Keep the balance right
Ethical issues and the view to quarantine during the SARS outbreak
Decision making in public health crises is associated with a high potential on ethical conflicts especially in restricting liberty measures such as quarantine. An effective and acceptable public health coping has the dual role of monitoring compliance and providing support to people in quarantine.
The global 2003 nonmedical response to severe acute respiratory syndrome (SARS) and experiences in various states like China, Vietnam, Singapore or Canada with large – scale quarantine, raised ethical questions in seeking the right balance between the tension of protecting the public`s health and human rights and human needs. The loss of liberty, privacy and free movement as well as experienced psychosocial harm like fear, discrimination and stigmatization were discribed as collateral damage but found problematic, also for further successful voluntary compliance.
This paper focusses on both sides and attempts to find recommendations for effective and acceptable use of quarantine in public health policies based on applied ethical values. By analyzing the quarantine experiences there are serious lessons to be prepared for future threats like SARS or SARS - like diseases with pandemic potential. (177 words)
Key words: quarantine, compliance, ethics in public health emergencies, severe acute respiratory syndrome
Quarantine and isolation is an ancient public health tool to control and prevent the spread of contagious diseases. Already the old testament discribes the sequestering of persons with leprosy as found by Leviticus. In the 14 thcentury quarantine was the common practice to control the spread of pneumonic and bubonic plague. The term quarantine derived from the italian quaranta meaning 40, was used to prevent disease transmission when officials in Venice forced arriving ships to protect locals from the plague for 40 days [1, 3]. The quarantine practice often has negative connotations, although applied since centuries because of the equation by disease with crime. Quarantined persons, not always separated from ill, were often detained for a long time without regarding their needs and were strongly avoided and stigmatized [1–4]. Until today the implementation evokes a set of emotional reactions such as fear, uncertainty, resentment and associates social isolation and stigmatization as well as doubts in faith of political and social institutions. In a few cases in the past, the power of quarantine was abused to targeted foreigners by stigmatization on social class, race or economic status. For example in the beginning of the 19 thcentury the steerage and third class passengers of ships arriving from Europe to the United States were frequently quarantined and transported to quarantine stations to be examined on contagious diseases while first and second class passengers were briefly examined in their cabins and allowed to disembark or continue their journey [2, 3, 4]
The inconsistent communication to the public by confusion of information were shown in different definitions of "probable cases", "suspect cases" and "cases under investigation" by the WHO and public health officals. Additionally the term "voluntary quarantine" led to public suggestion of discretion and accountability of each person .
The contemporary use of quarantine refers to reduce the frequency of transmission by increasing the social distance between exposed and contact persons, which can significantly reduce the spread of an infectious disease. The quarantine strategies can range from active or passive monitoring, short term voluntary home curfew ("sheltering in place"), cancellation of public activities like “snow days” to the point of "cordon sanitaire", which is used in particular crises by erecting a barrier around the affected area [2, 11]. Modern quarantine and contact surveillance is required to preserve the individual liberties based on the Siracusa Principles. The application of this intervention must meet the interest of a legitimate objective of general interest by enforcing this public health intervention not arbitrarily, in an unreasonable or discriminatory manner and holding the restriction time-limited and in a review process .
This ancient public health intervention tool, also characterized by abuse of power and discrimination against groups and individuals in the past, but best countermeasures at times with no definitive diagnostic tests, effective vaccines or treatment against the spread of communicable diseases, has been widely used in the first major infectious disease of the 21stcentury, when the devastating SARS pandemic appeared. Within a short time the novel coronavirus (CoV) had spread rapidly across international borders, so 8445 cases and 774 deaths in 30 countries were finally reported by the World Health Organization (WHO) from Nov 1, 2002 to July 31, 2003 [2, 6]. During the SARS outbreak the data sole for the greater Toronto area was more than 30.000 persons to remain in voluntary quarantine .
In autumn 2005 the WHO released an underscored call on planners in influenza and other communicable likely diseases for pandemic preparedness to give attention to ethical issues and applied ethical framework. The emphasis issued such like quarantine concerning to worldwide experience with containment measures when the SARS threat appears . This paper estimates the enforced quarantine during the SARS pandemic and their results due to factors of compliance and attempts to find recommendations for an effective and ethical use of voluntary quarantine in a balanced process.
Background: Quarantine during SARS
China, Hong Kong, Vietnam, Singapore and Canada were hit the hardest caused by the novel corona virus. The median duration time of quarantine during the 2003 pandemic was about 10–12 days, according to the incubation time and time elapsed since exposure. It had been globally imposed to ten thousands of individuals with different sociopolitical and legal regulating systems by home and work containment [6, 7]
In Taiwan about 131.000 persons were confined in home quarantine or in “quarantine facilities” , Bejing held about 30.000 under similar conditions in quarantine . Utilizable research in studies and experiences of individuals in voluntary quarantine, mainly conducted and published by northamerican especially canadian authors, found inadequate application and inconsistencies concerning ethical questions in view to the collateral damage at the end of the pandemic.
The 2004 Hawryluck et al. and DiGiovanni et al. studies similarly found except from highly economic impact by the threat itself, the considerable psychological impact resulting from quarantine. Psychologically distress in forms of PTSD (post traumatic stress disorders) and depressive symptoms resulting from fear of illness and death, infecting others, stigmatization and discrimination by avoiding the quarantined persons were found [7-10].
Findings of DiGiovanni et al. study on public`s cooperation to quarantine and influencing facts estimated reducing the risk of transmission to another person as the most important reason for complying. The reason due to this considerable principal motivation was found in the civic duty of the protection of the community among health care workers and non health care workers. Moreover, the known fear of penalties by law did not influence the decision to comply to self-quarantine. The most common reasons for noncompliance and demotivating factors were found in the fear of loss of income, the inconsistencies in various application quarantine jurisdictions, inconsistencies in logistical support of quarantined and confused communication3 to the public by government and available media response and communication systems to allow to keep in touch with their families for quarantined individuals . The 2006 published survey by Blendon et al estimated the possible use of quarantine in Hong Kong, Taiwan, Singapore and United States. The findings additionaly show a less lower level of compliance and likely change of behaviour particulary in minorities, if people are not concerned about the health threat and don`t have appropriate and accurate information for quarantine preparation .
The conclusion of the publications is the simple fact, that quarantine restricts not only individual liberty by limiting freedom of movement and privacy, but also imposes psychological burden, disrupts and isolates individuals from common life and influences compliance to further quarantine by experienced inconsistencies of various supporting issues.
 Quarantine refers to the separation and movement restriction of exposed individuals who are not (yet) ill. Isolation refers to the separation and movement restriction of infected individuals who have a specific infectious transmissible disease.
 The chinese nomenclature did not fit with the established definitions between quarantine and isolation, it was all called "isolation" .