Monday, June 4, 2007
Quarantine and the Covenant of Trust
BY WENDY E. PARMET

The story of Andrew Speaker, the Atlanta attorney and first American quarantined by the federal government in over 40 years, reads like a Hollywood screenplay, a global action thriller, in which government agents track down a tubercular killer. As Hollywood might tell the tale, Speaker was a selfish man who threatened the lives of innocent travelers. Cast in this light, the script suggests that what we need to spare us from the dreaded XDR-TB (extensively drug-resistant tuberculosis) is 24’s Jack Bauer – somebody who can track down and detain the dastardly patient – or perhaps the public health version of the Patriot Act.

In a press conference last week, Dr. Julie Gerberding, director of the Centers for Disease Control and Prevention (CDC), tried hard to defend her agency’s failure to match Bauer’s toughness. Not mentioning that the CDC is still considering proposed quarantine regulations that would enhance the government’s authority to detain and hold, without judicial review, individuals who have or are suspected of having a contagious disease, Gerberding invoked the language of public health ethics, citing the “covenant of trust” between public health officials and those who have tuberculosis. To Gerberding, CDC should not be blamed for not detaining Speaker sooner. But once Speaker refused to comply with health officials’ recommendations, he broke the covenant and CDC was justified in issuing its quarantine order.

But was it Speaker who broke the covenant? And is quarantine the solution to the threat of XDR-TB? Although many of the facts remain murky, it does seem that Speaker did not react as we might want him to do. But did he act any differently than many would have under the circumstances? As the facts now appear, county officials recommended that he not travel to Europe. He ignored that advice. Is that unusual? How many people faithfully follow all medical recommendations? How many people would follow recommendations to postpone their wedding? Indeed, how many people listen to advice and never go to work or school when they might have the flu?

It also seems that Speaker fled once he was told to stay put in Rome. Clearly, going on the lam was not, as he now admits, a very wise decision. But according to Speaker, he was fearful that he would be “stuck in an Italian hospital indefinitely, where I could die.” Given the circumstances, is it really that strange that he tried to run home for help? How many people would run if threatened with an isolation order?

The main problem with both the Hollywood narrative and Gerberding’s pronouncement, however, is not that Speaker’s actions are what we would expect of most people. It is that he acted ways that are perfectly compatible with cultural norms.

It is trite but true that in America we admire individual self-sufficiency and rugged individualism. Not only do we admire this “taking care of number 1” attitude, but public health has encouraged it. Over the last several decades, public health has emphasized the role that individuals can and should play in determining their own health. Indeed, every day of week, we are bombarded with messages about how we can do this or that to take care of ourselves. Sometimes the message extends to what we can do for our families. Seldom are we told what or how we can do for unnamed others.

Even infectious disease policies perpetuate this myth of self-control. We are told to vaccinate our children to protect them. We are told to help ourselves by getting a flu shot. And the federal government provides us with information about how we should prepare to help ourselves and our family in the event of an influenza pandemic.

This “privatization” of infectious disease control is even evident in the U.S. approach to quarantine. During the SARS epidemic, governments in Canada and in Asia quickly realized that quarantines would not be effective without income protection. So laws were passed to assure that people would receive compensation while under quarantine. In the United States, in contrast, despite all the efforts that have been made at public health preparedness and public health law modernization, income replacement remains off the table (the Family and Medical Leave Act only guarantees unpaid leaves for some ill employees). Perhaps even more astonishingly, in its proposed quarantine regulations, the CDC failed to ensure that it would provide all necessary health care to those it quarantined.

The most significant breach of the covenant of trust with respect to TB, however, is the government’s failure to adequately support TB prevention and treatment programs both internationally and domestically. Although support for TB control has risen in recent years thanks to the Gates Foundation and the Global Fund for HIV, TB, and Malaria, funding remains inadequate compared to the global problem, and U.S. support is paltry. On the same day that the CDC announced Mr. Speaker’s quarantine, the Stop TB Partnership, a network of over 500 international TB control organizations, announced that it was experiencing a 60 percent funding shortfall for the year. According to the Partnership’s Executive Secretary, Marcos Espinal, the Partnership has received $77 million in the past year from Canada, and only $19 million from the United States.

Domestically, support for TB control is not much better. Since 9/11, federal public health money has poured into preparedness, leaving “core” public health services, such as TB control, to erode. Likewise, there has been insufficient attention to the growing problem of drug resistance and little support for the development of a new generation of antibiotics and TB treatments.

In the movies, tough guys and strict laws may solve the problem of XDR-TB. But in the real world, as Speaker remains in isolation, millions of people harbor a disease that continues to develop drug resistance, and millions of people live in environments in which XDR-TB flourishes. And while quarantine may at times be appropriate and useful, it alone cannot make the problem of drug-resistant TB go away. Perhaps, then, it is time to take the covenant seriously.

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