News Team member Rama Esrawee recommends the latest episode of Health Storytelling, featuring Lina Zeldovich and her new book "The Living Medicine."
Editor’s Note: This is the second in a three part series. Read the first part here.
By: Deanna Altomara
During medieval times, disease control techniques were a patchwork of quarantine stations, sanitary barriers, hidden observation posts, laws restricting the movements of foreigners, banishment, and even walling up the houses of plague victims. Some of the late medieval systems of quarantine may seem crude or barbaric, but they nonetheless laid the foundations for later methods of disease control in the modern era.
Like newcomers to fourteenth-century Venice, early immigrants to the United States were sometimes quarantined on a nearby island. In this case, if immigrants showed signs of yellow fever or smallpox, they were sent to Bedloe’s Island, the current home of the Statue of Liberty. Despite these precautions, a yellow fever epidemic struck the East Coast in 1793. When death tolls started nearing a hundred per day, the city of Philadelphia was evacuated. Unfortunately, yellow fever is a mosquito-borne disease, so the quarantine did little to slow the spread of the illness. Still recoiling from the outbreak, locals built a ten-acre lazaretto in Washington DC in 1799. The property can still be visited today.
But society was becoming more conscious of individual rights, and people began bristling against impositions of quarantine and other disease control measures, including mandatory smallpox vaccinations. In the 18th and 19th centuries, an increased awareness of individual freedoms led to protests against quarantines for cholera, a waterborne disease that ravaged communities throughout this time period.[5] Meanwhile, groups seeking to unite Italy’s city states used cholera quarantines as a tool for increased police presence. Before the development of germ theory, some people still refused to believe that cholera was even a transmissible disease, but was spread by dirty air.[5] In 1878, the National Quarantine Act laid the foundations for the involvement of the federal government with quarantine measures. Fourteen years later, a mandate ruled that ships carrying immigrants must be quarantined for 20 days in an effort to curb the spread of cholera.
Unfortunately, quarantine has sometimes been used to stigmatize or control certain populations. In 1900, a Chinese immigrant was found dead in a San Francisco basement. When news broke that he had died of plague, a mass panic ensued. In the uproar that followed, 25,000 Chinese immigrants were quarantined, an action that a court later decried as racist. The next year, Cape Town forced nearly all of its black residents into a quarantine camp to prevent the spread of plague. This quarantine provided a blueprint for forced removals in the apartheid era.
Over the next decades, the United States grappled with how to separate people who were infected–or at perceived risk of infection–from the public. One famous example was Mary Mallon, also known as Typhoid Mary, a poor Irish woman who worked as a cook in New York City. Mallon was a carrier for typhoid, which meant that she could spread but would never feel the effects of the food-borne illness. When officials tracked her down as the source of a series of infections, she was sent to the nearby North Brother Island. After her release from the island, she promised that she would never work as a cook again. Unfortunately, the reasons for her confinement were never properly explained to her, and she never fully understood why she was not allowed to return to cooking. Upon her release, Mallon began cooking again under the false name “Mary Brown,” infecting at least 25 more people. She was then sent to North Brother Island for the rest of her life.[6]
Quarantine measures continued to target those of low socioeconomic status. In New York City, children with polio were forcibly separated from parents (unless parents could afford a separate room for the child). A few years later, 30,000 sex workers were jailed to prevent the spread of venereal diseases like syphilis and gonorrhea. In jail, they were forced to undergo humiliating medical procedures.
The 1918 Influenza was one of the greatest pandemics of all time, killing an estimated 20-50 million people around the world. In an interesting new step, officials began to focus their efforts on preventing public events rather than quarantining a specific population. In St. Louis, schools, pool halls and other public gathering places were closed. This quick action saved lives. Cancelling events flattened the disease curve, so the sickness spread more slowly and the health system could handle a more manageable number of patients.
However, the opposite situation unfolded in Philadelphia. Despite warnings, the city public health director refused to cancel a military parade. Three days later, all of Philadelphia’s hospitals were swamped with cases of influenza. By the end of the week, 2,600 people had died. One study showed that cities, such as St. Louis, that introduced multiple interventions in the early phases of the epidemic, had peak death rates 50% lower than their counterparts. Additionally, fast-acting cities had flattened epidemic curves. These quick measures also reduced the cities’ overall excessive death rates, but not as much as if the measures had been put in place for longer periods of time.[7]
This pandemic was also one of the first to take place in a world newly connected by newspapers. In Italy, one of the most famous newspapers had to stop reporting the daily death count (150-180) to curb the widespread panic. In other countries, censorship ignited confusion and mistrust.[5]
In 1986, Cuba enacted a mandatory quarantine of all residents living with HIV. The country carried out a massive testing campaign, and confined anyone who tested positive in sanatoriums throughout the island. While the sanatoriums provided good living conditions and quality medical care, critics decried the policy as an abuse of human rights. The Communist nation maintained its mandatory quarantine policy until 1994, although residential sanatoriums are still a mainstay of the HIV treatment system in Cuba. Today, Cuba has a low HIV prevalence of 0.03%, a fact that Cuba attributes to its controversial history of quarantine (although other factors may also be at play).[8]
Following the September 11 attacks, the US government strengthened its laws allowing the state to quarantine people in the case of a suspected incidence of bioterrorism. Today, there are 20 quarantine stations in the US. These stations are located in travel hubs, and officials decide whether a person with an infectious disease can be admitted to the United States.
The 2003 global outbreak of Severe Acute Respiratory Syndrome (SARS) was also an important moment in the evolution of large-scale quarantine. In Toronto, over 20,000 people were quarantined, or 100 people for every SARS case.[9] After many months, SARS was “effectively eradicated” using surveillance, isolation, and quarantine measures. In China, entire villages, cities, or regions were placed under collective quarantine.[10] In Taiwan, where 150,000 people were quarantined, disease control efforts halved the number of infections and deaths that might have otherwise occurred. One study found that Taiwan’s efforts to quarantine the exposed contacts of SARS patients was much more effective than quarantining travelers from SARS-affected areas.[11] While several governments put travel advisories in place, none issued a travel ban during the SARS outbreak .[10]
Quarantines were also attempted to curb the spread of Ebola in 2014. Some governments used the medieval-era “cordon sanitaire,” raising fear among the locals. For three days in September, people were asked to stay indoors while community workers carried out door-to-door searches for hidden Ebola patients. In another instance, a Monrovian slum of 60,000-120,000 people was closed off. Doctors Without Borders explained that, “It has been our experience that lockdowns and quarantines do not help control Ebola, as they end up driving people underground and jeopardizing the trust between people and health providers.” This statement exemplifies the importance of transparency, cultural understanding, and trust in the development of any quarantine strategy. To be effective, quarantines must be implemented with great thought, care, and social and ethical consideration.
There are many ethical concerns surrounding the use of quarantines. But if undertaken correctly, they can still be a highly effective form of stopping disease transmission. Check in tomorrow to learn more about what is being done today to prevent the spread of COVID-19.
Editor’s Note: If you’d like to share your COVID-19 or quarantine story, please fill out the contact form on this post.
References:
[2] Wagner, D., Klunk, J., Harbeck, M., Devault, A., et al. (2014). Yersinia pestis and the Plague of Justinian 541-543 AD: a genomic analysis. The Lancet, 14(4), 319—326. doi: 10.3410/f.718258232.793493962
[3] Drews, K., 2013. A Brief History of Quarantine. The Virginia Tech Undergraduate Historical Review, 2. DOI: http://doi.org/10.21061/vtuhr.v2i0.16
[4] Alfani, G., & Murphy, T. (2017). Plague and Lethal Epidemics in the Pre-Industrial World. The Journal of Economic History, 77(1), 314-343. doi:10.1017/S0022050717000092
[5] Tognotti E. (2013). Lessons from the history of quarantine, from plague to influenza A. Emerging infectious diseases, 19(2), 254—259. https://doi.org/10.3201/eid1902.120312
[6] Marineli, F., Tsoucalas, G., Karamanou, M., & Androutsos, G. (2013). Mary Mallon (1869-1938) and the history of typhoid fever. Annals of Gastroenterology, 26(2), 132—134.
[7] Hatchett, R. J., Mecher, C. E., & Lipsitch, M. (2007). Public health interventions and epidemic intensity during the 1918 influenza pandemic. Proceedings of the National Academy of Sciences, 104(18), 7582—7587. doi: 10.1073/pnas.0610941104
[8] Hansen H, Groce N. Human Immunodeficiency Virus and Quarantine in Cuba. JAMA. 2003;290(21):2875. doi:10.1001/jama.290.21.2875
[9] Schabas R. (2004). Severe acute respiratory syndrome: Did quarantine help?. The Canadian Journal of Infectious Diseases & Medical Microbiology, 15(4), 204. https://doi.org/10.1155/2004/521892
[10] Wilder-Smith, A., Chiew, C. J., & Lee, V. J. (2020). Can we contain the COVID-19 outbreak with the same measures as for SARS? The Lancet Infectious Diseases. doi: 10.1016/s1473-3099(20)30129-8
[11] Hsieh, Y.-H., King, C.-C., Chen, C. W., Ho, M.-S., Hsu, S.-B., & Wu, Y.-C. (2007). Impact of quarantine on the 2003 SARS outbreak: A retrospective modeling study. Journal of Theoretical Biology, 244(4), 729—736. doi: 10.1016/j.jtbi.2006.09.015
[12] Upshur, R. (2003). The Ethics of Quarantine. AMA Journal of Ethics, 5(11). doi: 10.1001/virtualmentor.2003.5.11.msoc1-0311
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