Do you trust the government to protect you and your family from the novel coronavirus causing Covid-19? Centers for Disease Control and Prevention officials say more cases are inevitable in the United States, although they can’t predict how many and when they will appear. President Trump says the risk is low and “We’re very, very ready for this.” But what does it mean to be ready?
The emergence of a new infectious disease often prompts governments to consider quarantines. Officials in China recently turned to this drastic option, blocking most travel into and out of the city of Wuhan, the center of the Covid-19 outbreak. As cases appear in other countries, they, too, are thinking about quarantine.
The term “quarantine” means restricting the movements of individuals who have been, or might have been, exposed to a contagious disease. Although it is often used interchangeably with “isolation,” the latter means confining individuals known to have a contagious infection, usually as part of medical treatment. Quarantine and isolation can be voluntary or involuntary.
The CDC has broad authority — some say overbroad — to approve involuntary quarantines under final regulations governing domestic and foreign quarantine that were issued in January 2017.
Before resorting to the draconian measure of involuntary quarantine, I think we should make it unnecessary. Two complementary efforts can make that happen: providing credible information the public can trust; and making it possible for people to comply with disease-avoidance recommendations without excessive personal or financial cost.
So far, public health recommendations focus on asking people to protect themselves by washing their hands and covering their coughs. While this is good advice, it puts the onus on the individual. Threats of involuntary quarantine often come next, which looks a lot like blaming the victim: punishing people for getting sick or treating people like criminals, not patients. That makes the target of disease-control efforts a person — instead of a pathogen.
But when individuals are viewed as potential threats to public health, they may feel unfairly attacked and stigmatized. And if people doubt what the government says, they may decline to follow even sensible recommendations.
Infection is not the only harm to the public during an outbreak. During the 2014-2016 Ebola outbreak, hysteria, politicization, and some states’ rejection of CDC recommendations created more harm than the disease itself. People were threatened by law enforcement and public officials. Children were bullied in schools. Individuals were not allowed to work, or in some circumstances dismissed from their jobs. While the spread of misinformation, largely through the media, carries much of the blame, those who embraced, enforced, or advocated for overly strict quarantine measures certainly fanned the flames.
To gain public trust, health officials must be honest and transparent about what is and is not known about a disease outbreak, and provide useful recommendations for avoiding infection. Giving people credible information about what they can do is an important first step in facing an infectious disease outbreak.
Asking people to protect themselves is necessary to help prevent the spread of infectious diseases like Covid-19, for which there yet is no vaccine or cure. But it isn’t sufficient, because not everyone can comply with recommendations like social distancing, such as not going to school or work and avoiding places where others congregate.
Following such recommendations is almost impossible for day laborers who don’t get paid if they don’t go to work; for people with low-wage jobs; for people who don’t have paid sick leave; and others. For many Americans, a few days of lost wages can mean not being able to pay the rent, buy food, or afford medications. They may feel compelled to go to work even if they aren’t feeling well, because they need the money.
We need to make it possible for such individuals — who make up a large chunk of Americans — to stay home. That means providing some source of replacement income or job security, either through the private sector or the government.
Would that be expensive? Yes. But it is equally expensive — and may be even more costly — to put people in institutional quarantine settings because you still have to provide staff, food, water, medicine, and access to communication with friends and family. That’s not cheap. Just look at our prison system.
If we can give people the resources they need to stay home during a disease outbreak and avoid workplaces, schools, theaters, and other places where people gather, there would be fewer opportunities for people to fear that they could contract the virus. It would reduce the strain on our hospitals and health care systems. And most importantly, it would recognize and reward the sacrifice that people voluntarily make to protect the community.
People don’t want to make other people sick. They will comply with credible recommendations and voluntarily stay home, if it is possible for them to do so. This means preventive measures must include providing the resources that make it possible.
During the SARS outbreak, which first emerged in November 2002, the government in Singapore provided economic assistance to individuals and businesses affected by the quarantine; in Hong Kong, individuals received daily material and financial assistance. The CDC’s 2017 regulations don’t mention these legitimate concerns; they only allow the CDC director to authorize payment for treating people who are involuntarily confined in a quarantine facility.
Fear of being quarantined itself can create resistance. If you’re afraid you’re going to get locked up somewhere, you may not want to admit you have an illness. You may not want to go to the doctor for fear of being reported. If you are told you can’t leave your city, you might flee. That’s what happened in China during the SARS outbreak. A rumor that the government was planning a large-scale involuntary quarantine caused nearly 250,000 people to leave Beijing.
And quarantines aren’t without their costs. The Wuhan quarantine has had numerous unintended effects, some of them fatal. People were unable to reach sick, elderly parents in the city, let alone take them elsewhere for treatment of chronic conditions like heart disease and cancer. The United Nations AIDS agency recently announced that one-third of people in China who are living with HIV were at risk of running out of their HIV medications because of lockdowns and travel restrictions. The quarantine has also severely slowed China’s economy.
As the CDC and other public health agencies know, quarantine by itself may delay the spread of an infectious disease, but it cannot prevent or end any disease outbreak. It has not succeeded in the past and is ill-suited to the realities of the contemporary world.
A better way to fight infectious disease outbreaks is by creating a resilient population that is more likely to withstand potential epidemics. As my colleague Michael Ulrich and I wrote in the SMU Law Review in 2018, “Populations with good nutrition, high literacy rates, adequate income, and access to appropriate medical care, social services, and sources of reliable information are better prepared to understand the meaning of an outbreak and what to do in response.” They are also less likely to suffer severe illness if the infection spreads to them.
Even in a reasonably resilient population like the United States, limiting the spread of a novel pathogen depends on public trust in government recommendations. But trust goes both ways. Government must also trust people to follow reasonable recommendations. And it can do that if its recommendations are reasonable and credible and people have the means to voluntarily comply with them.
Wendy K. Mariner, J.D., is professor of health law at the Boston University School of Public Health and the Center for Health Law, Ethics & Human Rights.