Annas on Bush quarantine

Professor George Annas, Chairman of the Department of Health Law, Bioethics and Human Rights at Boston University School of Public Health, has a superb Op Ed in the Boston Globe this morning. Here it is:

Boston Globe: Bush's risky flu pandemic plan

By George J. Annas | October 8, 2005

WHENEVER THE world is not to his liking, President Bush has a tendency to turn to the military to make it better. The most prominent example is the country's response to 9/11, complete with wars in Afghanistan and Iraq. After Hurricane Katrina, Bush belatedly called on the military to assist in securing New Orleans, and has since suggested that Congress should consider empowering the military to be the ''first responders" in any national disaster.

On Tuesday, the president suggested that the United States should confront the risk of a bird flu pandemic by giving him the power to use the US military to quarantine ''part[s] of the country" experiencing an ''outbreak." So we have moved quickly in the past month, at least metaphorically, from the global war on terror to a proposed war on hurricanes, to a proposed war on the bird flu.

Of all these proposals, the use of the military to attempt to contain a flu pandemic on US soil is the most dangerous. Bush says he got the idea by reading John Barry's excellent account of the 1918 Spanish flu pandemic, ''The Great Influenza." Although quarantine was used successfully in that pandemic, on the island of American Samoa, Barry in his afterword suggests (sensibly) that we need a national plan to deal with a future influenza pandemic. He said last week that his other suggestions were the only ones he hoped public health officials and ethicists would consider, but they read like policy recommendations to me and apparently the president. Barry writes, for example, ''if there is any chance to limit the geographical spread of the disease, officials must have in place the legal power to take extreme quarantine measures." This recommendation comes shortly after his praise for countries that ''moved rapidly and ruthlessly to quarantine and isolate anyone with or exposed to" SARS.

Planning makes sense. But planning for ''brutal" or ''extreme" quarantine of large numbers or areas of the United States would create many more problems than it could solve.

First, historically mass quarantines of healthy people who may have been exposed to a pathogen have never worked to control a pandemic, and have almost always done more harm than good because they usually involve vicious discrimination against classes of people (like immigrants or Asians) who are seen as ''diseased" and dangerous.

Second, the notion that ruthless quarantine was responsible for preventing a SARS pandemic is a public health myth. SARS appeared in more than 30 countries; they all reacted differently (some used forced quarantine successfully, others voluntary quarantine, and others no quarantine at all), and all ''succeeded." Quarantine is no magic bullet.

Third, quarantine and isolation are often falsely equated, but the former involves people who are well, the latter people who are sick. Sick people should be treated, but we don't need the military to force treatment. Even in extremes like the anthrax attacks, people seek out and demand treatment. Sending soldiers to quarantine large numbers of people will most likely create panic, and cause people to flee (and spread disease), as it did in China where a rumor during the SARS epidemic that Beijing would be quarantined led to 250,000 people fleeing the city that night.

Not only can't we evacuate Houston, we cannot realistically quarantine its citizens. The real public health challenge will be shortages of health care personnel, hospital beds, and medicine. Plans to militarize quarantine miss the point in a pandemic. The enemy is not sick or exposed Americans -- it is the virus itself. And effective action against any flu virus demands its early identification, and the quick development, manufacture, and distribution of a vaccine and treatment modalities.

In 1918 the Spanish flu was spread around the US primarily by soldiers, and it seems to have incubated primarily on military bases. It is a misreading of history that a lesson from 1918 is to militarize mass quarantine to contain the flu. And neither medicine nor public health are what they were in 1918; having public health rely on mass quarantine today is like having our military rely on trench warfare in Iraq.

What has not changed in the past century, however, is the fact that national flu policy will be determined by national politics. In World War I, as Barry recounts, this policy demanded that there be no public criticism of the federal government.

That policy was a disaster, and did prevent many potentially effective public health actions. Today's presidential substitution of a military quarantine solution for credible public health planning will also be counterproductive and ineffective in the event of a real pandemic. It would leave US citizens sick with the flu to wonder -- like the citizens of New Orleans told to go to the Convention Center and the Superdome for help -- why the federal government had abandoned them.

Public health in the 21st century should be federally directed, but effective public health policy must be based on trust, not fear of the public.