The Ebola virus is posing challenging questions around the human rights of patients and health workers alike – and this isn’t the first time such questions have arisen. This week on PLOS TGH, Doctor/Lawyer and Harvard MPH Candidate Fiona Lander explores the issues that have arisen around quarantine.
When Kaci Hickox, a nurse working in Sierra Leone, returned home to the United States on Friday October 24, she clearly anticipated being screened for Ebola. After all, she had just returned from an area of the world where the virus is currently spreading out of control.
Having no symptoms suggestive of infection, however, she evidently did not expect to be put into compulsory quarantine. CNN reported that Ms Hickox was put into an isolation tent inside University Hospital in Newark, although she had twice tested negative for the virus.
As reported this week in the New England Journal of Medicine, the virus is generally not detectable prior to the onset of symptoms, so Ms Hickox’s negative tests were far from an ‘all clear’. However, as was also reported, the virus is not contagious prior to the onset of symptoms. The NEJM and the U.S. Center for Disease Control both conclude that asymptomatic healthcare workers can safely monitor their own temperature and other parameters upon their return home, provided they alert officials immediately if they develop symptoms.
Accordingly, the utility of mandatory hospital-based quarantine in Ms Hickox’s case was limited, and represented a curtailment of her rights; in particular, her right to freedom of movement. Ms Hickox was ultimately released from quarantine in New Jersey on Monday 27 October, and having travelled to Maine, continued to defy requests by the Governor of that State to voluntarily quarantine herself. A Maine court subsequently issued orders (in compliance with CDC protocols) that allow Ms Hickox to go outside, but which stipulate that she must stay away from public transit and workplaces, and that she must not to leave the town of Fort Kent without informing public health authorities.
Following a storm of criticism, New York’s Governor Andrew Cuomo relaxed the strict quarantining protocols that had previously been announced jointly with Governor Christie. However, Governor Christie has insisted on retaining the protocols in New Jersey on the basis that a voluntary system of quarantine is not reliable, apparently because of how serious this outbreak is. Some might argue, alongside Mr Christie, that the nature of the Ebola epidemic demands such stringent action, even if such protocols result in breaches of individual healthcare workers’ rights. However, this ignores the lessons of the recent past.
Learning from history: a human rights-based approach to epidemics
This is not the first time that quarantine requirements have been imposed without evidence to support their imposition. A classic example is that of the AIDS epidemic in the 1980s, where quarantine was utilized in an attempt to stop the spread of the virus, but ended up causing greater stigma, subsequently fuelling spread of the disease.
It is for this reason that the Ebola quarantine policies announced in the U.S. have drawn opposition from HIV activists, who have seen the pernicious effects of imposing quarantine when evidence suggests it is unnecessary. There is no doubt that Ebola is more readily transmissible than HIV, but the same legal principles in relation to compulsory quarantine apply in both cases.
The Siracusa principles outline the circumstances within which restriction of human rights are justified. In order for a restriction like compulsory quarantine to accord with the Siracusa principles:
- It must be provided for, and carried out, in accordance with the law;
- It must be in the interest of a legitimate objective of general interest;
- It must be strictly necessary to achieve the objective, in a democratic society;
- There should be no less restrictive/intrusive means through which the same objective can be achieved;
- The restriction must be based on scientific evidence, and not imposed arbitrarily or in a discriminatory way.
It is also vital that such restrictions be of limited duration, and subject to appeal and/or review.
Clearly, containment of the Ebola virus is a legitimate objective, and for a confirmed case, quarantine within a health facility is justified. The arguments for compulsory quarantining of asymptomatic health workers, however, are dubious.
The quarantine protocols put in place by Governor Christie appear to be unnecessary and discordant with scientific evidence. It is likely that the objective of the protocols can be achieved in a less restrictive manner, as borne out by the U.S Center for Disease Control guidelines referenced above; it is also likely that the protocols are also not strictly necessary to achieve the stated objective.
There are other compelling arguments against compulsory quarantine. As well as being of little utility and imposing on their right to freedom of movement, compulsory quarantining of asymptomatic health care workers has the potential to create stigma and fear around the very people whose skills are essential in the fight against Ebola. In addition, it would seem reasonable to assume that healthcare workers returning from East Africa are acutely aware of the risks that they pose to a community, should they be infected with the virus, and are likely to report to authorities promptly if they experience a fever or any other symptoms.
Freedom of movement is a human right and can only be legally curtailed in extreme circumstances. Compulsory quarantine of a patient suspected to have an infectious illness should be a measure of last resort, and only after voluntary measures to isolate the patient have failed.
The rights of patients
Different circumstances exist in relation to quarantine within West African countries where the epidemic continues to spread. Amongst the media storm concerning quarantine of healthcare workers in the U.S., it can be easy to forget that all three of the countries that have been worst hit by the virus – Liberia, Guinea and Sierra Leone – have imposed quarantines at various points in time, in an attempt to control further spread of the virus.
For example, Sierra Leone imposed a three-day quarantine in late September, confining individuals to their homes while healthcare workers toured affected areas searching for infected individuals who had not yet been identified as having the virus. The New York Times reported that the Sierra Leone quarantine met with mixed responses – some deeming the measures harsh but necessary, others (including representatives of Médecins Sans Frontières) expressing concerns that such quarantines could jeopardize trust between patients and healthcare practitioners.
The Siracusa Principles clearly anticipate the restriction of certain human rights, through measures such as quarantine, in situations such as the current Ebola outbreak in West Africa, where there is an enormous threat to health and security. However, such measures still need to be proportionate and adherent to international standards.
Human Rights Watch has expressed concern that quarantines imposed during the Ebola epidemic have not met these standards, noting that they have “not been based on scientific evidence, have been applied arbitrarily, and been overly broad in implementation”.
Keep calm…and don’t unnecessarily restrict human rights
As the epidemic continues, it will be increasingly necessary for human rights advocates to closely monitor the measures imposed to control spread of the virus, to ensure that the rights of individuals are not unnecessarily restricted.
The hysteria around the Ebola virus is, to some extent, understandable. We currently lack a vaccine or specific treatment for this virus. The mortality rate remains high – estimated at between 50 to 70% – and those who are infected will likely die without appropriate medical treatment. However, this does not mean that there is no treatment. Supportive therapy such as aggressive fluid resuscitation may improve chances of survival.
Moreover, for those outside West Africa, the situation is not as grim as it may seem. The odds of an epidemic occurring in a high-income country such as the U.S. are negligible – the U.S. Center for Disease Control has clearly stated that Ebola poses no substantial risk to the U.S. general population.
Although the West African epidemic demands stringent measures to prevent further spread of the virus – which may include imposition of quarantine protocols that comply with international law – it is fair to say that the quarantine protocols for returning health workers introduced in New Jersey, amongst other States, are not justifiable under international law, and are not supported by scientific evidence. –
Dr Fiona Lander is a medical doctor and lawyer, and a Frank Knox Fellow at Harvard University, where she is currently completing a Masters in Public Health, specializing in Law and Public Health. Dr Lander has previously worked in Mumbai, India, as Senior Officer assisting the United Nations Special Rapporteur on the Right to Health.