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.

It gives federal officials the authority to appoint quarantine officers, establish quarantine stations, and detain Americans "reasonably believed to be infected" with a communicable disease. Anyone violating a quarantine order can be punished by a fine of up to $1,000 and a one-year prison term. The law applies only to a list of deadly and easily communicable diseases that the president may amend at will, which Bush did in his executive order that added SARS to the list.

The Tradeoff

Then there's MEHPA, the proposed Model Emergency Health Powers Act, which began appearing in state capitals soon after the anthrax scare of late 2001. It expands upon the emergency authority that many cities and states already have arrogated themselves for times of crisis, making explicit what powers public health officials will have.

Among them: seizing property and land as "necessary to respond to the public health emergency," forcibly vaccinating Americans against infectious diseases, and quarantining those who refuse. No court order is necessary to detain someone: "The public health authority may temporarily isolate or quarantine an individual or groups of individuals through a written directive." Backing the proposal are the CDC, the National Governors Association, the National Conference of State Legislatures, and the National Association of County and City Health Officials. So far about two dozen states have enacted MEHPA into law.

MEHPA highlights the difficult tradeoffs of balancing individual liberty with community security. While it is a serious step to limit a person's freedom of movement, there seems to be little alternative in the case of highly infectious communicable diseases. The question then becomes how the law should be worded and how it might work in practice. Critics warn that earlier versions of MEHPA would have handed governors the power to declare public health emergencies over tobacco smoke or obesity -- and seize an extremely dangerous amount of power in the process. The liberal American Civil Liberties Union and the conservative Free Congress Foundation and American Legislative Exchange Council joined to oppose it.

According to the ACLU, MEHPA permits a governor to "declare a state of emergency unilaterally and without judicial oversight, fails to provide modern due process procedures for quarantine and other emergency powers, it lacks adequate compensation for seizure of assets, and contains no checks on the power to order forced treatment and vaccination."

Such powers can be used carefully and can be wildly abused; it's far too early to make predictions. Yet it's worth remembering -- and the 1918 flu epidemic is a major reminder -- that government officials are as prone to mistakes as anyone else. Guénael Rodier, the World Health Organization's director of communicable disease and response, recently admitted that the organization could have done a much better job of responding to SARS early this year by making an earlier public warning. If that had happened, "Toronto would very likely have been spared a SARS outbreak on the scale it has worked so admirably to contain," Rodier wrote in a commentary for the Canadian Medical Association Journal. Richard Schabas, a former minister of health for Ontario, has accused provincial officials of not analyzing SARS data properly, and causing unnecessary panic by overreacting when the disease was confined to hospitals.

Panic, and Other Responses

That's hindsight, of course. But overreaction is a threat whenever governments face an apparent crisis. Officials may respond to pressure either because they believe the crisis is genuine or because they think the appearance of activity on their part is necessary to head off panic. Who wants to repeat what Toronto experienced, when the WHO drove a stiletto through the heart of tourist travel by effectively declaring it a SARS hot zone?

Take what happened in 1998 and 1999, during the so-called Y2K computer glitch. Canadian newspapers reported at the time that the government was considering martial law and the invocation of the Emergencies Act in response to Y2K disruptions. In the U.S., Sen. Robert Bennett (R-Utah) asked the Pentagon what plans it has "in the event of a Y2K-induced breakdown of community services that might call for martial law"; a House subcommittee recommended that then-President Clinton consider declaring a Y2K "national emergency."

One traditional way to manage public reaction is to manage tightly the flow of information, a task that technological advance has made more difficult. Reports of the spread of SARS, for instance, rocketed around the globe even faster than the virus itself. During the early days of the outbreak, an intensive-care specialist at a hospital in Hong Kong turned to e-mail lists to distribute his stark, first-hand reports. "This pneumonia is out there in the community," Tom Buckley told the Critical Care Medicine mailing list on March 24, in a widely forwarded message. "The numbers are increasing daily, and a third hospital is being prepared for the influx. How big this is going to get is anyone's guess." Buckley warned that the Hong Kong government "is downplaying the whole thing presumably because of the economic implications." Buckley's post was prescient. In the two months following his warning, cases of SARS in Hong Kong leapt sevenfold, from 260 to over 1,700 infections. (When contacted for a response, Hong Kong's Health, Welfare and Food bureau replied with a statement saying: "To reassure you that we are not trying to downplay any of the effects, we recognize that in fact the public health considerations must be first and foremost and all the other things are secondary to this.")

In China, the birthplace of SARS, the communist government lied for months. Beijing officially, and implausibly, denied the existence of hundreds of SARS patients in hospitals that had been visited by Western journalists. Then China Premier Wen Jiabao took the unusual step of saying that while progress had been made in limiting the spread of SARS, "the overall situation remains grave." This is the same government that last year, in just one day, upped its official estimate of HIV infections from 30,000 cases to 1 million. In a sign of China's growing desperation, the government said in May that those who break quarantine and spread SARS would be executed. If authoritarianism helped save lives in Singapore, in China it has been deadly.

In this climate of official deception, misinformation about SARS has been spreading so efficiently it would do the common cold proud. Some residents of China's Shanxi province reportedly place their faith in steamed vinegar. A Singapore department store advertises perfume atomizers as effective SARS countermeasures. A teenager's Web hoax claiming Hong Kong's borders would be closed prompted runs on canned foods and toilet paper. A supermarket owner in Sacramento spent two weeks arguing that, contrary to rumors, neither he nor his family is infected with SARS and his stores are entirely safe. A Sacramento city councilman tried to quell panic by bravely chewing a ceremonial Granny Smith apple from the store's produce section in front of reporters.

An in-depth New York Times analysis showed that America is not immune to this 21st-century information contagion. The Times reported that high levels of anxiety existed in states such as New York, California, and Washington that experienced the most SARS cases or had sizeable Asian-American communities. New York City Mayor Michael Bloomberg was worried enough about public panic to dine in a Chinatown restaurant and then hold a press conference about it. OnlineAllergyRelief.com, an Internet retailer in Metairie, Louisiana, that sells air filters and purification products, reports that business is booming. "We have gone through case after case of masks," a representative says. "They're just slow to come in now….A lot of things are back ordered. Our manufacturer doesn't have a really big supply."

Panic mongers inevitably arise to prey on public nervousness. Web sites of dubious provenance tout dietary supplements -- colloidal silver, oregano oil -- as effective anti-SARS measures. Spam touting SARS remedies is on the rise. Gary North, the Christian Reconstructionist who has made a living predicting that modern society will end in panic and ruin, has seized on SARS. In 1980, North forecast rationing of housing and a nuclear war with the Soviet Union, warning his followers to buy "gold, silver, a safe place outside the major cities." Later he found rich topics in AIDS and then Y2K, recommending to his newsletter subscribers that they head for the hills to avoid total social collapse. In an announcement in April, North seized on SARS. He wrote: "It's a race between medical science and the bugs. There is no scientific reason to believe that the scientists will always beat the bugs."

Perhaps not. While technology may aid panic-mongering, technological advance is also what makes the fight against SARS so different from previous epidemics. Technology lets researchers collaborate in ways simply not possible just a few years ago. Perhaps the most impressive way in which research has been accelerated is in the analysis of the virus' complete genetic code. More than a dozen sequences of the virus -- all demonstrating slight differences, which is typical for a coronavirus -- are up on the WHO's Website. As a result of this genetic sequencing and collaboration, companies like AVI BioPharma in Oregon think that the first drug to combat SARS could be available in months, not years.

Henry Niman, a Harvard instructor in surgery at Massachusetts General Hospital in Boston, has long studied retroviruses. He says the collaborative process normally would have taken researchers at least months. "The fact that the virus has been sequenced in two weeks by two groups, that's pretty quick," Niman says. "That's unprecedented speed. You would probably not have had two groups going simultaneously if you didn't have this information out there. The exchange of information has sped things up."

Niman cautions against SARS complacency. "It's not really clear that the epidemic is that much under control," Niman says. "This has the potential to spread very dramatically. It's something that many people are trying to slow down. How successful that's going to be is an open question."

Nearly 100 years ago, the Spanish Flu tested medical science's ability to respond to a deadly worldwide threat, with researchers in 1918 venturing beyond the germ theory of disease and postulating the then-novel existence of a virus as the cause of the infection. Their attempts to unravel the mystery of influenza soon led to the creation of a hybrid vaccine administered to the British military.

Today, researchers already have used the virus' genetic sequence to create tests that weed out people who may have breathing problems but are not infected with SARS. While the panic mongers have an undeniable head start, so far the ability of modern science to deal with such a novel and destructive threat seems up to the task. Let's only hope that governments' reactions to SARS are equally careful.