Public health law and ethics: lessons from SARS and quarantine.

• Author: Ries, Nola M.

The 2003 global outbreak of severe acute respiratory syndrome (SARS) was an abrupt reminder that infectious diseases pose a continuing threat to human health. In 1967, U.S. Surgeon General W.H. Stewart had optimistically declared "it was time to close the book on infectious diseases." (1) SARS proved that wrong. Outside Asia, Canada was the country hardest hit by SARS. The outbreak took 44 lives in our country, threatened many others and created numerous challenges for public health officials and the acute health care system. (2) In particular, SARS highlighted serious deficiencies in public health infrastructure and preparedness. As in other countries, officials in Canada were required to weigh the legalities and ethics of various interventions to control the spread of the disease, including quarantine.

Quarantine during SARS

At the height of the SARS outbreak, tens of thousands of people in Ontario were quarantined. (3) Anyone who had visited certain hospitals during specific time periods was asked to observe quarantine. 1,700 high school students were quarantined after one student at the school became ill. Many health care workers had to abide by "work quarantine," which required them to travel directly from home to work without using public transit and without stopping at any other destination. At home, health care workers had to separate themselves from family members, wear masks when in contact with others in their household, and not have visitors. (4) More than half of Toronto's 850 paramedics ended up under 10-day home quarantine during the outbreak. (5)

As SARS spread, the Ontario government amended its public health statute to empower officials to order individuals suspected of being exposed to the disease into quarantine. (6) Similarly, the federal government amended the Quarantine Act regulations so quarantine officers stationed at airports and other entry points to Canada could screen travelers and, if necessary, detain them for suspected SARS infection. (7) For the most part, Canadian authorities did not have to resort to coercive legal measures to control the outbreak. Ontarians generally complied voluntarily with quarantine and public health officials sought legally enforceable quarantine orders in only a small number of cases. (8)

Outside Canada, countries such as China, Hong Kong and Singapore also used quarantine in an effort to stem the spread of SARS. However, while Canadian public health officials relied primarily on voluntary compliance with quarantine requests, measures elsewhere were not so benign. In Hong Kong, officials used barricades and tape in an attempt to confine residents in a large housing complex where over 300 people were known to be infected with SARS. (9) Authorities in Singapore enforced quarantine with surveillance cameras and electronic monitoring devices. (10) Chinese citizens faced penalties as harsh as imprisonment and execution for breaching quarantine orders. (11)

The Ethics of Quarantine

Quarantine represents the archetypal conflict that confronts public health: the tension between society's dual interests in safeguarding individual liberty while protecting and promoting the health of its citizens. Lawrence Gostin, a leading public health law expert, counsels that "in a democratic society, ... coercive...