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msJAMA
December 3, 2003

Quarantine and Social Inequity

JAMA. 2003;290(21):2874. doi:10.1001/jama.290.21.2874

On March 6, 1900, the body of a working man was found in a basement in San Francisco's Chinese quarter, apparently dead of plague. The San Francisco Board of Health took prompt action, quarantining the entire Chinatown area. A house-to-house search, led by uniformed police officers, was made for other victims and for various unsanitary conditions. Within hours, the Chinatown community was alarmed and the sick and dead were hidden, while fears were voiced that the entire quarter would be razed, as had happened in Honolulu's Chinatown. Despite pathological confirmation of plague, the strong public response forced the quarantine to be lifted after 3 days. Over the next 2 months, while San Franciscans debated the scientific, public health, and commercial aspects of the discovery, more plague cases were identified. Unable to organize an effective response, concerned about the spread of the disease to other cities, and convinced by the notion that Asians were particularly susceptible to plague because of their dietary reliance on rice rather than animal protein, President McKinley ordered a quarantine of all Chinese and Japanese persons in San Francisco. Railroads and other means of public transportation were forbidden from carrying Asians and other members of what McKinley called "races liable to the plague" out of the city unless they held health certificates from the Marine Hospital Service, the predecessor of the US Public Health Service.1 The presidential order was challenged in federal court, which held that it was a clear violation of the equal protection guarantees of the Fourteenth Amendment to the Constitution, and the quarantine was overturned.2 But the combination of scientific and medical uncertainty, commercial concerns, and the vulnerability of marginalized groups would recur repeatedly over the succeeding century, leading to unjust and often ineffective control of infectious outbreaks.

Even in situations of less urgency than plague, social inequities have intruded into apparently scientific infection control measures. At the turn of the 20th century, when communicable diseases like diphtheria and typhoid were thought of as major public health threats, quarantine regulations were enforced differently for the rich and for the poor. While well-to-do families were permitted to quarantine their sick in their own homes or were entirely shielded from the issue by private physicians who simply chose not to report their cases to the city, the poor were more often carried off to municipal isolation wards, while their homes were placarded with signs warning that a case of "scarlet fever" or "measles" had occurred there.3 Similar disparities occurred among persons traveling to the United States from Europe. While steerage and third-class passengers were taken off the incoming ships in the harbor and landed at quarantine stations like Ellis Island in New York City to be examined for signs of contagion, cabin-class passengers were examined only briefly in their cabins and then landed directly in Manhattan to continue their journeys without further interruption.4 Public health concerns were defined by many public health officials as issues of race and economic status. In fact, so closely were the signs and symptoms of infection linked to ethnicity in the minds of public health officials that when physicians diagnosed typhus in the Devlin sisters, 2 native-born New York school girls, the health department simply rejected the diagnosis, and the girls were not quarantined.3 Although some conditions of life for the poorer classes may have made them more vulnerable to infection, in many cases the targets for quarantine were populations with low rates of morbidity and mortality due to infectious diseases.3

Maintaining public health is a police function of the state5; the government may impose restrictions on private rights to promote the health and welfare of the general public. At the turn of the 20th century, the New York City Board of Health included the police commissioner. Police officers can be used to enforce quarantine orders, as they were in San Francisco in 1900. However, government coercion conflicts with US traditions of antiauthoritarianism and personal liberty, requiring careful thought if quarantine is to be considered for control of infectious disease.6 A strategy of cooperation, though, depends on trust in the public health system and in the authorities responsible for it. Traditional methods of quarantine and isolation, such as those used in San Francisco in 1900, those applied to immigrants in the early 20th century, and those used to detain persons with tuberculosis in more recent times,7 have frequently fallen short of these standards. Isolation strategies have often dealt differently with persons of different social and economic status, and the burdens of infection control policies have fallen more heavily on those least able to bear them—the poor, immigrants, and marginalized ethnic groups.

Funding/Support: This work was supported in part by the US Public Health Service Centers for Disease Control and Prevention Cooperative Agreement for Academic Centers for Public Health Preparedness.

References
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Goodman RA, Rothstein MA, Matthews GW, Hoffman RE, Lopez W. Law in Public Health PracticeOxford, England: Oxford University Press; 2003:14-15.
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Barbera J, Macintyre A, Gostin L.  et al.  Large-scale quarantine following biological terrorism in the United States.  JAMA.2001;286:2711-2717.PubMed
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Lerner BH. Tuberculosis in Seattle, 1949-1973.  West J Med.1999;171:44-48.PubMed
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