This commentary argues that 100 years after the deadly Spanish flu, the public health emergency community’s responses to much more limited pandemics and outbreaks demonstrate a critical shortage of personnel and resources. Rather than relying on nonpharmaceutical interventions, such as quarantine, the United States must reorder its health priorities to ensure adequate preparation for a large-scale pandemic.

The lethal consequences of the onset of a modern full-blown pandemic cannot be ignored. Overreliance on the reactive and blunt use of nonpharmaceutical interventions (NPIs), such as quarantine, indicate the need for a serious and commonsense reordering of our public health priorities. If we continue on our current path and fail to make changes to meet the almost certain likelihood of future critical public health needs, we may, by virtue of policy negligence, be right back where we were in 1918.

The Spanish influenza of 1918–1919, a pandemic flu estimated to have infected more than 500 million people worldwide, likely caused between 50 and 100 million deaths globally.1 In the United States alone, the Spanish flu devastated families, businesses, and communities, leaving approximately 670 000 Americans dead in its wake. Cities such as Philadelphia, Pennsylvania, came to a grinding halt, with Spanish flu killing nearly 12 000 of its residents, almost all of them within a six-week period.1

Because of its time and place in history, the common and untutored wisdom is that medical science and public health have so advanced in the intervening years that the scope of a pandemic such as the Spanish flu cannot be repeated. In truth, 100 years after the deadly Spanish flu, the public health emergency community’s responses to much more limited pandemics and outbreaks demonstrate a critical shortage of personnel and resources as the United States continues its recent trend of cutting back on infectious diseases funding and research.

Thus, despite technological and pharmaceutical advances, our public health defenses and countermeasures have not strengthened but withered. Relatively recent onsets of Ebola, Zika, Middle East respiratory syndrome, and a host of other emerging infectious diseases—as well as the 2017–2018 flu season—have made it clear that we are not adequately prepared for a large-scale pandemic. In fact, experts have reported that

[e]ven with modern antiviral and antibacterial drugs, vaccines, and prevention knowledge, the return of a pandemic virus equivalent . . . to the virus of 1918 would likely kill [more than] 100 million people worldwide.2(p.21)

Significant scientific advances since the Spanish flu’s onset 100 years ago foster in the public a false sense of complacency about the ability to combat a nationwide and deadly influenza outbreak. Yet, in the face of that threat and despite the advent of drugs, protocols, and vaccines available to treat the flu and associated infections, we remain dangerously vulnerable.

One need only look to recent events. For example, the 2017–2018 flu season has been among the worst in recent history. By May 2018, the flu had caused more than 30 000 people to be hospitalized, and it caused 160 pediatric deaths.3 Frighteningly, this flu season was the first such outbreak in which high levels of flu activity were spread throughout the continental United States. High rates of hospitalization, overall mortality, and particularly pediatric deaths have fueled fears among public health experts about the health care system’s preparedness for a much more deadly pandemic, because hospitals in areas hit hardest by the recent flu had to treat patients in waiting rooms or set up tents in parking lots to help accommodate the patient surge.4

This stretching of limited medical resources is exacerbated by local health departments that face increasing day-to-day responsibilities, coupled with dramatically decreasing funding. From fiscal year 2015–2016 to fiscal year 2016–2017, 31 states cut their public health budgets, contributing to lower state public health spending than in fiscal year 2008–2009.5 The continuous and decreasing commitment to public health has left the nation without any margin of error to respond to a pandemic-like environment.

Over recent years, the onset of each new pandemic finds medical science belatedly racing to identify and catalog the disease, while at the same time developing new countermeasures—rapid testing, vaccines, care protocols—to respond and then implementing those countermeasures. In the absence of known response protocols, the present public health response falls back on familiar but archaic and blunt measures, such as NPIs, to help contain and control the spread of disease. More often than not, these NPIs, such as quarantine, are implemented in a highly reactive, fear-based environment, in which they are likely not based on a clear, evidence-based, scientific assessment of the pandemic. Consequently, these NPIs often neither protect the public health nor safeguard civil liberties.

Without ready disease surveillance and adequate medical countermeasures, US pandemic preparedness has fallen into a disproportionate reliance on a reactive approach to addressing recent pandemics that emphasizes NPIs. NPIs encompass a variety of measures ranging from washing hands and staying home from work when ill to isolating those who are sick and quarantining healthy individuals suspected to have been exposed.6 Whether for a strain of the flu not adequately covered by the yearly flu vaccine or for another infectious disease such as Ebola, Middle East respiratory syndrome, or the Zika virus, when public health officials do not have effective pharmaceutical treatments or protocols or may not yet fully understand critical facts about disease transmission, NPIs may seem to offer an immediate, familiar solution to limit the spread of disease and the severity of its effects. Indeed, the Centers for Disease Control and Prevention (CDC) recommend practicing hygiene and social distancing to contain the flu, and quarantine and isolation are two of the oldest methods of disease containment in the world.

The success of NPIs varies widely and depends not just on implementation, but “crucially . . . on the biology and natural history of the pathogen in question.”7(p4023) In fact, researchers assessing the effectiveness of quarantines versus active monitoring in limiting the spread and effect of diseases such as Ebola, severe acute respiratory syndrome, Middle East respiratory syndrome, and other strains of influenza have found that, overall, active monitoring has proven to be more effective than quarantine. Even when quarantine was found to be effective in containing Ebola, success was dependent on external factors such as robust contact tracing. Given these limitations, researchers have determined that quarantine should be considered “only if [disease] control is infeasible through symptom monitoring.”7(p4026) Although quarantine may be useful in certain cases of influenza, which can be infectious for a short period and without observable symptoms, researchers have ultimately concluded that “data-driven decision making” that “incorporate[s] the context and epidemiology of an outbreak” prove “more useful than one size fits all [quarantine] guidelines.”7(p4026)

Quarantine is often implemented as an overly broad, reactionary measure of limited effect, untethered to an evidence-based, scientific approach to the biological and epidemiological profile of a disease. This is exemplified by its use in response to the Ebola outbreak of 2014. In that year, when the Ebola virus spread rapidly throughout West Africa and ultimately to the United States, many states responded by quickly instituting quarantine policies seemingly without regard to the scientific evidence of how Ebola spread and how its symptoms manifest themselves. These overly aggressive approaches did little to contain the disease, at great expense to civil liberties, and went well beyond the evidence-based recommendations of the nation’s foremost public health agency, the CDC.

The inappropriate use of quarantine and its susceptibility to adoption under political pressure are illustrated vividly in the case of Kaci Hickox. In their response to the Ebola outbreak, the governors of New York and New Jersey on October 24, 2014, announced that there would be 21-day mandatory quarantines for medical personnel returning to the United States who had direct contact with an Ebola patient while abroad, regardless of symptoms.8 Just hours after that announcement, Kaci Hickox, an American nurse returning from treating Ebola patients in Sierra Leone, landed at Newark Liberty Airport in New Jersey. On landing, Hickox informed airport personnel that she was returning from Sierra Leone. She was then taken to a CDC quarantine station at the airport.9 There, she was questioned and had her temperature taken by thermal scan. Hickox then registered a fever.

Despite inconsistent temperature readings, Hickox was subsequently transported to University Hospital in Newark, where she was involuntarily quarantined outside of the building for approximately 80 hours in the now infamous isolation tent with a portable toilet.9 Less than 24 hours after Hickox spoke with her attorney, hospital staff entered the tent and told her she was being released. New Jersey then transported Hickox in a convoy to her home state of Maine. In Maine, she was immediately subject to a Maine public health order that directed her to engage in direct active monitoring and substantially restricted her movements until the 21-day incubation period for Ebola had passed.10

While under quarantine in Maine, Hickox was prohibited, inter alia, from being in public places, attending public gatherings, taking public transportation, and entering workplaces. She was also required to coordinate all of her travel with public health officials. In reality, Hickox was confined to her house, with the exception of “non-congregate public activities while maintaining a three-foot distance from others.”11(p.5–6)

Hickox challenged these restrictions in Maine state court and was ultimately successful. Although the state court judge found that direct active monitoring was reasonable and should continue, the court also found that Maine had failed to meet its burden to show, by clear and convincing evidence, that the many additional restrictions on Hickox’s freedom of movement were necessary to prevent the spread of the disease.10 The court noted that “people are acting out of fear and that this fear is not entirely rational.”10(p3)

Hickox later filed a civil rights lawsuit against New Jersey officials, including then Governor Chris Christie and then Commissioner of the New Jersey Department of Health and Human Services Mary O’Dowd. She alleged that in quarantining her, the New Jersey defendants had violated her rights under the 4th and 14th Amendments and had committed the torts of false imprisonment and false light.9 In 2017, Hickox settled her lawsuit,12 dismissing her complaint after Governor Christie’s administration agreed to revise New Jersey’s quarantine and isolation procedures. Under the new procedures, individuals subject to quarantine or isolation must be afforded the opportunity to contest the order and have access to legal counsel.12 Informally known as the Quarantine Bill of Rights, the settlement also requires New Jersey to provide notice of all hearings and “guarantees a person the right to privacy so long as it does not interfere with vital public health needs.”12

Against this backdrop, and recognizing the need for an approach that properly balances public health and civil liberties, the CDC in 2017 revised its Rule for the Control of Communicable Diseases: Interstate and Foreign. In doing so, the CDC cited the 2014 to 2015 Ebola outbreak, the Middle East respiratory syndrome outbreak, and repeated measles outbreaks.13 The new rule more clearly articulates the CDC’s powers and more explicitly provides for the protection of civil liberties. For example, it requires health officials to inform individuals of their right to legal and medical representation and also stipulates accommodations for detained individuals,14 including sufficient food and water, avenues for necessary communication, and appropriate medical treatment.13

Under the new rule, the CDC maintains that it will apply the least restrictive approach when considering and implementing quarantine and isolation.13 However, the newly adopted CDC rule still leaves the CDC broad discretion to detain individuals and impose travel limitations; in fact, it clarifies that individuals may be apprehended when the CDC “reasonably believes” 13(p6909) the individual or group of individuals to be infected—and is in the qualifying stage of the disease.13 Critically, this kind of detention applies to the precommunicable stage of the disease—which for many diseases, including Ebola, means that individuals are asymptomatic and appear healthy.13 In fact, the CDC is not even required to identify the generic symptoms of illness to detain an individual; the mere possible risk of exposure is enough to justify an initial quarantine order.15

Although the CDC criticized New Jersey’s strict quarantine policy in 2014, its new rule has now set the bar so low for apprehending or quarantining individuals that Hickox’s situation could easily occur again under the CDC’s own guidance, even without a showing of fever. Although this clarification drew criticism in the proposed rule, it remained unchanged in the CDC’s final rule. The CDC reiterated in its final rule that it “explicitly references diseases ‘likely to cause a public health emergency.’”13(p6906) These diseases, however—such as Ebola, or an unknown pandemic—are also the ones that will cause people to act out of fear and implement overly inclusive—and intrusive—detention measures.

Furthermore, changes to federal policy cannot address the fundamental flaw of NPIs. Given the scientific evidence of the limited benefit of NPIs and their cost to civil liberties, there should not only be a greater focus on how to better implement NPIs, but also very substantial increased investment in global disease surveillance and medical countermeasures.

Yet at every turn, substantial public health funding cuts threaten pandemic readiness. Congress and the current administration have cut $1.35 billion from the Prevention and Public Health Fund over the next 10 years, including a 12% budget cut for the CDC, forcing the CDC to reduce its public health efforts in “some of the world’s hot spots for emerging infectious disease,” including China, Pakistan, Haiti, Rwanda, and Congo.16 These cuts have prompted global health organizations to caution that “critical momentum will be lost if epidemic prevention funding is reduced, leaving the world unprepared for the next outbreak.”16

Tom Frieden, former director of the CDC, likewise warns that “like terrorism,” epidemic disease cannot be fought “just within our borders. You’ve got to fight epidemic diseases where they emerge.”16 Frieden emphasized that these cuts mean

surveillance systems will die, so we won’t know if something happens. The lab networks won’t be built, so if something happens, we won’t know what it is. [The US] can’t be safe if the world isn’t safe.17

Even with the medical and scientific advances made since the Spanish flu, the public health emergency community’s approach to pandemics still follows a cycle of panic–neglect–panic–neglect,18 and, through inadequate and slow development of countermeasures, we remain dangerously vulnerable to the threats these pandemics pose. Changing this dynamic requires greater investment in global public health preparedness and medical and scientific innovation so that personnel and scientific resources can be devoted to combating the pandemic likely to come rather than scrambling to address the pandemic already upon us.

If we were to once again have a severe, nationwide pandemic such as the Spanish Flu, our public health system would be ill prepared. The 2017 to 2018 flu season, along with rising concerns about other dangerous influenza strains such as H7N9, show that the question of preparedness is not academic: The answer has real, life-or-death consequences. Even with medical progress over the past century, the United States is not now as prepared as it needs to be for present-day threats, and quarantine and isolation will likely not be sufficient to stop a true pandemic.

See also Parmet and Rothstein, p. 1435.


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Michael Greenberger, JDMichael Greenberger is with the Carey School of Law and the Center for Health and Homeland Security, University of Maryland, Baltimore. He is also the founder and director of the University of Maryland Center for Health and Homeland Security. “Better Prepare Than React: Reordering Public Health Priorities 100 Years After the Spanish Flu Epidemic”, American Journal of Public Health 108, no. 11 (November 1, 2018): pp. 1465-1468.

PMID: 30252520