States are improvising to confront the Ebola crisis, raising questions about uniformity, effectiveness and legality.
Quarantine policies are established, and then softened. A nurse is detained, and then freed. Lawsuits seem likely, and a 19th-century law seems relevant once more. Confusion, so far, is the constant.
“We don’t really have a public health system in this country,” Deborah Burger, the Oakland, Calif.-based president of National Nurses United, said in an interview Monday. “We have a state-by-state system, and we all know what happens when states get to decide.”
Meanwhile, in an effort to exercise some control over the sudden patchwork development of Ebola quarantines, the U.S. Centers for Disease Control and Prevention announced revamped guidelines Monday, based on risk, for monitoring people who might have been exposed. The guidelines don’t carry the force of law, however.
CDC Director Dr. Thomas Frieden said in a call with reporters that he was concerned about some states’ policies, which “might have the effect of increasing stigma or creating false impressions.”
Ebola, he said, “is not nearly as contagious as the flu, the common cold, measles or any other infectious diseases.”
But the piece-by-piece rollout of Ebola-containment policies continued Monday, with officials from Maryland, Virginia, Georgia and North Carolina among the states announcing their game plans. New Jersey officials, however, relented and loosened the reins on a nurse who’d been forced into quarantine after returning from Sierra Leone.
The release of Kaci Hickox to her home in Maine came the day after New Jersey Gov. Chris Christie defended his state’s initial plan to quarantine her for three weeks, despite her displaying no symptoms of the disease. Decisive action was needed, Christie declared on Fox News, because federal guidelines have been a “moving target.”
A New Jersey law, dating to the worldwide influenza epidemic of 1918, authorizes state officials to impose quarantines. Other states have similar laws.
“There has been a long-standing recognition that states, under their police powers, can protect the public health through things like quarantines,” Alexander Shalom, senior staff attorney for the American Civil Liberties Union of New Jersey, said in an interview Monday, “but those powers are not unlimited.”
Shalom said “we’re certainly looking at” a potential legal challenge to the New Jersey quarantine actions, citing requirements that the public health measures follow due process and impose the least restrictive limitations on personal liberty.
Other states, on their own or under behind-the-scenes pressure from Obama administration officials, have settled on policies that are strict but less draconian than the Garden State’s.
North Carolina will require any traveler from affected areas in West Africa who has Ebola symptoms to be immediately isolated in a health care facility. Travelers who might have been exposed to the virus but have no symptoms will receive daily face-to-face assessments by public health nurses and their movements will be monitored and possibly restricted for 21 days.
Maryland is requiring that health care workers returning from West Africa refrain from attending mass gatherings and using public transportation for 21 days. The workers may travel long distances only with the approval of state health officials and are subject to surprise home inspections. Virginia imposed similar rules, but some limitations will be determined on a “case by case” basis.
“We have a federal system in this country, in which states are given significant authority for governing their constituents,” White House spokesman Josh Earnest said Monday. “That is certainly true when it comes to public safety and public health.”
Underscoring the potential perils of decentralized decision-making, reports circulated Monday that the Defense Department was quarantining personnel returning from Africa. Earnest, though, said the Pentagon hadn’t issued a policy for its workers in West Africa. He said the quarantine was a decision made by one commanding officer, but “does not reflect a department-wide policy that I understand is still under development.”
Politicians should be cautious about imposing overly restrictive quarantine policies because overreacting might cost them the public’s trust, said Dr. Georges Benjamin, the executive director of the American Public Health Association.
“At some point, an outbreak may get so bad that you may have to use quarantine in a much more aggressive manner, and you want people to comply with it,” said Benjamin. “If people believe you are doing this in an arbitrary and capricious manner, people will begin to lie about their symptoms and they’re going to hide from you, and that’s the overwhelming risk.”
People’s movements shouldn’t be restricted as long as they don’t have any symptoms, he said, adding that it would be best if there were one national standard across the country.
“The states always have the right to do what they want, but I think the CDC and administration’s standards that they had adopted – with active monitoring and recording (of temperature) without further restriction of movement – were reasonable and appropriate,” he said.
In contrast, he said, the decisions of states such as New York and New Jersey to quarantine travelers who showed no symptoms of Ebola “were not based in the best science and not well thought through.” New York subsequently eased its policy.
The federal government does have some authority, apparently never used, under the 1893 Quarantine Act.
The law declares that if the president concludes “there is serious danger of introduction” into the United States of “infections or contagious diseases,” the administration may “prohibit, in whole or in part, the introduction of persons and property from such countries.”
The law came at a time of considerable anxiety over foreign infection.
A late 19th-century yellow fever outbreak prompted the House Interstate and Foreign Commerce Committee to decry, in an 1898 legislative report, “the constant friction and collision between federal and state officials.”
Cities and towns were “quarantined against rival communities,” according to the report, and in some cases railroad passengers were “forcibly taken from the cars and taken to improvised fever camps.”
The CDC’s new guidelines Monday recommend that those at highest risk – anyone who came into direct contact with the bodily fluids or dead body of an Ebola patient – avoid public transportation and crowded places and submit to daily monitoring for symptoms by local health officials.
For people deemed to be at “some risk,” including people living in the same household as an Ebola patient or health care workers returning from West Africa, the CDC also recommended daily monitoring by health officials, and travel restrictions to be determined on a case-by-case basis. Those judged to be at low risk, such as nurses and doctors who treat Ebola patients at U.S. hospitals, would self-monitor for symptoms and check in regularly with health officials.
National Nurses United, the country’s largest nurses’ union, wants the federal government to impose national standards in safety areas that include the personal protective equipment worn by health care providers. This could be done, Burger said, either through legislation or a White House executive order.
“It’s really time to look at a national standard,” Burger said. “In a perfect world, it should be the federal government that does what’s rational and right for public health, but we don’t live in a perfect world.”