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Given the scope of the Ebola outbreak unfolding in Western Africa, it seems possible that a case will eventually emerge in the U.S.
We could even see an isolated cluster of infections in an American city.
Considering the nature of the Ebola virus, and the medical infrastructure we have to combat its spread, the diagnosis of some cases on American soil shouldn’t be reason to panic. We have a plethora of tools and public health practices to readily combat its spread. Yet because the virus is so dangerous, and feared, its arrival in America would likely to trigger a robust response from our public health establishment.
For most Americans, it may be the first time they glimpse the tools that our government has staked out over the last decade, as preparation for public health emergencies like a pandemic flu, or even bioterrorism. Some of these authorities are wholly necessary. Others will prove controversial and worthy of closer scrutiny.
Chief among them are authority maintained by the Centers for Disease Control to quarantine Americans suspected of having a dangerous, communicable disease. In some cases, this includes the power to isolate people, and hold a healthy person against his will. The CDC’s quarantine authority has been strengthened in recent years. But we haven’t had sufficient debate about how to balance individual rights against public health in these circumstances. And when quarantine is even effective. We should revisit these issues before we find ourselves invoking these tools.
What will happen if Ebola arrives in America?
First, there will be a lot of misplaced panic. But there’s no reason for most Americans to fear of Ebola’s wider spread. While Ebola is highly infectious, it is not very contagious.
It’s highly infectious because someone stricken with Ebola is very likely to get sick (and harbors a lot of virus particles that they can readily transmit to another person, given the right conditions). But the virus itself is fragile, and does not easily spread. So it’s not very contagious. In short, Ebola is harder to contract than many other viruses.
The Ebola virus can only be spread by direct contact (through broken skin or mucous membranes) with the blood, or other bodily fluids or secretions (stool, urine, saliva) of infected people. Infection can also occur if the broken skin of a healthy person comes into contact with environments that have become contaminated with an Ebola patient’s infectious fluids (such as soiled clothing).
Moreover, patients usually only become contagious – and can spread the virus — once they start contracting symptoms. Prior to the onset of symptoms, it’s typically harder to spread the virus. Yet the onset of symptoms is usually quite severe. So it’s easy to recognize that a person is sick. Moreover, stricken individuals are less likely to travel about – and spread the virus — given their debilitated condition.
All of these factors make control of the infection feasible. If isolated cases emerge in the U.S., our public health apparatus should be able to readily contain its spread.
Yet it’s highly plausible that a case of Ebola could soon be diagnosed in the U.S.. For one thing, the virus has a long incubation period, up to three weeks. So an infected individual could travel abroad and contract symptoms only well after arriving at their destination.
Moreover, the same factor that’s fueling its spread in Africa makes it more likely that Ebola travels abroad. The African outbreak has occurred in urban areas. In the past, outbreaks have been confined to rural communities, making it easier to contain. The emergence of Ebola in urban settings has made control harder, and put the virus in closer proximity to people who may contract it and unwittingly get on an airplane.
If Ebola appears in the U.S., we have a robust public health infrastructure to contain its spread. In the past decade, five people have entered the U.S. with Lassa fever and Marburg, two viral hemorrhagic fevers that are similar to Ebola. This includes a case in March of a Minnesota man diagnosed with Lassa fever after traveling to West Africa. No one else contracted the diseases as a result of these five cases.
Yet given the deadly nature of the Ebola virus, and the popular worry it’s likely to engender, one can expect the CDC and health authorities to pull out all the stops. The response could include invocation of the CDC’s evolving quarantine authorities.
These federal powers comprise a set of rules that gives CDC sweeping authority to hold and isolate Americans in a public health emergency. These authorities haven’t been fully updated in decades. They’ve only been amended in piecemeal fashion to deal with modern threats like SARS and MERS. In advance of what may be a very public test of these powers, the collected scheme deserves closer scrutiny.
Updated quarantine regulations were first proposed in 2005 during the Bush Administration amid fears of pandemic flu. The regulations spelled out in detail how CDC would exercise its sweeping powers to involuntarily confine sick individuals and those believed to be exposed to certain deadly and contagious diseases. The rules also focused efforts on quarantine at airports. Among other things, it held airlines responsible for keeping records to help health officials track down people coming off flights, in the event they would need to be located later for quarantine.
The set of regulations also included a new “provisional quarantine” rule that would have allowed CDC to detain people involuntarily for up to three days, with no mechanism for appeal. CDC had to believe a person was infected with certain pathogens. Among the diseases included were pandemic flu, infectious tuberculosis, plague, cholera, SARS, diphtheria, and viral hemorrhagic fevers such as Ebola.
The regulations also defined “ill person” to include anyone with the signs or symptoms commonly associated with the diseases in question. This gave CDC more flexibility in deciding whom to quarantine by capturing a broader and earlier range of symptoms as the basis for holding an individual. It allowed for greater exercise of discretion public health officials and those staffing quarantine stations.
The regulations were an attempt to provide clarity to how quarantine would be implemented. But in spelling out its proposed procedures, the rule raised concerns that the feds were assuming too much jurisdiction to detain people involuntarily. In short, CDC got itself into political trouble by merely clarifying how it proposed to implement federal authorities that the agency long held, and still maintains.
While the rule was never fully implemented, in its absence, one can assume that CDC would implement quarantine in keeping with these general constructs.
President Obama withdrew the Bush quarantine rule in 2010 because the provisions, when spelled out in regulation, proved controversial. Airlines, in particular, balked. Yet in its place the Obama Administration implemented a series of Executive Orders, and fell back on the CDC’s original quarantine provisions. The status quo could be just as troubling as the controversial regulation that it displaced.
The existing rules leave a murky and potentially intrusive scheme largely intact. The Bush era regulation laid out some spooky scenarios where people could be detained for long periods, merely on a suspicion they might have been exposed to some pathogen. And forced to submit to certain medical interventions to gain their freedom. But the existing rules in force today leave possible these same scenarios – only without any protections that could be spelled out in clear regulations.
Quarantine will be a key measure that public health officials will use to contain the spread of a deadly pathogen like Ebola. The authority is an essential element of public health protection. But it needs to be exercised with ample safeguards for those people who may be held against their will.
In the absence of clear, modern rules implementing CDC’s authority, there’s reason to worry that the current measures don’t readily afford the proper protections.
In the presence of a suspect case of Ebola, the official CDC website details ‘Specific Laws and Regulations Governing the Control of Communicable Diseases’, under which even healthy citizens who show no symptoms of the virus could be forcibly quarantined at the behest of medical authorities. The existing regulations stipulate, “Quarantine is used to separate and restrict the movement of well persons who may have been exposed to a communicable disease to see if they become ill.”
In other words, you don’t have to be sick to be detained. Just suspected by health officials of having been in contact with someone who might have had the disease.
The regulations say a person “may be detained for such time and in such manner as may be reasonably necessary.” Is that three days or thirty? There are no rules.
While local public health officials on uncooperative patients sometimes impose quarantines, federal quarantine has been almost unheard of in modern times. The emergence of disease such as SARS, MERS, and swine flu make it more probable that a widespread quarantine may one day be necessary. But our quarantine provisions have never undergone sufficient scrutiny, public debate, or modern clarification.
Under involuntary quarantine, people only need to be held until they test negative for the suspected pathogen. But that can also include the period of time it would take for them to incubate the disease after an alleged exposure. In the case of Ebola, that could last weeks. Moreover, testing for Ebola could take some time as well.
While the virus can be ruled out by a blood test that only takes a few days to perform, there are only a handful of high-security (BLS-4) labs capable of performing the specialized test. What if doctors were sending off a lot of samples to rule out the Ebola virus, all at the same time? For example, what if a case of Ebola emerged during flu season, when doctors are seeing a lot of people with symptoms that could be easily confused with Ebola. The number of tests that nervous doctors send off, to rule out Ebola, could overwhelm the facilities. People could be caught in a quarantine limbo while they wait for a negative result to come back.
The attempt during the Bush Administration to draft specific regulations interpreting the CDC’s vast quarantine provisions failed precisely because the mechanisms for exercising that authority, once articulated clearly, concerned a lot of observers both in and out of government. That should provide no comfort to those who opposed the Bush era provisions, since the same powers still reside with CDC.
Those provisions have been laid out largely in piecemeal. One of those pieces came just a week ago. In a move that raised some eyebrows, President Obama amended a 2003 Executive Order that gives the Federal government authority to quarantine people showing signs of severe respiratory illness. While the original provision pertained largely to SARS, the Obama revision was meant to apply the quarantine authority to a broader range of respiratory illnesses.
The timing of the revision struck many as odd, since it didn’t appear to pertain directly to the unfolding Ebola outbreak. Some speculated it was done in response to concerns about respiratory diseases that are being spread as a result of recent immigration trends across our Southern border.
If Ebola does arrive in the U.S., quarantine will be a primary tool for preventing its further spread. While mass detentions are unlikely given the nature of how Ebola spreads, one day perhaps soon we will be confronted with an equally deadly pathogen, but one that spreads far more easily. Whether its SARS or MERS or some yet undiagnosed illness, the principal tool for thwarting spread will be the ability of public health officials to isolate those exposed, and maybe keep them in quarantine.
Before government officials draw on these tools and authorities, we deserve to have an open debate about just how quarantine will be implemented. How we will balance individual rights against public safety, and establish clear rules on what rights detained individuals will have in such circumstances.
We also need to consider whether widespread quarantine is even practical, or effective. If some cases of Ebola emerge during flu season, for example, efforts to quarantine those suspected of having Ebola could be challenged by the fact that the initial symptoms of that virus can mimic the onset of ordinary influenza.
Regulations implementing the CDC’s power to quarantine were last substantively amended in 1985. Having scrapped the controversial Bush era regulations, which for all their reproach were nonetheless an attempt to get some clear and modern parameters around these authorities, it’s time we revisit these considerations.
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