California was not one of the states that initially imposed a quarantine rule on people traveling from Ebola-impacted countries, perhaps in part because none of its airports are normal destination points for those arriving in the US from western Africa. That changed quietly yesterday, as the state’s top health official announced a mandatory 21-day quarantine on anyone who had contact with Ebola patients. The Golden State joins New York, New Jersey, and Illinois in the use of quarantines to contain any potential exposures until after the virus’ incubation period.
The state had an immediate opportunity to use its new policy. The CBS affiliate in San Francisco learned that one doctor has been placed under a quarantine order in Redwood City after returning from volunteer service in Liberia. The Stanford University surgeon has pledged to honor the home quarantine, declaring that he “won’t take a single chance” of exposing others to potential infection. That prompted the TV station to send someone out to his door to come into contact with him, naturally:
Dr. Colin Bucks returned to the Bay Area on Friday, but no state or federal quarantine orders were in place at the time. Dr. Bucks is not experiencing any symptoms of Ebola, but he is the first Californian to be quarantined under the new guidelines. Bucks is considered by health officials to be at “some risk.”
The doctor contacted San Mateo County health officials. After consultation with the U.S. Centers for Disease Control and the California Dept. of Public Health, Dr. Bucks was told to stay away from work and to stay away from others for 21 days. However, he can leave his house to go jogging by himself. He is taking his temperature every day and has not developed any symptoms.
“I’m California’s most experienced Ebola physician. I won’t take a single chance,” said Dr. Bucks in a New York Times interview. “My wife is away, my dog is away — there’s no downside to a little personal convenience, 3 weeks will pass.”
He spent a little over a month in Liberia with the International Medical Corps, working directly with Ebola patients. “This is a medical public health emergency. When I saw the news of the outbreak occurring, it wasn’t so much whether I would go, it was how and in what capacity.”
Er, exactly what part of quarantine does Christin Ayers not grasp? Could they not do that interview on the phone, perhaps, with an establishing shot of the house? And nice job of telling all the neighbors, too. That’s first-class journalism, right there.
Three weeks should pass quickly enough, especially in a home quarantine, as the doctor notes. On the other side of the country, another health-care professional insists that she won’t abide by any quarantine order, even for home isolation for less than three weeks:
The nurse who was quarantined after returning from treating Ebola patients in West Africa has given the State of Maine until Thursday to let her move freely, setting up what could be a test case of whether state quarantines are legal.
The nurse, Kaci Hickox, 33, who was confined first by New Jersey when she came back to the United States and then by Maine, did a blitz on morning television challenging her confinement by Maine officials.
“I remain really concerned by these mandatory quarantine policies,” Ms. Hickox told ABC News via Skype from Maine on Wednesday morning. “I think we are only adding to stigmatization that again is not based on science or evidence.”
If the state does not lift her quarantine order by Thursday morning, she said, “I will go to court to attain my freedom.”
Doug Mataconis thinks she may have a case, if the lawsuit continues past the quarantine period:
As I said, even though most of the law in this area is quite old and tends to pre-date recent developments in area like due process, it seems fairly clear that a Court would have no problem with a quarantine imposed against someone who is obviously contagious with a disease like Ebola. Things could be quite different, though, in the case of someone like Ms. Hickox who is not displaying any symptoms at all to date and is therefore not contagious according to all available medical science. Yes, it’s true that she coulddevelop symptoms at any point in time, Dr. Craig Spencer for example was apparently okay up until his first registered a fever of 100.3° last Thursday afternoon, but it’s equally possible that she won’t develop any symptoms at all and it isn’t clear to me that, even under the most generous interpretation of the police power laws that allow for quarantines, such a person could or should be forced to quarantine themselves for any period of time.
Perhaps attorneys who are looking into this might have more insight, but I don’t believe that quarantine orders in the past relied on a definitive ruling as to active contagion, but potential contagion. The three-week incubation period could change her from potential to active overnight, which would not give the state a reasonable period in which to act to prevent further spread — which courts would find to be a legitimate state interest, especially considering the 70% fatality rate of the virus in Africa.
Speaking of legitimate state interest, the Associated Press has a good explanation of why states would rather use quarantines than try to play catch-up after secondary infections begin to occur. The US health system is not prepared for anything more than an occasional case of Ebola, and multiple levels of contagion would quickly overwhelm our ability to respond:
The U.S. health care apparatus is so unprepared and short on resources to deal with the deadly Ebola virus that even small clusters of cases could overwhelm parts of the system, according to an Associated Press review of readiness at hospitals and other components of the emergency medical network. …
Without any stress caused by Ebola cases, the emergency care system in the U.S. is already overextended. In its 2014 national report card, the American College of Emergency Physicians gives the country a D-plus grade in emergency care, asserting the system is in “near-crisis,” overwhelmed even by the usual demands of care.
According to data from the Centers for Medicare & Medicaid Services, patients spend an average of 4 1/2 hours in emergency rooms of U.S. hospitals before being admitted. The data also show that 2 percent of patients leave before even being seen.
In a CDC study on hospital preparedness for emergency response in 2008, the latest data available, at least a third of hospitals had to divert ambulances because their emergency rooms were at capacity.
Add an influx of people with Ebola, along with those who fear they might have the disease, and the most vulnerable segments of the health care system could wobble.
“Even though there have been only a couple cases, many health systems are already overwhelmed,” said Dr. Kenrad Nelson, a professor at Johns Hopkins Bloomberg School of Public Health and former president of the American Epidemiological Society, referring to new federal procedures for screening, tracking and treating the disease and people who are exposed. He added that if a major flu outbreak also occurred, “it would be really tough.”
That’s why states like California would rather have people isolate themselves for three weeks under a mandatory order after contact with active Ebola cases regardless of the level of protection used. It’s a lot easier to deal with an occasional case of an isolated transmission than with monitoring hundreds or thousands of potential secondary and tertiary contacts because that person suddenly became symptomatic and made bad choices — like two of the three American health-care professionals did who developed active Ebola infections.
Update: Via our comment section, Eugene Volokh actually addressed the legal issues with Hickox’s situation, and thinks she doesn’t have a case at all:
Still, in part because quarantines have rarely been imposed since World War II, there is relatively little direct precedent on their permissible scope and circumstances. But a brief review of the cases suggests it extremely difficult to challenge such an action without a clear showing of medical unreasonableness, or discriminatory application. Indeed, I found no cases in which a quarantine has been lifted due process grounds (though there have been some successful challenges to conditions of quarantine).
One case upholding a quarantine has facts that look strikingly like Hickox’s. In U.S. ex rel Siegel v. Shinnick, 219 F.Supp. 789 (E.D. NY 1963), the plaintiff was confined for 14 days on her return from a “smallpox infected area” abroad, despite a lack of any evidence of direct exposure or symptoms. The court upheld the action, noting:
[The] judgment required is that of a public health officer and not of a lawyer used to insist on positive evidence to support action; their task is to measure risk to the public and to seek for what can reassure and, not finding it, to proceed reasonably to make the public health secure. They deal in a terrible context and the consequences of mistaken indulgence can be irretrievably tragic. To supercede their judgment there must be a reliable showing of error.
Perhaps the ACLU, which is also questioning the current quarantine, thinks that due process has expanded so much that it might even prohibit this most traditional use of the police power. I doubt it. There are extremely few contexts where the state can deprive someone of liberty without any showing of wrongdoing, or any personal conduct whatsoever: conscription, quarantine, and in a milder fashion, jury service. The case law basis for conscription goes back only to 1918 (also the time of the first widespread quarantines n the U.S.), but it has proven impervious to a liberalized due process clause. Quarantine is safe too.
Here’s another thought, too. If Hickox is this reckless here in the US, what was the likelihood of her precise compliance with protocols in western Africa?