I’ve given a few talks recently on pandemic influenza. This topic of isolation and/or quarantine hasn’t come up frequently during the question-and-answer period, but almost every time I’ve had someone approach me after the talk to ask about it (since I mention it briefly during the presentation). It seems to be something that really concerns people, and it’s a difficult topic. No one wants someone out spreading a deadly disease that could kill you or your loved ones, but at the same time, no one wants to be locked away from their loved ones if they’re potentially dying from a deadly disease, either. It’s a difficult scenario and there are no easy solutions. However, it’s my impression that the general public probably hasn’t been exposed to this potential controversy very frequently, so I wanted to highlight a recent example of just what could happen:
Robert Daniels has been locked up indefinitely, perhaps for the rest of his life, since last July. But he has not been charged with a crime. Instead, he suffers from an extensively drug-resistant strain of tuberculosis, or XDR-TB. It is considered virtually untreatable.
County health authorities obtained a court order to lock him up as a danger to the public because he failed to take precautions to avoid infecting others. Specifically, he said he did not heed doctors’ instructions to wear a mask in public.
I’ve mentioned XDR-TB here and here. Though it hasn’t been a huge problem yet in the United States, cases like this one show just how quickly it could potentially become one–and that’s the reason for isolation and/or quarantine in the first place.
Let me back up just for a second to explain the difference between these two. “Quarantine” sometimes is used in the media as a catch-all for just separating diseased from non-diseased, but that’s not quite right. Rather, quarantine refers to the act of removing people who are *potentially exposed* to an infectious agent from the general population for a specific window of time (historically 40 days, hence the name). It doesn’t matter if one shows symptoms of the disease or not; what matters is that they’ve been exposed to someone who does, and therefore they may be incubating it as well. That symptomatic person, then, may be put into isolation (as is the case with Robert Daniels, above) to prevent them from spreading the disease to others. As noted, this could be indefinite, and certainly is controverisal:
How to deal with people infected with the new strain is a matter of debate.
Dr. Ross Upshur, director of the Joint Centre for Bioethics at the University of Toronto, said authorities should detain people with drug-resistant tuberculosis if they are uncooperative.
“We’re on the verge of taking what was a curable disease, one of the best known diseases in human endeavors, and making it incurable,” Upshur said.
And of course, it’s not only XDR-TB; the same principles can be applied to someone who may be knowingly spreading other illnesses, or someone who has influenza during a pandemic. It’s a murky area, but one that has huge potential impact on the public health:
University of Pennsylvania medical ethicist Art Caplan said Maricopa County health officials were confronted with the same ethical dilemma that communities wrestled with generations ago when dealing with leprosy and smallpox.
“Drug-resistant TB, or drug-resistant staph infections, or pandemic flu will raise these questions again,” Caplan said. “We may find ourselves dipping into our history to answer them.”