Everything old is new again when it comes to battling a novel coronavirus with no cure or vaccination.
Public health officials point to face masks, social distancing and good hand hygiene as pillars of the response to the coronavirus, along with robust testing and contact tracing. But there’s one last-resort tool: the quarantine order.
Quarantines have been used to control disease among humans and animals for hundreds of years. The word derives from the Italian word for 40 days, quaranta giorni, because ships returning to port from far-off lands with infections would have to anchor for 40 days before unloading their crew and cargo.
Today, if an infected person refuses to comply with recommendations to quarantine or isolate, state health officials can issue the quarantine orders, which in Oklahoma are hand-delivered to the recipient. The orders must be signed by the health commissioner.
Since the state’s first recorded instance of coronavirus infection in March, the Oklahoma State Department of Health has issued 49 quarantine orders through September. All but one were for coronavirus. (One was for rabies.) The agency issued one measles-related quarantine order in 2019, and none going back to 2014.
The quarantine orders are usually requested by a regional director at the health department after they’ve tried everything else to get compliance, said Keith Reed, deputy commissioner for community health services. A summary of the situation is prepared and a conference call is set up between Reed, the regional director, the agency’s general counsel and other leaders at the health department.
“We talk through it and ask is this something that we really need to do?” Reed said. “We really do want this to be a last resort.”
Oklahoma’s quarantine orders can be challenged through the health department’s administrative hearing process. The coronavirus quarantine orders are typically for 10 days to two weeks, shorter than the usual timeline for administrative hearings involving attorneys and administrative law judges. On the flip side, the department can force compliance with a quarantine order by getting an emergency order from a district judge.
“We don’t have quarantine jail. We don’t have isolation jail. We’re not doing anything like that,” Reed said. “We’re just doing the best we can to mitigate the spread. This is one of those tools in the toolbox.”
Health officials were reluctant to share specific stories of issuing quarantine orders because of medical privacy, but they said most have gone smoothly.
“In one instance, we told the guy, ‘You can’t continue working. You have to go home.’ When we handed him an order, he was like, ‘OK.’ And he got in his car and went home,” said Brandie Combs, regional director for the southwest part of the state. She is one of nine regional directors at the health department.
Combs said after a quarantine order is issued, the department follows up to see if the person needs help getting groceries, medicine or other support.
“None of us like to quarantine individuals or groups of individuals,” Combs said. “We don’t like disrupting lives. But when you look at the consequences of not taking these actions, we could have outbreaks that would cost loss of life or even loss of years of life. We want to avoid that. And if it’s a matter of 14 days or 11 days in a home, we really are asking for participation in that rather than an argument.”
Every state has some form of quarantine order law in their public health laws, according to research compiled by the National Conference of State Legislatures. The federal government has its own quarantine laws, mostly dealing with international travel and imported goods.
Oklahoma Watch surveyed states surrounding Oklahoma about their use of quarantine orders this year. Some states, like Missouri and Kansas, leave the decisions to local or county health departments and don’t compile statewide numbers. Others, like Texas, had statewide numbers only for the counties outside of large metropolitan areas. Through June, the latest month available, Texas health officials had issued 25 quarantine control orders outside of metro counties.
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Colorado has issued 13 quarantine orders and 23 isolation orders since March. Arkansas issued 22 quarantine orders through September. New Mexico has issued three orders.
Alta Charo, a professor of law and bioethics at the University of Wisconsin Law School, said quarantine orders in the United States started in the late-1800s.
“That’s where you begin to see it all begin to coalesce where you’ve got a state government that has some statutory authority and then it delegates to an agency with expertise,” Charo said.
Charo said the most famous quarantine court case came in 1900 in San Francisco, where the city health department quarantined a 12-block section of Chinatown, ostensibly to control bubonic plague. The quarantine covered about 12,000 people, even though bubonic plague is carried by rats, and applied only to Chinese-American residents.
A grocer, Jew Ho, challenged the quarantine. The city health department lost in a federal appeals court because it had misdiagnosed the disease, the quarantine was arbitrary and it affected too many people. The court said the state had the burden of showing the scientific evidence and a quarantine couldn’t be overly broad.
In the early months of the coronavirus pandemic this year, Japanese authorities quarantined the Diamond Princess cruise ship, which had more than 400 American passengers. A similar quarantine by U.S. authorities on another cruise ship, the Grand Princess, affected some Oklahomans.
“The best quarantines are the ones that are actually very focused,” Charo said. “You quarantine a ship like the Diamond Princess where in fact it’s very hard to not have been exposed. Or you quarantine a building where there’s a lot of people living that has a lot of common areas and people are mixing.”
For about a century after the San Francisco case, Charo said courts were generally deferential to public health authorities in quarantine orders that were challenged.
“That seems to be changing a little bit,” Charo said. “And we’re beginning to get a few more courts that are more willing to take the kind of ‘liberty’ analysis and say the state has a bigger burden.”
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Kaci Hickox is a recent example. She was a nurse who volunteered to treat Ebola patients in Sierra Leone in 2014. Even though she had no symptoms, she was immediately placed in quarantine by public health officials in New Jersey when she landed at Newark airport. Hickox successfully challenged that quarantine order only to return to her home in Maine and face house arrest from authorities in that state. Hickox flouted the house arrest by going on a well-publicized bicycle ride.
“Ultimately she won that case and the court said that this was more aggressive than it needed to be and this quarantine didn’t have the scientific justification for the extent of the isolation that they were imposing on her,” Charo said.
So far, none of Oklahoma’s coronavirus quarantine orders have been challenged, health officials said. Treatments for coronavirus are being refined, and multiple drugmakers are working on possible vaccines under Operation Warp Speed.
“We’re very fortunate,” Reed said. “We live in a time when there are ways to control communicable disease beyond just quarantine and isolation. If you go back before the time of immunizations, that was all you had. Certainly, at that point, this was a very important tool in the public health toolbox.”