In War on Pathogens, Our Defenses Are Down

You are sitting on a plane next to a passenger who looks pale and ill. You glance at him and you see thin, dark tracks of blood streaming from his nose and eyes. It looks like Ebola.

You panic. You reach for a button and call the flight attendant. You hand the man your napkin; he mops his face, dropping the bloody napkin on the floor. The flight attendant comes over, then rushes away to tell the pilot. Moments later the pilot announces that there is a sick passenger on board and that you’ll be landing at the nearest airport. The plane lands and rolls up to the terminal. But they won’t let anyone off.

After a half-hour wait, two emergency workers in hazmat suits enter the plane and move down the aisle toward you. They move the sick man to the back of the plane. Panic rises. You are told that you’ve been exposed to an infectious disease, and you have to be decontaminated and then detained -- no one knows for how long -- to make sure you aren’t sick and don’t spread the virus.

In March, the University of Louisville Center for the Deterrence of Biowarfare and Bioterrorism, working with local public health and law enforcement authorities, mounted an exercise much like this scenario. Though everyone on the plane had been well trained and well briefed -- and the exercise thoroughly scripted -- something quite close to panic nevertheless set in. The “sick” people, a man and a woman, wore terrifyingly realistic makeup: Their eyes showed vivid hemorrhaging, and the man’s nostrils were crusted in dried blood. Massive bruises stained their skin.

One passenger, unscripted, tried to take off the emergency exit door. Later, when finally let off the plane, he tried to run into the terminal and was twice tackled by police.

It took well over an hour in the stuffy plane to get all the passengers off. But that wasn’t the problem. What’s frightening about this exercise is not how the participants reacted but what it makes clear. As a nation we have no blueprint for treating mass exposure to infectious diseases. Although the federal government has the ability to order quarantines for certain diseases in cases in which people have arrived from foreign countries or are moving from one state to another, that jurisdiction is seldom exercised and is not widely understood. As a practical matter, health officials must rely on a patchwork of quarantine laws in individual states.

We have, says quarantine expert Victoria Sutton, director of the Center for Biodefense, Law and Public Policy at Texas Tech University, no national biodefense policy at all. The Centers for Disease Control and Prevention lacks authority to enforce quarantines inside the country. The Department of Homeland Security cannot step into a state’s jurisdiction unless it has definitely established that a disease outbreak has been caused by bioterrorism -- by which time it might well be too late to control an outbreak. And Homeland Security has no “block on their organization chart for public health,” Sutton says.

Making matters worse, she says, is the jurisdictional confusion when you’re dealing with airports and disease. If passengers are still on an airplane, federal law prevails, but this jurisdiction extends only as far as the tarmac. Once passengers are inside the terminal, control reverts to state and local authorities. Quarantine laws vary widely from state to state and are often surrounded by confusion. In theory, to keep passengers in quarantine a judge would have to issue an order. This could take hours, during which healthy people would be kept together with the sick, making the spread of disease much more likely.

Furthermore, there is no way of knowing how American citizens would react to a quarantine order. Last year, when five passengers on a flight from Asia experienced respiratory symptoms suggestive of SARS, passengers were held on the plane for two hours. Ultimately, three of the ill passengers agreed to go to the hospital in a waiting ambulance, but the other two refused, saying they’d call health officials if they got sicker. Authorities watched helplessly as the two left the airport.

And what if the entire planeload had been quarantined? Forbidden to work, perhaps for weeks, deprived of their incomes, with their jobs threatened by prolonged absence, would people try to break quarantine? Where would they -- and their unexposed family members -- stay? We pay jurors a nominal fee for their services; shouldn’t we also pay those deprived of work through quarantine? Furthermore, who would feed these people and bring them medical services? No one knows.

The United States needs to develop policies that address these questions because quarantine remains the surest way to handle outbreaks of infectious diseases, particularly ones for which we have no vaccine or no sure treatment. Quarantine (for people who have been potentially exposed but haven’t developed symptoms) and isolation (for those who are actually sick) were the principal tools used to control the SARS outbreak last year, which popped up around the globe before it was contained.

The strategy is not new. Quarantine and isolation were the only tools available during two explosive epidemics of pneumonic plague in Manchuria early in the 20th century, before antibiotics had been discovered. In 1910, led by the young Cambridge-educated physician Wu Lien-teh and backed by Chinese imperial power, an international team of doctors and public health workers aborted an epidemic that otherwise, like the Black Death of the 14th century, might have burned across the world. Unlike bubonic plague, the pneumonic type infects the lungs and can spread from person to person through the air.

In Manchuria, those with the plague were sent to hospitals and died -- pneumonic plague, without antibiotics, is virtually always fatal. Those merely exposed were kept in quarantine. Despite the frigid Manchurian winter, Wu insisted that the quarantined patients be kept in the fresh air, where the infection would be less likely to spread. By 1911, it was over. About 60,000 people had died of plague, but Wu’s enlightened policies brought the epidemic to an end.

In 1920, another epidemic, smaller in scale, proved harder to control. The emperor of China had abdicated, and Sun Yat-sen’s new Chinese republic could devise regulations but not enforce them. In Dalainor, restive Chinese soldiers allowed nine apparently healthy miners to escape from quarantine. These nine fanned out across Manchuria, and the bacterial infection followed in their wake. Ten thousand people died before the outbreak ended.

Now, in the 21st century, we have to relearn what Wu understood almost 100 years ago. Quarantine and isolation are necessary tools in a national biodefense policy, a policy that must take into account the nature and relative threat of different disease agents as well as the protection of the population.

Policies that are too strict would backfire -- like quarantining for two weeks people who had been seated on an airplane 20 rows away from someone with Ebola, which is spread through direct contact with bodily fluids. In such a case, people might well break quarantine, as they did last year during the SARS outbreak in Toronto. Overly lax policies could allow epidemics to burst into the wider populace and spread uncontrollably.

We cannot rely on local and state health authorities -- few of which will be as prepared as the Louisville team -- to make these decisions for us. “Congress is going to have to address some tough questions about a national plan for biodefense, even though it may raise some controversial state-power issues,” said Sutton, the Texas Tech professor.

The SARS outbreak, which did not kill anyone in this country, was a warning shot across our bow. The total absence of a national biodefense policy, of rules governing quarantine and isolation, is a frightful oversight -- one we had better address before any new threat takes us by surprise.