Something's in the Air

Liberties in the face of SARS and other infectious diseases

Visiting Singapore is a little like flying into some twisted Father Knows Best time warp. Lining the streets next to such familiar stores as Reebok, Esprit, and Timberland are government ministries with names like "Board of Film Censors," along with buildings housing the "Social Development Unit" state-run dating service and the "Home Ownership for the People Scheme."

For a few weeks in April and May, such downtown streets were speckled with gauzy white squares: mask-wearing Singaporeans fearful of catching the deadly SARS pneumonia. They had reason to be concerned. According to the World Health Organization, Sudden Acute Respiratory Syndrome kills roughly 15 to 20 percent of the people who contract it, and it had been spreading through parts of Asia faster than pirated copies of the latest Microsoft beta release. What's more, the average death rate can be misleading. SARS is an age-sensitive disease: If you're over 65 years old and you have the misfortune of being infected, the WHO believes your death-rate odds are a dismaying 50 percent or higher.

Singapore's nanny-state meddling and unabashed authoritarianism may have spared it the worst. Even though it had the third-worst outbreak of SARS, behind China and Hong Kong, Singapore's death rate was 15 percent, lower than the less severe North America outbreak centered in Toronto. (Canada's death rate, as of press time, was 17.5 percent.)

The reasons for the difference are complex and unclear. SARS has been mutating into strains of varying lethality, and a lone "super spreader" infectee can lay waste to an entire hospital that isn't properly prepared. Another explanation for Singapore's comparative success in containing SARS is its single-minded determination to take whatever steps necessary, with scant regard for such individual liberties as the right to travel and associate freely. This is the city-state the cyberpunk writer William Gibson once described as "Disneyland with the death penalty": While free trade is largely embraced, chaos is verboten. Chewing gum sales are prohibited. Sell drugs, you face the gallows. Canings are routine. Playboy, Penthouse, and Cosmo are all banned.

When SARS hit, the authoritarian proclivities of Singapore's government were channeled into aggressive quarantines. After a few possible SARS cases were identified at the popular Pasir Panjang Wholesale Market, the state took no chances. Nearly 2,000 people who had worked at the market between April 5 and April 19 were placed under mandatory home quarantine for 10 days. Health Minister Lim Hng Kiang said a team of 50 to 60 nurses would make house calls on quarantined homes, and the government would offer a daily home quarantine allowance of $41. Web cams were installed in quarantined homes for surveillance, with residents asked to step in front of the camera on demand. Anyone nabbed for flouting the quarantine was outfitted with an electronic tracking bracelet.

Medical Powers

The good news -- for now -- is that SARS is less of a threat than it was a few months ago, though it could return with a vengeance when winter comes to the northern hemisphere and people spend more time inside in close quarters. As of this writing (late May) there have been no confirmed SARS deaths in the U.S., and an analysis prepared by The New England Journal of Medicine indicates that the worldwide SARS growth rate is more arithmetic than exponential.

But if the virus does return, other nations besides Singapore will have to balance suggestions such as broad quarantine orders with the preservation of civil liberties and the rights to privacy, property, and freedom of movement.

What does this mean for the U.S.? What might happen is anyone's guess, but imagine if there were a serious outbreak this fall that threatened to overwhelm the nation's health system. This is the kind of scenario the Centers for Disease Control and Prevention (CDC) dreads -- one in which hospitals are deluged with scores or hundreds of patients showing up at the same time. As physicians in Singapore and Hong Kong found out, emergency rooms and critical care wards can be lethally efficient in spreading SARS. Government officials at the state and federal level have been warning since 9/11 that the U.S. is not prepared for a biological attack. SARS appears to be natural in origin, but the effects could be the same.

So consider, as a thought experiment, what might happen in the U.S. after a major outbreak of SARS or a similar communicable disease.

We already know that President George W. Bush has signed an executive order triggering a World War I-era law that lets him add SARS to the ranks of such diseases as cholera, smallpox, and the plague. The current version of that law grew out of well-justified fears of the deadly flu epidemic of 1918, sometimes called Spanish influenza, which infected about 28 percent of all Americans and killed about 675,000 -- about 10 times the number of U.S. soldiers felled in battle during the war. Globally, over 30 million people died, and even President Woodrow Wilson was infected in early 1919 while negotiating the Treaty of Versailles.

Reactions to the 1918 epidemic provide a cautionary tale. State governments across the U.S. responded by levying quarantines and imposing mask laws. In San Francisco, the city sterilized public telephones and drinking fountains. It also required people to wear gauze masks in all public places, giving rise to the far-too-optimistic slogan: "Wear a Mask and Save Your Life! A Mask is 99% Proof Against Influenza." In November, city sirens wailed to signal that it was safe to remove the masks -- an announcement that was terribly premature, as thousands more people came down with influenza the following month.

In Philadelphia, city officials made the fatal mistake of sending mixed signals. While one agency was warning against public coughing, sneezing, and spitting, the Department of Health and Charities was informing the public that influenza would not spread outside the military. Then, over a matter of weeks, nearly 13,000 people died. Too late, the city government ordered schools, churches, theaters, and other public gathering places closed. Elsewhere, "open-faced sneezers" were fined and the District of Columbia imposed blanket quarantines that restricted residents to their homes.

The history of quarantine dates back at least to the Bible's Leviticus 13, which describes a seven-day period of isolation that priests must impose when an infection is apparent. Quarantine literally means a period of 40 days, which cities along the Mediterranean shipping routes imposed during the plague of the 15th century. English common law recognized that a government must take aggressive steps to limit the spread of plague, a concept that was adopted by the American colonies and the young Republic. In the 1849 case Smith v. Turner, the Supreme Court described early efforts at quarantine in New York: "Never did the pestilence rage more violently than in the summer of 1798. The State was in despair. The rising hopes of the metropolis began to fade. The opinion was gaining ground, that the cause of
this annual disease was indigenous, and that all precautions against its importation were useless....The whole country was roused. A cordon sanitaire was thrown around the city." At times, Bedloe's Island -- where the Statute of Liberty is today -- and Ellis Island have been used for quarantines.

And today? Under current federal law, 42 U.S.C. 264, the Surgeon General has broad power to "make and enforce" any rules that may be necessary to prevent the spread of communicable diseases. The law makes for fascinating -- if disquieting -- reading.

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