In the time of the black plague, people with symptoms were often placed into separate areas. The sick and symptomatic were separated from the general populace. When ships came into harbors they were often kept there for weeks until it was assured that they did not carry disease with them. Cities would close their gates to travels to prevent anyone from arriving who might bring disease as well as to protect travelers from disease when it raged within.
When immigrants passed through Ellis Island with symptoms of infectious diseases they were kept on the island until they were better or sent back home. During measles outbreaks in the 1950s, my parents tell stories of houses having red marks on them so you knew that someone in this house was sick and you should not enter.
Quarantine and isolation are the oldest and most successful tools of public health. When a disease has the potential to infect others, isolating those who suffer from infection as well as those who have contact with them helps to prevent the disease from spreading throughout the general populace. When used properly, quarantine is very effective, especially for diseases that spread human-to-human without an animal or insect vector (like plague which is passed by fleas that feed on rats).
Isolation is when people are asked to voluntarily isolate themselves from the general populace. They are asked to keep to themselves to protect us. Yes, this limits their civil liberties of travel, commerce, and socializing. But they undertake this with the understanding that in certain times the well-being of the community takes precedence over the convenience of the individual.
Apparently two health care professionals never heard this lecture in school or, like many, assumed that such courtesy and obligation to your neighbors does not apply to them. Nancy Snyderman, a physician and NBC chief medical correspondent had recently returned from West Africa. She was supposed to isolate herself, especially since a freelance camera operator with whom she worked had been brought back to the United States with Ebola. However, she allegedly left her home and drove to pick up food at a soup restaurant.
Amber Vinson is a nurse in Dallas who had cared for Thomas Duncan, an Ebola patient. Like all of his care providers she was under “controlled movement” where she was not supposed to be on public transportation or with large groups. She took her temperature daily and was to report if she had any symptoms of Ebola. Instead of following the isolation, she hopped on a plane to Cleveland, Ohio to visit her family.
On Vinson’s return flight to Texas she had a slight fever of 99.5 degrees. Airport screeners are looking for 100.4 degrees on travelers coming from West Africa. Before her flight she called the CDC and described how she was feeling. Vinson reports that the CDC did not tell her not to fly. In a case of the right hand not knowing what the left hand is doing, CDC Director Tom Frieden stated that she never should have flown. Now, not only her family but every person who flew on that plane is being sought so that they too can be isolated. Vinson has now been diagnosed with Ebola and is being transferred to Atlanta, to one of the four hospitals in the nation equipped to deal with highly dangerous diseases.
Why can’t people be trusted to do the right thing? Have we become such a selfish society that we no longer care about the well-being of our neighbors? Has our worship at the altar of individualism gone so far that we are willing to spread a deadly disease to simply satisfy our desire for soup?
In 2003, one of the epicenters of the SARS outbreak was Toronto. When the government there asked people with the disease or symptoms to voluntarily isolate themselves, they did. The Canadians stayed at home, stayed away from other people and the outbreak fizzled. At that time there was much discussion over whether such a voluntary effort would work in the individualistic society of the United States. The answer to the question posed during the SARS crisis—based on the evidence of these two knowledgeable health care providers—is clearly “no”. After all, Canadians trust their government while Americans generally do not. One of the founding principles of Canada is trust in each other and the government. In the U.S. we trust in a deity and are founded on a principle of what has been interpreted as unbridled liberty.
Now Snyderman is subject to quarantine enforced by New Jersey public health authorities. Quarantine differs from isolation in that it is enforced by public health officials who have police powers when it comes to a health crisis. Isolation is voluntary and quarantine is enforced. If you can’t be civil and think of others then the state will quarantine you so that you do not pose a risk to the health of others. This is the same power that was used to imprison Typhoid Mary in the early 1900s when, as an asymptomatic carrier of the disease, she refused to stop cooking for families or to take any precautionary efforts.
The history of quarantine shows it is not a panacea. Those people on Ellis Island who were kept on the island or sent back home were mostly poor, of low education, and members of stigmatized ethnic groups. Typhoid Mary was partly a victim of racism against the Irish, sexism, and her poverty. This police power needs to be used sparingly, with oversight, so that it is not abused or used as an excuse to persecute or stigmatize a community. Which is why isolation is generally used first. It is the least restrictive means of limiting individual liberty, while also protecting the public.
The good news is that, of the people who were isolated because of their contact with Duncan before his hospitalization, none has the disease. They have just passed the two week mark, which is significant. Although there is a 21 day possible period for symptoms to appear, the chances of their becoming sick have significantly decreased. Isolation worked in SARS and it has worked in Dallas. The bad news is that two of his nurses have been diagnosed.
The Snyderman and Vinson cases are our wake up call. It’s time to act like adults. It’s time to take responsibility for the potential we have to affect those around us. There is no reason for Ebola to become a problem in the U.S. As I’ve written previously, we have medical resources and the ability to properly isolate patients. Efforts like screening travelers and ceasing flights to other countries will not work, as I outlined in an earlier blog.
But, if we do not respect isolation, if we do not trust in public health officials (who may have made some missteps and are learning), then this preventable problem will become the nightmare epidemic. The U.S. needs to come out of its prolonged adolescence and realize that we are all in this together. Ebola doesn’t care that you were simply sneaking out for food or that you wanted to see you family. This is about coming together for the common good. We have to respect isolation. The race to control Ebola is ours to win. Or to lose.
Professor Craig Klugman is a bioethicist and medical anthropologist who is chair of the Department of Health Sciences at DePaul University in Chicago. This article was first published in the blog of the American Journal of Bioethics and has been republished with permission.