When Kaci Hickox, a Doctors Without Borders nurse, returned to New Jersey from working with Ebola patients in West Africa in 2014, she was surprised by her reception. Instead of a quiet return to her home in Maine after four weeks on the front line of Ebola treatment, she was quarantined by the State of New Jersey in Newark. She later filed a lawsuit in U.S. District Court for violation of her civil rights, false imprisonment, and invasion of privacy.
As a hemorrhagic disease, Ebola is fearsome. In 2014, an outbreak of Ebola virus caused widespread death and sickness in West Africa. The Centers for Disease Control and Prevention (CDC) reports that 11,325 people died from the disease, caused by Ebolavirus. After entering the body, Ebola disables immune cells responsible for signaling the presence of the virus, hampering the production of antibodies and the overall ability of the body to respond to the infection.
As Ebola multiples quickly in the body, it hijacks white blood cells called macrophages. Literally known as big eaters, macrophages usually consume and kill invading pathogens. However, once infected with Ebola, macrophages instead produce secretions and clotting proteins that reduce oxygen delivery to internal organs and damage vascular strength. Overall, this causes victims to seep blood from the eyes, nose, and other orifices, giving Ebola its hemorrhagic—and horrifying—reputation.
When an individual is quarantined, they are placed under living conditions that confine their movements while being observed for symptoms of illness. Isolation refers to conditions whereby a contagious sick person is isolated from others in order to avoid spread of the disease.
In the United States, four cases of Ebola were reported, two contracted by healthcare workers within the country, and one medical worker and one private citizen who caught the disease in Guinea and Liberia, respectively.
One of the healthcare workers, Craig Spencer, tested positive and eventually developed Ebola after returning to the US, after going bowling in Brooklyn, grabbing coffee, taking the subway, and walking the High Line in Manhattan. His friends were quarantined at home in New York after he tested positive, and his fiancée was quarantined at the hospital. A media correspondent who did not develop Ebola, Nancy Snyderman, faced intense public criticism after defying her unofficial quarantine by picking up takeout food at a restaurant.
While the CDC stopped short of mandatory quarantines, it offered guidelines for voluntary quarantines, while some states, like New Jersey and New York, pursued stronger measures.
The quarantine policies had a chilling effect on enrollment and volunteerism for health agencies trying to combat the crises. The International Medical Corps reported a 25% drop in recruitment after US quarantine policies.
A new federal rule recently proposed by the CDC would broadly expand the authority of that agency to act rapidly and effectively in the face of another outbreak like Ebola, or other diseases like the highly contagious Middle East Respiratory Syndrome. While the public comment period on the rule is closed, the proposed rule is generating plenty of controversy.
Before and after the Ebola crisis in 2014, many agreed on the need for national readiness in the face of microbial or other challenge to public health. Outdated, existing regulations governing the CDC identify limited diseases that could trigger CDC authority, like smallpox, and did not anticipate or equip the agency for outbreak readiness in an age of air travel, extensive immigration, and global trade.
The provisions under which the CDC currently operates in an outbreak situation were created in 1944 and signed by then-President Franklin Delano Roosevelt.
To address these out-of-date rules, the agency proposed amendments in August of 2016. The revised rules were open for public comment until October 2016, and give the agency expanded authority and powers, some provisions which include:
- Implement non-invasive public health prevention measures, like traveler health screening, at US ports of entry and other locations.
- Define language to protect the due process rights of individuals served with federal public health orders of quarantine or isolation.
- Provide for reporting requirements of suspected illness or death on commercial passenger flights.
- Allow creation of travel restrictions and travel permits for quarantined individuals as identified by the CDC.
- Clarify processes allowed by the CDC when dealing with a person deemed by the agency as "reasonably believed to be infected," that allow the individual to be apprehended and examined for infection.
- Prohibit import of animals or goods that could pose a threat to public safety.
- Authorize expanded forms of public health monitoring, including personal visits by public health agents.
- Monitor individuals suspected of illness with methods to include electronic and internet based apps, including email and webcam.
- Modify language to provide criminal penalties for violations of quarantine rules.
The proposed rule appears to widen the regulatory powers of the CDC to declare and enforce quarantine conditions like those imposed on Hickox in 2014. But without clear checks and balances, the potential for abuse of poorly defined powers that allow agencies to detain, examine, isolate, or quarantine individuals exists.
A report prepared by the Yale Global Health Justice Partnership and the American Civil Liberties Union examines the fear and political reaction to the Ebola cases confirmed in this country in 2014. They write:
Government authorities at all levels must ensure that the public health polices they implement to address infectious diseases are based on scientific evidence and public health necessity, rather than political expediency. Any other approach is likely to be ineffective in protecting the public and to violate constitutional rights.
The proposed rules allow routine search and non-invasive screening of individuals. While this type of screening may be necessary, in a criminal action, this type of search cannot be undertaken without some kind of finding of evidence.
Questions also rise about invasion of personal privacy and disclosure of personal information. The new rules also allow health authorities to quarantine a group, such as passengers on a flight, or residents of a building, if officials reasonably believe there is a threat.
In September of 2016, US District Judge Kevin McNulty dismissed aspects of Hickox's case involving violation of constitutional rights on the grounds that Governor Chris Christie and other state health officials are immune to the charges brought against them. On the issues of false imprisonment and invasion of privacy, the judge allowed the case to proceed.
After her days in quarantine, Hickox will eventually have her day in court. At present, the proposed rule remains under consideration by the CDC. As the Director of the CDC can be dismissed and replaced by the President without confirmation hearings by any legislative body, concern for federal policy dismissive of individual rights and freedoms remains very much on the table.
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