by Craig Klugman, Ph.D.
The World Health Organization (WHO) has just declared “a public health emergency of international concern” for the coronavirus. The statement means that all countries should take this disease seriously and allows countries to close borders, cancel flights, and screen people in airports, all measures that some countries (such as the U.S.) were already taking. As scientists learn more about this disease and governments respond, China has taken several drastic measures to block the spread of the infection including an unprecedented quarantine of 50 million people.
What is Coronavirus?
This latest outbreak is not “The Coronavirus” because that term refers to a family of viruses that range from the common cold to MERS to SARS. These are viruses transmitted between animals and people. Infection can often include symptoms of respiratory illness, fevers, trouble breathing. Kidney failure and death are possible in some circumstances.
The current coronavirus has been traced to a market in Wuhan China (pop. 11 million) and was first reported on December 31, 2019. This virus is known as 2019-nCoV or “current novel coronavirus outbreak”. According to the World Health Organization (WHO), as of January 31, 2020, there have been 9.826 reported cases worldwide resulting in 230 deaths (all in China). Ninety-nine percent of all cases have been in China. Most cases of the disease come from people who were in a particular marketplace though there are also a few confirmed cases of human-to-human transmission. One such case took place here in Chicago where a woman returning from a trip to Wuhan seems to have spread the infection to her husband.
The term “reported cases” is important. There are an additional 12,167 suspected cases and likely a large number of unknown cases. Some patients have a severe reaction to the illness and others have a mild reaction that most likely would not lead them to seek out medical assistance. Thus, it’s hard to know the mortality rate for this disease given that we do not know how many people have actually been infected.
For comparison: From October 1, 2019 through January 18, 2020, in the U.S. there have been 21 million cases of flu resulting in up to 250,000 hospitalizations, and 8,200-20,000 deaths from seasonal influenza. Thus, statistically you should be more concerned about the flu than 2019-nCoV. Luckily, preventive measures for both are similar, washing your hands frequently, avoiding touching your mouth and face.
In response to the outbreak, several countries have initiated screening of passengers on flights from Wuhan and other Chinese cities. A number of countries are evacuating their citizens and diplomats in Wuhan. Thirty-four Asian, European, and American airlines are canceling flights to cities in China, mainly Wuhan but also Shanghai, Beijing, and Hong Kong.
The Ethics of Quarantine
Quarantine is a term that comes from the Italian quaranta for “forty” which was the number of days a ship had to remain in harbor before it could dock at the port of Venice in 1343 during the Black Death. However, the concept of quarantine is much older and mentions can even be found in the Bible. Quarantining a sick or at risk population from a healthy population is one of the oldest tools of public health to prevent the spread of disease. If the cordon sanitaire is maintained and main transmission is human-to-human, then a quarantine can be highly effective in limiting an epidemic.
Quarantine differs from isolation in the public health arsenal. A quarantine is an enforced separation of a population where policy and military prevent movement into and out of the boundary area. Isolation is when people answer a call to voluntarily separate themselves. During the SARS epidemic, a call for isolation in Toronto was highly effective in limiting the spread of that disease in Canada. In the U.S., calls for isolation, such as when aid workers returned from Western Africa during the recent Ebola outbreak were often ignored, even by health care professionals. Thus, the effectiveness of a voluntary isolation call can be limited and depends on whether people are willing to believe their government and put the health of others before their own convenience and movement.
Last week, China shut down air, road, bus, and train travel to Wuhan, essentially cutting it off. The quarantine now extends to 17 cities and 50 million people. The quarantine is unlikely to be effective in this case. In part, its scale makes enforcement difficult. In part, the mayor of Wuhan says that 5 million people left the city before the travel restrictions were imposed, and they all may have been exposed (2019-nCoV is infectious before the host shows any symptoms). And in part, because the ban in place means that food and other goods are not coming into the city, creating a situation where there may be shortages of essential items.
Public health ethics is a way of looking at population health concerns and policies. In some frameworks, the emphasis is placed on how do we limit restricting individual rights. In other frameworks, the importance is placed on the community first and given that every person is a member of the community, they stand to benefit. By the first approach, a city-wide quarantine is a dramatic step. People can move around inside the cordon which gives more freedom than being forced to stay individually at home (though many individuals have taken this approach with Wuhan’s streets being mostly empty). Limiting people’s freedom of movement is generally an action that infringes upon what many see as a basic human right.
From the more communitarian or population-first perspective, the highest value is on group well-being. In one iteration, one can use four principles of public health ethics to examine the ethics of a public health measure: Solidarity, efficacy, integrity, and dignity. “The notion of solidarity holds that as a result of common needs and interests, a community comes together to improve its aggregate health by reducing morbidity and mortality.” Thus, one must ask if the proposed solution will reduce death, injury, and illness. A large quarantine is an unusual step, but if enforced can have the effect of limiting spread of the virus.
Second, “Efficacy is the idea that a program should be scientifically sound and have a significant chance of being successful in achieving its goals of improving a community’s health and wellness. An efficacious program is one that is feasible in regard to social, political, and cultural climates.” If it’s true that 5 million potentially infected people left the city, then a quarantine may not be effective. If various nations fly into Wuhan to evacuate their people, it is important that those individuals are quarantined before returning home or they will have spread the disease elsewhere. In a U.S. evacuation flight, passengers were tested for the virus in flight, during a stop in Anchorage, and again in reaching California. They were also to be monitored for 3 days at an air base and those who showed any symptoms would be held for up to 2 weeks. I say “were”, because as of Thursday night, they are now quarantined for 2 weeks (incubation period is 2-14 days). Once they are home, they will be tracked by public health to see if they develop any symptoms. The other important part of efficacy is whether it is feasible—is it acceptable socially, politically, and culturally. For a short term, monitoring and isolation are likely to be acceptable but on a longer term basis, at least in the U.S., the feasibility decreases. In China, though, there is a more communitarian mindset and a tradition of a more authoritarian style of rule: Longer term quarantine might be feasible there.
Integrity “holds that cultural communities have value and are deserving of respect. Integrity creates an obligation to preserve the nature and character of a cultural community, to include the community in program development, and to provide interventions that match community values and are explained in terms of local knowledge.” In short, while steps might need to be taken to protect the community, is the community involved in the decision? Are the reasons explained in language the community will understand? Are local leaders and the local populace being included in conversations? Given that China is a more controlled society where people are expected to follow the instructions of authorities at all times, integrity is likely an uncommon idea.
“Dignity is the recognition that human life is vulnerable and needs to be protected. All people are equally worthy of moral respect and consideration. Therefore, dignity says that one should respect people as members of the interconnected community and choose the least restrictive alternative in programming.” As mentioned above, the restriction of movement is a human rights question. Other questions that arise in a long-term quarantine are making sure the populace has access to adequate food, medical supplies, and other goods they may need. In modern life, this could include access to the internet, virtual communication with people outside the cordon, and being informed of the disease progress, plans for how long the quarantine may last, and organizing within the cordon to maintain all needed services and support for the population. The last restrictive alternative is usually voluntary isolation like what was originally proposed for the American evacuation which has now become more restrictive with a mandatory 2 week quarantine. Even if a nation does not have a strong tradition of individual human rights as we think of them in the West, such preservation of the individual needs to be considered in choosing plans of action.
Quarantines and their effect can be seen not only from history but from literature. A quarantine is the key event in Albert Camus’ The Plague, José Saramago’s book Blindness, and apocalyptic science fiction such as Justin Cronin’s The Passage. Two of these novels had endings where the epidemic ends, though those behind the cordon suffer loss, deprivation, and an erosion of civility. In the third, the world basically ends.
What is next in the this real-life story is that WHO experts are travelling to meet with the Chinese health authorities and planning the next steps. Scientists will study the virus to determine how it is transmitted, how to block that transmission, and will attempt to develop both vaccines (at least 3 months until trial) and cures. Although movies like Contagion may make this seem like a quick process, it is not.
While governments react to the spread of this disease, it is important for officials to rationally consider the ethics of their policy and actions rather than simply acting out of fear.