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HISTORY OF MEDICINE: QUARANTINE AND SOCIAL INEQUITY

The following points are made by Paul J. Edelson (J. Am. Med. Assoc. 2003 290:2874):

1) On March 6, 1900, the body of a working man was found in a basement in San Francisco's Chinese quarter, apparently dead of plague. The San Francisco Board of Health took prompt action, quarantining the entire Chinatown area. A house-to-house search, led by uniformed police officers, was made for other victims and for various unsanitary conditions. Within hours, the Chinatown community was alarmed and the sick and dead were hidden, while fears were voiced that the entire quarter would be razed, as had happened in Honolulu's Chinatown.

2) Despite pathological confirmation of plague, the strong public response forced the quarantine to be lifted after 3 days. Over the next 2 months, while San Franciscans debated the scientific, public health, and commercial aspects of the discovery, more plague cases were identified. Unable to organize an effective response, concerned about the spread of the disease to other cities, and convinced by the notion that Asians were particularly susceptible to plague because of their dietary reliance on rice rather than animal protein, President McKinley ordered a quarantine of all Chinese and Japanese persons in San Francisco. Railroads and other means of public transportation were forbidden from carrying Asians and other members of what McKinley called "races liable to the plague" out of the city unless they held health certificates from the Marine Hospital Service, the predecessor of the US Public Health Service.(1)

3) The presidential order was challenged in federal court, which held that it was a clear violation of the equal protection guarantees of the Fourteenth Amendment to the Constitution, and the quarantine was overturned.(2) But the combination of scientific and medical uncertainty, commercial concerns, and the vulnerability of marginalized groups would recur repeatedly over the succeeding century, leading to unjust and often ineffective control of infectious outbreaks.

4) Even in situations of less urgency than plague, social inequities have intruded into apparently scientific infection control measures. At the turn of the 20th century, when communicable diseases like diphtheria and typhoid were thought of as major public health threats, quarantine regulations were enforced differently for the rich and for the poor. While well-to-do families were permitted to quarantine their sick in their own homes or were entirely shielded from the issue by private physicians who simply chose not to report their cases to the city, the poor were more often carried off to municipal isolation wards, while their homes were placarded with signs warning that a case of "scarlet fever" or "measles" had occurred there.(3-5)

References (abridged):

1. Risse GB. "A long pull, a strong pull, and all together": San Francisco and bubonic plague, 1907-1908. Bull Hist Med. 1992;66:260-286

2. McClain C. Of medicine, race, and American law: the bubonic plague outbreak of 1900. Law Soc Inq. 1988;13:447-513

3. Markel H. Quarantine! European Jewish Immigrants and the New York City Epidemics of 1892. Baltimore, Md: Johns Hopkins University Press; 1997

4. Kraut AM. Silent Travelers. Germs, Genes, and the "Immigrant Menace." New York, NY: Basic Books; 1994:53

5. Goodman RA, ed, Rothstein MA, ed, Matthews GW, ed, Hoffman RE, ed, Lopez W, ed. Law in Public Health Practice. Oxford, England: Oxford University Press; 2003:14-15

J. Am. Med. Assoc. http://www.jama.com

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ON QUARANTINE FOLLOWING BIOTERRORISM IN THE US

The following points are made by J. Barbera et al (J. Am. Med. Assoc. 2001 286:2711):

1) Concern for potential bioterrorist attacks causing mass casualties has increased recently. Particular attention has been paid to scenarios in which a biological agent capable of person-to-person transmission, an agent such as smallpox, is intentionally released among civilians. Multiple public health interventions are possible to effect disease containment in this context.

2) One disease control measure that has been regularly proposed in various settings is the imposition of large-scale or geographic quarantine on the potentially exposed population. Although large-scale quarantine has not been implemented in recent US history, it has been used on a small scale in biological hoaxes, and it has been invoked in federally sponsored bioterrorism exercises.

3) The authors review the scientific principles that are relevant to the likely effectiveness of quarantine, the logistic barriers to its implementation, legal-issues that a large-scale quarantine raises, and possible adverse consequences that might result from quarantine action.

4) The authors suggest that imposition of large-scale quarantine -- compulsory sequestration of groups of possibly exposed persons or human confinement within certain geographic areas to prevent spread of contagious disease -- should not be considered a primary public health strategy in most imaginable circumstances. The authors suggest that in the majority of contexts, other and less extreme public health actions are likely to be more effective and create fewer unintended adverse consequences than quarantine.

J. Am. Med. Assoc. http://www.jama.com

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