Thursday, September 4, 2014
Last month’s riots in an Ebola-infected slum in Monrovia, Liberia demonstrated anew the perils of relying on quarantine, and similar highly coercive public health laws, to contain highly contagious diseases.
At first blush, Ebola viral disease (EVD) is exactly the type of disease for which broad quarantines (more precisely, sanitary cordons) would seem appropriate. Transmitted through direct contact with the bodily fluids of an infected person, EVD can spread rapidly through a community, as it has done in several West African nations. Although experimental treatments and vaccines offer promise for the future, they have not yet been shown to be effective in humans; nor are they readily available. As a result, health officials are forced to rely on tried and true public health strategies, such as identifying cases, isolating and treating them with strict infection control measures, and monitoring their contacts. Needless to say, doing so is very challenging and very expensive, especially in highly urbanized areas, with weak health systems.
Given the challenges, health officials and government leaders are often tempted to call in the troops, and rely on more heavy-handed measures, such as imposing sanitary cordons around whole towns or neighborhoods, quarantining those who have had contact with patients, and restricting travel into and out of affected regions. Although the impetus for these measures is understandable given the magnitude of the EVD threat, history suggests that such highly coercive tactics frequently backfire. Like the military-style show of force employed by the police department in Ferguson, Missouri earlier this summer, highly coercive public health measures can undermine the public’s trust in authorities. Thus, rather than reduce travel, identify contacts, and come forward if they show symptoms, individuals are more apt to try to leave affected areas and avoid the health care system. Or they riot, as they did in Monrovia and China during the SARS outbreak. In any case, the problem is made worse not better.
Of course, the absence of coercion alone is insufficient to create and maintain trust. Trust in public health, especially during an emergency, requires a functioning and effective public health system, one that works for the population at risk. That in turn requires both laws that limit liberty as well as other laws that ensure that restrictions on liberty are applied fairly and with due regard to the rights of those affected. It also requires sufficient resources to maintain a public health system that works well even in the absence of an emergency. Trust cannot be called upon in during a crisis if it is not earned in ordinary times.
Unfortunately, it is often difficult for public health to maintain the needed balance between under and over-regulation. Even in wealthy countries with relatively robust public health systems, there is a tendency to ignore public health problems and deride public health regulations when times seem good; and demand strong actions and turn upon scapegoats when they are not. So with Ebola we can see the pivot from neglect to coercion, from under-reaction to panic.
In its recent Roadmap on Ebola, the WHO has tried to avoid both extremes. Coming far too late in the epidemic, the Roadmap offers a relatively balanced approach, one that recognizes that individual liberties may at times need to be restrained, while also emphasizing the need for more resources and better relationships with affected communities. We can only hope that governments, here and abroad, heed the message, and respond with neither excessive force nor deadly denial.