U.S. border by a Customs and Border Protection Officer even though an alert had been placed on Speaker's passport because, according to the agent, Speaker "did not look sick." The agent was soon after fired.
Authorities immediately placed Speaker under the first involuntary isolation order since 1963. Facing a wave of negative backlash, Speaker apologized to the passengers on the airplanes on which he had flown, but seven Canadian and two Czech passengers sued him. Ironically, Speaker is a personal injury lawyer.
Ebola - Texas 2014
While a patient, Thomas Eric Duncan, was being treated for Ebola, Texas officials placed four of his family members under quarantine, ordering them "not to leave the apartment or to receive visitors without approval."
Measles - Los Angeles 2019
On April 11, 2019, the Department of Public Health quarantined up to 200 students and employees for one week at the California State University, Los Angeles (Cal State LA) after they were exposed to measles in the school's library. Those quarantined were exposed to measles and couldn't provide evidence that they had been immunized.
On April 24, 2019, at the University of California, Los Angeles (UCLA), 119 students and eight staff members who were exposed to measles and couldn't provide proof of immunization were quarantined.
CDC quarantine stations
Quarantine is administered by the Division of Global Migration and Quarantine, which is a part of the CDC's National Center for Emerging and Zoonotic Infectious Diseases, and is headquartered in Atlanta, Georgia.
The CDC currently has 18 quarantine stations located in: Anchorage, Atlanta, Boston, Chicago, Dallas, Detroit, El Paso, Honolulu, Houston, Los Angeles, Miami, Minneapolis, New York, Newark, Philadelphia, San Diego, San Francisco, San Juan, Seattle, and Washington, D.C.