How should a free society respond to an Ebola outbreak? Unfortunately, that question is not hypothetical. The deadly disease continues to ravage West Africa and future Ebola cases in the United States are to be expected. To get a handle on how to strike the proper balance between public health and personal liberty, Reason.com asked four leading experts in the areas of law, health, science, and privacy to offer their recommendations for how U.S. medical and governmental officials should respond to the next domestic case of Ebola.
Don't Sacrifice Civil Liberties
George J. Annas
It is important to begin with the conclusion: trade-offs between civil rights and public health measures are not always necessary, and are almost always counterproductive. That is because we can generally rely on Americans to follow reasonable instructions of public health officials for their own medical protection.
Americans do not want to develop Ebola themselves, and have no interest in spreading it to their families or others. They will almost always demand treatment, rather than flee from it. Quarantine should only be considered for persons who are likely to have been infected with an infectious disease (like Ebola), and then only when they are a possible danger to others (in Ebola exposure, only after they have a fever).
In all cases where quarantine is deemed medically reasonable, it should be done only in the least restrictive way possible. For example, fever monitoring for those exposed should first be done by the individual, and only if this does not seem reasonable, overseen by a public health agency. The next step up in enforcement would be an agreement (like those in Dallas) to be monitored and not to travel out of the area or go to crowded places. Only if this agreement was broken should home quarantine be considered, and only if that was violated should quarantine in a state facility be considered.
Individuals with disease are not the enemy and are not criminals; they a sick citizens and deserve to be treated with respect. That makes it most likely that government will retain the trust of the people, which is absolutely necessary to deal effectively with an epidemic. In other words, as the AIDS epidemic demonstrated, the promotion of human rights and human dignity can be essential for dealing effectively with an epidemic. We do not have to sacrifice our civil liberties for an effective public health response.
George J. Annas is the William Fairfield Warren Distinguished Professor and Chair of the Department of Health Law, Bioethics & Human Rights at Boston University School of Public Health, School of Medicine, and School of Law. He is co-author of the ACLU report "Pandemic Preparedness: The Need for a Public Health—Not a Law Enforcement/National Security—Approach."
When Is Coercive Quarantine Justified?
Disease microbes know no boundaries between people, countries, and continents. They treat human bodies as an open access commons that they exploit for reproduction until they kill their hosts or they are defeated by immune defenses. To prevent the invasion and destruction of the medical commons through microbial overexploitation requires germ management. The best way to prevent invasive viruses, bacteria, and fungi from wreaking havoc is to enclose the commons of human bodies by erecting immune system fences via vaccination. Good fences make good healthy neighbors.
Vaccines or antibiotics are, however, not always available. Then isolation and quarantine–the erection of literal barricades–becomes the appropriate way to keep microbes out of the commons of human bodies. Obviously there is a gradation of harm, e.g., we do not quarantine folks who are ill with cold viruses. Quarantine for airborne, easily communicable, deadly diseases is certainly justified. In such cases, protecting the majority from death and disease can and should override a person's right to freedom of movement.
Although the Ebola virus is not nearly as communicable as many airborne microbial diseases, coerced home isolation would be warranted in West Africa as way to break the chain of infections, given the lack of health care infrastructure and the large number of folks who are now ill. Unfortunately, pervasive misgovernment in the region undermines the ability to monitor and coerce people suffering from Ebola virus.
In the U.S. folks who are ill with Ebola must be isolated, but coerced Ebola quarantine of symptomless people is not warranted. Monitoring health care workers and any others who have been in close contact with actual Ebola patients is sufficient to protect the public. Given that microbes do not respect national or continental boundaries, the U.S. and other rich country governments should focus on how best to help health care workers to enclose the Ebola outbreak in the West African medical commons.
Ronald Bailey is a science correspondent at Reason and the author of Liberation Biology (Prometheus).
Expect the Government to Overreact
I continue not to know the right thing to do with people exposed to Ebola who show no symptoms of infection. But I do know that governments make prudent and imprudent quarantine decisions.
English common law authorized quarantines to limit the spread of plague, a concept adopted by the American colonies. A Supreme Court opinion described an early New York City outbreak of yellow fever: "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 whole country was roused. A cordon sanitaire was thrown around the city."
Sometimes outbreaks of disease combined nastily with anti-immigrant sentiment. In 1900, San Francisco levied a quarantine preventing people from leaving without documentation of bubonic plague vaccination—but it applied only to Chinese residents. New York City over-quarantined some 1,200 Russian Jewish immigrants on an East River island in 1892.
We don't yet know enough about Ebola to decide what the right answer is. Studies have shown that 12 to 20 percent of Ebola patients who died had no fever, so a normal temperature by itself is no clean bill of health.
A key question is how readily the virus can be transmitted by coughing and sneezing, especially in the early stages of the disease. In a Democratic Republic of the Congo outbreak, 5 of 19 Ebola patients reported no physical contact with an infected person, implying aerosol transmission. Similarly, researchers found Ebola can be transmitted between non-human primates and from pigs to non-human primates through aerosol droplets without physical contact. What about humans?
Until we answer those questions, state and federal governments will overreact and under-react. Let's hope we learn more soon.
Declan McCullagh is the founder of Recent.io, a forthcoming news recommendation and prediction engine. He is a former CNET and CBSNews.com political correspondent. McCullagh previously wrote about SARS and quarantines for Reason.
Pandemics vs. Personal Liberty
Jeffrey A. Singer
Public health policy should not be exempt from the "non-aggression principle." Force must be prohibited from interpersonal relationships, except when used in self-defense or retaliation.
In the case of a highly contagious lethal disease, I believe that screening potential carriers, and containing them via quarantine, represents an act of self-defense.
One of the few legitimate functions of the government is to protect people from physical assault. The transmission of a disease with significant lethal potential fits that description.
Therefore, it is appropriate to screen people reasonably considered potential carriers. It is completely proper to confine people found to be a threat to the lives of others until that threat no longer exists.
That's the easy part. The hard part is the science. Who poses a threat and who does not? How long should the quarantine last?
Here, panic and emotion must not cloud rational evaluation of scientific data. It would be a tragedy to curtail liberty through quarantine without a sound, evidence-based rationale. But it is also important to remember that all knowledge is contextual. We know what we know based upon the available evidence. We must be willing to revise our conclusions as more is learned. We must rapidly adjust the criteria for quarantine as new knowledge dictates.
Jeffrey A. Singer, MD, is a practicing general surgeon and an adjunct scholar at the Cato Institute.