Kaci Hickox, confined to quarantine in October 2014.

Kaci Hickox, confined to quarantine in October 2014. (photo credit: Reuters)

This article is one of two on the O’Neill Blog this week that focus on confinement, human rights, and public health.

In October 2014, Kaci Hickox, upon her return to the United States, found herself confined to a tent outside of Newark, New Jersey’s University Hospital. Hickox, a nurse, was returning from Sierra Leone, where she had been caring for patients during what would eventually become the deadliest Ebola outbreak ever. Hickox had assented to tests that would determine if she was infected with the deadly virus, but despite testing negative and exhibiting zero symptoms of the disease, she was placed in mandatory quarantine.

Hickox was the first person quarantined under the joint policy announced between Governors Chris Christie (New Jersey) and Andrew Cuomo (New York) which stated that any traveler returning from West Africa with possible exposure to Ebola-infected persons would be held for 21 days (the incubation period for Ebolavirus, the period of time between exposure and onset of symptoms), regardless of how healthy they appear to be. The policy was in contradiction to others in place at airports receiving similar travelers—Chicago, Atlanta, and DC’s Dulles airports—which required a health screening at arrival, and asked those that passed to report daily temperature readings with thermometer given to them. Hickox would eventually file suit against Governor Christie and his administration, saying that her three-day detention in that tent was unlawful, and a violation of her civil and human rights.

The history of quarantines officially begins in 14th century Venice, when city officials would force ships arriving from infected ports to remain anchored offshore for quaranta giorni (40 days, in Italian). Since then, quarantines have continued to be tools for municipalities, states, or nations to prevent the introduction or importation of infectious diseases, often undermining the rights of the individual. In 1994, the United States passed the Public Health Service Act, which granted the U.S. Public Health Service the responsibility for preventing the introduction, transmission, and spread of communicable diseases from other countries. Today, this responsibility is taken on by the Centers for Disease Control and Prevention (CDC), whose new focus is less about routine inspections, and more about program management and intervention.

Hickox’s lawsuit contended that Governor Christie and his administration’s decision to detain and isolate her was based on politics, not science—that the decision to quarantine her was meant to show a tough stance on protecting the public from Ebola. The lawsuit contended that the Christie administration’s actions were based on flawed policy that was based on standards that were unnecessarily rigid, and more stringent than federal standards. Hickox and her attorneys felt that she was confined in spite of evidence supporting that she was not ill, and not a risk for spreading the disease. Udi Ofer, her attorney, said, “The decision to quarantine anyone must be made based on science, not fear and politics. In holding Kaci Hickox, the governor and the former head of the Department of Health not only violated her basic constitutional rights, but they did so without any scientific foundation.”

In June this year, the lawsuit was settled. Hickox did not receive monetary damages; instead, a change was made to New Jersey’s procedures for quarantine. Under the settlement, a person designated for quarantine is guaranteed the opportunity to hire and meet with an attorney, “send and receive communications, have visitors, present evidence, and cross-examine witnesses”. Also, oral thermometers will be used to determine if a person has a fever—Hickox originally registered a fever with a temporal thermometer, but not with an oral thermometer. Finally, and most importantly, the state must demonstrate why more restrictive quarantines, such as the one Hickox received, are needed over less restrictive ones.

Especially dangerous pathogens, such as Ebola, are sure to threaten national security again in the future; quarantine is but one tool in the toolbox that can be considered under such extreme circumstances as an Ebola outbreak. If it must be used, less restrictive options should be attempted prior to or in tandem with confinement. The 2014 New Jersey Ebola Quarantine serves as a reminder that to use such a tool without sound science or reasoning is to do so potentially at the expense of human and civil rights.