In 1918 American school children created a new schoolyard rhyme:
I had a little bird,
And its name was Enza.
I opened a window,
And in flew Enza.
That year and the following, 25 million Americans became sick with the flu and an estimated 670,000 people died. It was one of the worst epidemics the country has ever faced.
One might wonder: What would the government do today if there was an outbreak the size of the 1918 influenza pandemic? This question is not as fanciful as it might seem. The world has recently seen a number of alarming outbreaks. Between 2003 and 2005 SARS and avian flu sickened thousands of people around the world. And in 2009, swine flu infected between 15 to 20% of the world population and killed somewhere between 151,700 to 575,400 people. Recently avian flu has returned to China and in Saudi Arabia there are now well over a hundred cases of the SARS-like coronavirus MERS (Middle East Respiratory Syndrome).
What would the US government do if one of these viruses became as deadly as the 1918 influenza pandemic? One way to predict future public policy is to examine what the US government has done in the past. When we look at America’s history of disease control we find that quarantine has been one of the government’s main strategies.
The federal government began to comprehensively respond to outbreaks of disease around the end of the 19th century. After a devastating yellow fever outbreak in 1878 President Hayes passed the National Quarantine Act. This created a system of quarantine stations and required states and local communities to follow certain regulations. At the time quarantine meant maritime quarantine – screening incoming ships for sick passengers and then isolating those ships with infected passengers.
The emphasis on quarantine was influenced by the rise of germ theory. At this time, medical practitioners came to accept the idea that disease is caused by microscopic organisms that are transmitted from one person to the next. To stop disease from entering the country, public health authorities believed that you had to keep out the people who carried it. Public health authorities consolidated this germ based quarantine approach to disease control in the 1880s and 1890s. Described as the “bacteriological revolution,” public health authorities lost interest in sanitation, previously one of the main ways governments managed disease, and instead focused predominantly on controlling the infectious bodies of the sick.
This germ based approach lead to some quite coercive state methods of disease control. Quarantining whole communities and isolating sick individuals became accepted practice. When typhus struck New York City in 1892, health officials connected the outbreak to a ship that had recently travelled from Eastern Europe. Health officials rounded up the passengers on board, especially the Jewish travelers, and forced them, under armed guard, to go to hospital wards.
In 1900, when cases of plague appeared in San Francisco and Honolulu, public health officials instituted a community wide quarantine of Chinatown districts in both cities. Armed guards barred any of the residents from leaving and in Hawaii the whole district was accidently burned to the ground.
In the early part of the 20th century quarantine continued to be used. In 1915 Mary Mallon, otherwise known as “Typhoid Mary,” was isolated on an island off of New York City for over 23 years of her life because she was suspected of being a typhoid carrier. Her case and the actions taken in San Francisco, Hawaii, and New York City show the lengths to which the American state was willing to go to control the spread of disease.
But that is old history right? One of the lessons that historical sociology teaches us is that the past and the present are not foreign countries, but are connected together in a landscape of time. This means that the way America constructed its system of disease control in its formative period influences what that system looks like today. Isolating the sick and border controls are still some of the main ways that our government responds to outbreaks of disease.
There are number of ways that we see the quarantine power of the state being used in the contemporary period. In 2003 President Bush put SARS on a list of communicable diseases that allows border agents to detain sick passengers and in 2009 avian flu and swine flu were both put on a list of diseases of “public health significance” that allows foreigners to be stopped from entering the country.
In terms of internal quarantine, the government has set up the organizational and legal basis for the domestic isolation of the sick. In cases of SARS and pandemic influenza federal law allows for the compulsory isolation of the sick.
It is in the laws of the states however that we find the strongest expression of the government’s right to isolate the sick. After the September 11th attacks and the mailing of letters laced with anthrax, legal scholars, at the behest of the CDC, produced the Model State Emergency Health Powers Act. This act allows state governments to forcibly quarantine and isolate both sick individuals and entire groups of people for up to ten days without a court hearing and indefinitely if the court agrees that the person poses a public health risk. As of 2006, thirty-eight states have passed versions of the act.
Compulsory quarantine of the sick is not a hypothetical. In 2003 the New York City Department of Health isolated a foreign tourist believed to be infected with SARS, placing a police officer at his hospital room door. In 2007 the CDC and the Georgia state board of public health put an Atlanta lawyer suspected of having a drug resistant strain of tuberculosis, into involuntary isolation for three days. And in 2007 a Russian man was placed in mandatory isolation in an Arizona hospital jail for just over ten months, before being deported back to Russia, because he too had a drug resistant strain of tuberculosis.
While other countries, like Britain, have moved away from border control and quarantine, the US government has increased its use. This contemporary emphasis on quarantine is the most recent iteration of a style of disease control that the United States has been developing for the last hundred and fifty years. Viruses evolve and mutate quickly. The systems that humans create to deal with these problems are built up over long periods of time and are slow to change.